JMIR Publications

JMIR Diabetes

Emerging Technologies, Medical Devices, Apps, Sensors, and Informatics to Help People with Diabetes.

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Journal Description

JMIR Diabetes (JD) is a new sister journal of JMIR (the leading open-access journal in health informatics (Impact Factor 2016: 5.175), focusing on technologies, medical devices, apps, engineering, informatics and patient education for diabetes prevention, self-management, care, and cure, to help people with diabetes. As open access journal we are read by clinicians and patients alike and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies, as well as on diabetes epidemiology. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews) covering for example wearable devices and trackers, mobile apps, glucose monitoring (including emerging technologies such as Google contact lens), medical devices for insulin and metabolic peptide delivery, closed loop systems and artificial pancreas, telemedicine, web-based diabetes education and elearning, innovations for patient self-management and "quantified self", diabetes-specific EHR improvements, clinical or consumer-focused software, diabetes epidemiology and surveillance, crowdsourcing and quantified self-based research data, new sensors and actuators to be applied to diabetes.

 

Recent Articles:

  • Videoconsultation between a patient in his home  and the physcian at the healthcare center. Source: The Authors; Copyright: Renewing Health Norrbotten; URL: https://www.ltu.se/centres/eic/Avslutade-projekt; License: Public Domain (CC0).

    Telemonitoring and Health Counseling for Self-Management Support of Patients With Type 2 Diabetes: A Randomized Controlled Trial

    Abstract:

    Background: The prevalence of diabetes is increasing among adults globally, and there is a need for new models of health care delivery. Research has shown that self-management approaches encourage persons with chronic conditions to take a primary role in managing their daily care. Objective: The objective of this study was to investigate whether the introduction of a health technology-supported self-management program involving telemonitoring and health counseling had beneficial effects on glycated hemoglobin (HbA1c), other clinical variables (height, weight, body mass index, blood pressure, blood lipid profile), and health-related quality of life (HRQoL), as measured using the Short Form Health Survey (SF-36) version 2 in patients with type 2 diabetes. Methods: This was a pragmatic randomized controlled trial of patients with type 2 diabetes. Both the control and intervention groups received usual care. The intervention group also participated in additional health promotion activities with the use of the Prescribed Healthcare Web application for self-monitoring of blood glucose and blood pressure. About every second month or when needed, the general practitioner or the diabetes nurse reviewed the results and the health care activity plan. Results: A total of 166 patients with type 2 diabetes were randomly assigned to the intervention (n=87) or control (n=79) groups. From the baseline to follow-up, 36 patients in the intervention group and 5 patients in the control group were lost to follow-up, and 2 patients died. Additionally, HbA1c was not available at baseline in one patient in the intervention group. A total of 122 patients were included in the final analysis after 19 months. There were no significant differences between the groups in the primary outcome HbA1c level (P=.33), and in the secondary outcome HRQoL as measured using SF-36. A total of 80% (67/87) of the patients in the intervention group at the baseline, and 98% (47/50) of the responders after 19-month intervention were familiar with using a personal computer (P=.001). After 19 months, nonresponders (ie, data from baseline) reported significantly poorer mental health in social functioning and role emotional subscales on the SF-36 (P=.03, and P=.01, respectively). Conclusions: The primary outcome HbA1c level and the secondary outcome HRQoL did not differ between groups after the 19-month follow-up. Those lost to follow-up reported significantly poorer mental health than did the responders in the intervention group. Trial Registration: Clinicaltrials.gov NCT01478672; https://clinicaltrials.gov/ct2/show/NCT01478672 (Archived by WebCite at http://www.webcitation.org/6r4eILeyu)

  • Diabetes children share experience. Source: Image created by the authors; Copyright: Goran Petrovski; URL: http://diabetes.jmir.org/2017/1/e9/; License: Creative Commons Attribution (CC-BY).

    Impact of Facebook on Glucose Control in Type 1 Diabetes: A Three-Year Cohort Study

    Abstract:

    Background: As the world is changing, traditional health care services should be adapted for the new era of technology and the Internet. One of the possible ways for communication between health care providers and patients is social media. There are several benefits of social media in health: increased interactions with others; more available and shared information; increased accessibility; social or emotional support. Objective: The aim of this study was to evaluate the results of Facebook and CareLink software as a possible Internet tool to improve diabetes control in type 1 diabetes patients using a sensor augmented pump. Methods: A total of 67 adolescents with type 1 diabetes and in the age range of 14-23 years were randomized in 2 groups: (1) Traditional group and (2) Internet group. In the traditional group, 34 patients were treated using standard medical protocol with regular clinic visits, where data were uploaded at the clinic and interventions (pump settings-basal bolus insulin and education) were delivered to the patient. In the Internet group, 33 patients were treated using Facebook and CareLink software (Medtronic Diabetes) on a monthly basis, where the data were uploaded by the patient at home and interventions (same as traditional group) were delivered via Facebook (written reports and chats). Both the traditional and Internet group had regular visits every 3 months with standard medical protocol. Glycosylated hemoglobin (HbA1c) was obtained before and every 3 months during the study for a 3-year-period. Results: The improvement in glucose control was found in both groups: 7.9% (SD 1.4) [62.8 mmol/mol (SD 12.9)] to 6.9% (SD 1.2) [51.9 mmol/mol (SD 10.8)] in the traditional group, and 7.8% (SD 1.8) [61.7 mmol/mol (SD 17.2)] to 6.7% (SD 1.8) [49.7 mmol/mol (SD 17.3)] in the Internet group). Significant improvement of HbA1c (P<.05) was found in favor of the Internet group. Conclusions: Social media such as Facebook as a tool can assist in standard medical care to improve glucose control in a long term period in adolescents with type 1 diabetes using insulin pump therapy.

  • Source: iStock by Getty Images; Copyright: monkeybusinessimages; URL: http://www.istockphoto.com/photo/senior-couple-jogging-in-park-gm177249609-19540517; License: Licensed by the authors.

    Phone Messaging to Prompt Physical Activity and Social Support Among Low-Income Latino Patients With Type 2 Diabetes: A Randomized Pilot Study

    Abstract:

    Background: Given disparities in diabetes prevalence, receipt of diabetes education, diabetes knowledge, and self-management behaviors among Latinos, there is a need to provide education and ongoing support to this population. Phone-based interventions have the potential to reach and engage both patients and their family members and friends. Objective: The aim of this study was to investigate the feasibility, perceived usefulness, and potential effectiveness of a short text or voice message (STVM) intervention to activate (1) physical activity (PA) behavior change among urban, low-income Latino adults with type 2 diabetes and (2) supportive behaviors by their family members and friends. Methods: A 12-week pilot study randomized 42 participants recruited in person from a safety-net ambulatory care clinic in Los Angeles into one of the 3 study arms: control, phone messaging (PM), and phone messaging plus social support from family members and friends (PM+FF). All participants were prompted to set PA goals and to self-monitor PA behavior using pedometers and walking logs. PM and PM+FF participants received STVMs with reminders to review goals and self-monitor, PA behavior change education, and feedback on performance. Participants in the PM+FF arm also had their family members and friends receiving STVMs with suggestions for how they could support the participant’s PA behavior change efforts. Participants completed semistructured assessments in person at baseline, 6 weeks, and 12 weeks. Outcomes were PA (steps/day) and perceived social support from family members and friends. Results: Among PM and PM+FF participants, those who opted to receive text messages (short message service, SMS) responded to 62.7% (128/204) of SMS text messages requiring a response while those who opted to receive voice messages responded 30% (12/40) of the time. Participants perceived guidance in self-regulation as useful, particularly self-monitoring, goal setting, self-instruction, feedback, and social support. All participants increased PA at 6 weeks, but only the PM and PM+FF arms increased PA at 12 weeks. All study arms experienced an increase in perceived social support from family members and friends at 6 weeks, but only those in the PM+FF arm had an increase in the perception of social support at 12 weeks. Conclusion: Designing an STVM intervention based on self-regulation techniques is feasible and perceived as useful by participants. The STVM intervention has the potential to improve PA in terms of daily steps and perceived social support from family members and friends. Trial Registration: Clinicaltrials.gov NCT02850770; https://clinicaltrials.gov/ct2/show/NCT02850770 (Archived by WebCite at http://www.webcitation.org/query?id=1495567756845570)

  • Source: Qatar is booming.; URL: http://www.qatarisbooming.com/article/qatar-petroleum-backs-action-diabetes-workplace-campaign;

    Situation of Diabetes and Related Factors Among Qatari Adults: Findings From a Community-Based Survey

    Abstract:

    Background: Diabetes mellitus (DM) is a prominent public health problem in Qatar with one of the highest prevalence in the Gulf Cooperation Council region. Obesity continues to be a challenging public health problem in Qatar along with other social determinants contributing to the high DM prevalence. Objective: This paper examines the data from Qatar National STEPS survey (2012) to determine diabetes prevalence among Qatari adults and identify the effect of both generalized and central obesity on it. The article also describes the contribution of selected social and demographic factors on diabetes prevalence in Qatar. Methods: Secondary data analysis of 1471 Qatari adults (18-64 years) from STEP 3 component of the 2012 STEPS Survey was executed. Multivariate binary logistic regression analysis was carried out to assess the role of social and biomedical factors in the prevalence of DM. Results: Among participants, 18.97% (279/1471) of the study population had DM. Both generalized (OR 1.8, P=.005) and central obesity (OR 1.9, P<.001) were significantly associated with DM when adjusted for various respondent characteristics. Older age (P<.001), marital status of ever married (P<.001), and lower educational status (P=.01) were associated with DM. Hypertension (OR 1.5, P=.003 total cholesterol level ≥190 mg/dL (OR 2.2, P<.001) and triglyceride level ≥150 mg/dL (OR 3.6, P<.001) were significantly associated with DM among the study participants. Although family history of DM was significantly associated with development of DM (OR 1.7, P=.01), parental consanguinity was not associated with DM (OR 0.96, P=.80). Conclusions: The DM prevalence in Qatar seems to be highly associated with obesity; however, various additional population characteristics and comorbidity factors should also require attention and should be incorporated while developing intervention strategies.

  • Opening page of the "How is your sugar" website, collage on mockup. Copyright: JMIR Publications; License: Creative Commons Attribution (CC-BY).

    How’s Your Sugar? Evaluation of a Website for Aboriginal People With Diabetes

    Abstract:

    Background: Australia’s Aboriginal and Torres Strait Islander peoples (hereafter referred to as “Aboriginal people”) have the longest continuing culture in the world, living sustainably for at least 65,000 years on the Australian continent. In relatively recent times, colonization processes have resulted in Aboriginal people experiencing unacceptable health inequalities compared with other Australians. One disease introduced due to colonization is diabetes, the second leading cause of death for Aboriginal peoples. Objectives: The objective of this study was to describe the construction and utilization of the website “How’s Your Sugar, ” a website for Aboriginal people with type 2 diabetes (herein after referred to as diabetes). The questions for the evaluation were as follows: how was the website constructed; did target groups utilize the website; and did engagement with the website improve diabetes management. Methods: A mixed-method study design was employed. A content analysis of project documents provided information about the website construction. Data from Google analytics provided information about website utilization. To describe patterns of website sessions, percentages and numbers were calculated. A voluntary survey provided more information on website utilization and diabetes self-management. Percentage, numbers, and 95% CIs were calculated for each variable. A chi-square test was performed for Aboriginal status, age, gender, and Aboriginal diabetic status using Australian population estimates and Aboriginal diabetes rates. Results: The website development drew on Aboriginal health, social marketing, interactive health promotion frameworks, as well as evidence for diabetes self-management. The website build involved a multidisciplinary team and participation of Aboriginal diabetics, Aboriginal diabetic family members, and Aboriginal health workers. This participation allowed for inclusion of Aboriginal ways of knowing and being. The highest number of website sessions came from Australia, 98.15% (47,717/48,617) and within Australia, Victoria 50.97% (24,323/47,717). There were 129 survey respondents, and the distribution had more female, 82.9% (107/129, 95% CI 76-88), Aboriginal, 21.7% (28/129, 95% CI 16-30), and Aboriginal diabetic, 48% (13/27, 95% CI 31-66) respondents than expected with P<.001 for these three groups. Most common reasons for visits were university assignment research, 40.6% (41/101), and health workers looking for information, 20.8% (21/101). The sample size was too small to calculate diabetes self-management change. Conclusions: Inclusion of Aboriginal ways of knowing and being alongside other theoretical and evidence models in Web design is possible. Aboriginal people do utilize Web-based health promotion, and further understanding about reaching to this population would be of use. Provision of an education resource would likely have enhanced educational engagement. Web-based technologies are rapidly evolving, and these can potentially measure behavior change in engaging ways that also have benefits for the participant. A challenge for designers is inclusivity of cultural diversity for self-determination.

  • Image Source: Copyright sturti, via iStockPhoto. License purchased by author.
Stock file ID:516185934.

    A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes

    Abstract:

    Background: Type 2 diabetes (T2D) is typically managed with a reduced fat diet plus glucose-lowering medications, the latter often promoting weight gain. Objective: We evaluated whether individuals with T2D could be taught by either on-site group or remote means to sustain adequate carbohydrate restriction to achieve nutritional ketosis as part of a comprehensive intervention, thereby improving glycemic control, decreasing medication use, and allowing clinically relevant weight loss. Methods: This study was a nonrandomized, parallel arm, outpatient intervention. Adults with T2D (N=262; mean age 54, SD 8, years; mean body mass index 41, SD 8, kg·m−2; 66.8% (175/262) women) were enrolled in an outpatient protocol providing intensive nutrition and behavioral counseling, digital coaching and education platform, and physician-guided medication management. A total of 238 participants completed the first 10 weeks. Body weight, capillary blood glucose, and beta-hydroxybutyrate (BOHB) levels were recorded daily using a mobile interface. Hemoglobin A1c (HbA1c) and related biomarkers of T2D were evaluated at baseline and 10-week follow-up. Results: Baseline HbA1c level was 7.6% (SD 1.5%) and only 52/262 (19.8%) participants had an HbA1c level of <6.5%. After 10 weeks, HbA1c level was reduced by 1.0% (SD 1.1%; 95% CI 0.9% to 1.1%, P<.001), and the percentage of individuals with an HbA1c level of <6.5% increased to 56.1% (147/262). The majority of participants (234/262, 89.3%) were taking at least one diabetes medication at baseline. By 10 weeks, 133/234 (56.8%) individuals had one or more diabetes medications reduced or eliminated. At follow-up, 47.7% of participants (125/262) achieved an HbA1c level of <6.5% while taking metformin only (n=86) or no diabetes medications (n=39). Mean body mass reduction was 7.2% (SD 3.7%; 95% CI 5.8% to 7.7%, P<.001) from baseline (117, SD 26, kg). Mean BOHB over 10 weeks was 0.6 (SD 0.6) mmol·L−1 indicating consistent carbohydrate restriction. Post hoc comparison of the remote versus on-site means of education revealed no effect of delivery method on change in HbA1c (F1,260=1.503, P=.22). Conclusions: These initial results indicate that an individualized program delivered and supported remotely that incorporates nutritional ketosis can be highly effective in improving glycemic control and weight loss in adults with T2D while significantly decreasing medication use.

  • Image Source: http://www.diabetespa.com/ (fair use).

    The Use of Mobile Health to Deliver Self-Management Support to Young People With Type 1 Diabetes: A Cross-Sectional Survey

    Abstract:

    Background: Young people living with type 1 diabetes face not only the challenges typical of adolescence, but also the challenges of daily management of their health and evolving understanding of the impact of their diagnosis on their future. Adolescence is a critical time for diabetes self-management, with a typical decline in glycemic control increasing risk for microvascular diabetes complications. To improve glycemic control, there is a need for evidence-based self-management support interventions that address the issues pertinent to this population, utilizing platforms that engage them. Increasingly, mobile health (mHealth) interventions are being developed and evaluated for this purpose with some evidence supporting improved glycemic control. A necessary step to enhance effectiveness of such approaches is to understand young people’s preferences for this mode of delivery. Objective: A cross-sectional survey was conducted to investigate the current and perceived roles of mHealth in supporting young people to manage their diabetes. Methods: Young adults (16-24 years) with type 1 diabetes in Auckland, New Zealand, were invited to take part in a survey via letter from their diabetes specialist. Results: A total of 115 young adults completed the survey (mean age 19.5 years; male 52/115, 45%; European 89/115, 77%), with all reporting they owned a mobile phone and 96% (110/115) of those were smartphones. However, smartphone apps for diabetes management had been used by only 33% (38/115) of respondents. The most commonly reported reason for not using apps was a lack of awareness that they existed. Although the majority felt they managed their diabetes well, 63% (72/115) reported wanting to learn more about diabetes and how to manage it. A total of 64% (74/115) respondents reported that they would be interested in receiving diabetes self-management support via text message (short message service, SMS). Conclusions: Current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. mHealth has potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods.

  • Diabetes Management via Mobile Health Technologies. Image source: https://pixabay.com/en/ui-mobile-app-apple-iphone-771829/. Copyright: CC0 Public Domain.

    Mixed-Methods Research in Diabetes Management via Mobile Health Technologies: A Scoping Review

    Abstract:

    Background: Considering the increasing incidence and prevalence of diabetes worldwide and the high level of patient involvement it requires, diabetes self-management is a serious issue. The use of mobile health (mHealth) in diabetes self-management has increased, but so far research has not provided sufficient information about the uses and effectiveness of mHealth-based interventions. Alternative study designs and more rigorous methodologies are needed. Mixed-methods designs may be particularly useful because both diabetes self-management and mHealth studies require integrating theoretical and methodological approaches. Objective: This scoping review aimed to examine the extent of the use of mixed-methods research in mHealth-based diabetes management studies. The methodological approaches used to conduct mixed-methods studies were analyzed, and implications for future research are provided. Methods: Guided by Arksey and O’Malley’s framework, this scoping review implemented a comprehensive search strategy including reviewing electronic databases, key journal searches, Web-based research and knowledge centers, websites, and handsearching reference lists of the studies. The studies focusing on mHealth technologies and diabetes management were included in the review if they were primary research papers published in academic journals and reported using a combination of qualitative and quantitative methods. The key data extracted from the reviewed studies include purpose of mixing, design type, stage of integration, methods of legitimation, and data collection techniques. Results: The final sample (N=14) included studies focused on the feasibility and usability of mHealth diabetes apps (n=7), behavioral measures related to the mHealth apps (n=6), and challenges of intervention delivery in the mHealth context (n=1). Reviewed studies used advanced forms of mixed-methods designs where integration occurred at multiple points and data were collected using multiple techniques. However, the majority of studies did not identify a specific mixed-methods design or use accepted terminology; nor did they justify using this approach. Conclusions: This review provided important insights into the use of mixed methods in studies focused on diabetes management via mHealth technologies. The prominent role of qualitative methods and tailored measures in diabetes self-management studies was confirmed, and the importance of using multiple techniques and approaches in this field was emphasized. This review suggests defining specific mixed-methods questions, using specific legitimation methods, and developing research designs that overcome sampling and other methodological problems in future studies.

  • Smartphone app for diabetes management. Image source: https://stock.adobe.com/ca/stock-photo/close-up-of-woman-with-smartphone-doing-blood-test/105110393. Image purchased by authors.

    Smartphone App Use for Diabetes Management: Evaluating Patient Perspectives

    Abstract:

    Background: Finding novel ways to engage patients in chronic disease management has led to increased interest in the potential of mobile health technologies for the management of diabetes. There is currently a wealth of smartphone apps for diabetes management that are available for free download or purchase. However, the usability and desirability of these apps has not been extensively studied. These are important considerations, as these apps must be accepted by the patient population at a practical level if they are to be utilized. Objective: The purpose of this study was to gain insight into patient experiences related to the use of smartphone apps for the management of type 1 diabetes. Methods: Adults with type 1 diabetes who had previously (or currently) used apps to manage their diabetes were eligible to participate. Participants (n=12) completed a questionnaire in which they were required to list the names of preferred apps and indicate which app functions they had used. Participants were given the opportunity to comment on app functions that they perceived to be missing from the current technology. Participants were also asked whether they had previously paid for an app and whether they would be willing to do so. Results: MyFitnessPal and iBGStar were the apps most commonly listed as the best available on the market. Blood glucose tracking, carbohydrate counting, and activity tracking were the most commonly used features. Ten participants fulfilled all eligibility criteria, and indicated that they had not encountered any one app that included all of the functions that they had used. The ability to synchronize an app with a glucometer or insulin pump was the most common function that participants stated was missing from current app technology. One participant had previously paid for a diabetes-related app and the other 9 participants indicated that they would be willing to pay. Conclusions: Despite dissatisfaction with the currently available apps, there is interest in using these tools for diabetes management. Adapting existing technology to better meet the needs of this patient population may allow these apps to become more widely utilized.

  • Depression. Image source: https://pixabay.com/en/lonely-hiding-sad-young-alone-1822414/. Author: Wokandapix. Copyright: CCO License.

    The Case for Jointly Targeting Diabetes and Depression Among Vulnerable Patients Using Digital Technology

    Abstract:

    It is well publicized that mobile and digital technologies hold great promise to improve health outcomes among patients with chronic illnesses such as diabetes. However, there is growing concern that digital health investments (both from federal research dollars and private venture investments) have not yet resulted in tangible health improvements. We see three major reasons for this limited real-world impact on health outcomes: (1) lack of solutions relevant for patients with multiple comorbidities or conditions, (2) lack of diverse patient populations involved in the design and early testing of products, and (3) inability to leverage existing clinical workflows to improve both patient enrollment and engagement in technology use. We discuss each of these in depth, followed by new research directions to increase effectiveness in this field.

  • An eye care professional prepares for laser surgery for diabetic retinopathy (leaking blood vessels). Image source: https://www.flickr.com/photos/nationaleyeinstitute/7543921240. Author: National Eye Institute, National Institutes of Health. Copyright: https://creativecommons.org/licenses/by/2.0/.

    Widely Viewed English Language YouTube Videos Relating to Diabetic Retinopathy: A Cross-Sectional Study

    Abstract:

    Background: An emergent source of information on health issues is the Internet. One such platform with 1 billion users is YouTube, the global video-sharing service. Objective: The purpose of this study was to describe the content and characteristics of the most widely viewed YouTube videos related to diabetic retinopathy. Methods: Videos were sorted according to number of views using the key words “diabetic retinopathy.” For each video, general descriptive information was collected. This information included date and source of upload (news, professional, or consumer), length, and total number of views as of July 18, 2016. Content categories were largely informed by a National Eye Institute fact sheet. Each video was viewed to determine which, if any, of the given content categories were present. Results: Of the 98 most widely viewed videos related to diabetic retinopathy, 42 were generated by consumers, 40 were generated by professionals, and 16 were generated from news-based sources. The largest number of views were generated from professionals (624,770/994,494, 63.82%). Compared with professional videos, consumer videos were viewed less frequently (W=622, P=.04). The main purpose of the majority of videos was to provide information (59/98, 60%), and most of the videos showed or mentioned retinopathy in general (75/98, 77%). Smaller numbers offered information about specific types of retinopathy, namely proliferative (26/98, 27%) and nonproliferative (17/98, 17%). Compared with consumer-generated videos, professional videos were 5.57 times more likely to mention that diabetic retinopathy can go unnoticed (95% CI 1.59-26.15). More than 80% (80/98) of the most widely viewed videos did not address the asymptomatic nature of the disease, only about one-third (33/98) mentioned prevention, and only 58 of the 98 videos (59%) mentioned screening. Conclusion: Future research is needed to identify aspects of YouTube videos that attract viewer attention and best practices for using this medium to increase diabetic retinopathy screening among people with diabetes.

  • iPhone user. Image source: https://pixabay.com/en/iphone-4s-technology-mobile-app-830480/. Author: MariusMB. Copyright: CC0 Public Domain.

    DiaFit: The Development of a Smart App for Patients with Type 2 Diabetes and Obesity

    Abstract:

    Background: Optimal management of chronic diseases, such as type 2 diabetes (T2D) and obesity, requires patient-provider communication and proactive self-management from the patient. Mobile apps could be an effective strategy for improving patient-provider communication and provide resources for self-management to patients themselves. Objective: The objective of this paper is to describe the development of a mobile tool for patients with T2D and obesity that utilizes an integrative approach to facilitate patient-centered app development, with patient and physician interfaces. Our implementation strategy focused on the building of a multidisciplinary team to create a user-friendly and evidence-based app, to be used by patients in a home setting or at the point-of-care. Methods: We present the iterative design, development, and testing of DiaFit, an app designed to improve the self-management of T2D and obesity, using an adapted Agile approach to software implementation. The production team consisted of experts in mobile health, nutrition sciences, and obesity; software engineers; and clinicians. Additionally, the team included citizen scientists and clinicians who acted as the de facto software clients for DiaFit and therefore interacted with the production team throughout the entire app creation, from design to testing. Results: DiaFit (version 1.0) is an open-source, inclusive iOS app that incorporates nutrition data, physical activity data, and medication and glucose values, as well as patient-reported outcomes. DiaFit supports the uploading of data from sensory devices via Bluetooth for physical activity (iOS step counts, FitBit, Apple watch) and glucose monitoring (iHealth glucose meter). The app provides summary statistics and graphics for step counts, dietary information, and glucose values that can be used by patients and their providers to make informed health decisions. The DiaFit iOS app was developed in Swift (version 2.2) with a Web back-end deployed on the Health Insurance Portability and Accountability Act compliant-ready Amazon Web Services cloud computing platform. DiaFit is publicly available on GitHub to the diabetes community at large, under the GNU General Public License agreement. Conclusions: Given the proliferation of health-related apps available to health consumers, it is essential to ensure that apps are evidence-based and user-oriented, with specific health conditions in mind. To this end, we have used a software development approach focusing on community and clinical engagement to create DiaFit, an app that assists patients with T2D and obesity to better manage their health through active communication with their providers and proactive self-management of their diseases.

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  • Behavioral and medical mechanisms that link diabetes to disability depend on the intersection of place and gender

    Date Submitted: Jun 23, 2017

    Open Peer Review Period: Jun 25, 2017 - Aug 20, 2017

    Background: The mechanisms that link diabetes to disability may vary across populations. Objective: This study investigated gender by place differences in the behavioral and medical mechanisms behind...

    Background: The mechanisms that link diabetes to disability may vary across populations. Objective: This study investigated gender by place differences in the behavioral and medical mechanisms behind the link between diabetes (DM) and disability in eight countries. Methods: We borrowed data from Research on Early Life and Aging Trends and Effects (RELATE). This analysis included adults from eight countries including Barbados, Brazil, Costa Rica, Chile, Cuba, Puerto Rico, Mexico, and Uruguay. Diabetes was the independent variable, disability (activities of daily living) was the dependent variable, socioeconomics, obesity, health behaviors, and comorbidities were covariates, and gender was the moderator. We used country by gender specific- logistic regressions to test the effect of DM on disability after adjusting for socioeconomics (Model 1), socioeconomics, health behaviors, and obesity (Model 2), and socioeconomics, obesity, health behaviors, and medical comorbid conditions (Model 3). Results: Gender by country specific patterns of association between DM and disability were observed in Puerto Rico, Mexico, Brazil, Chile, and Cuba. In Puerto Rico, in men, DM – ADL could be explained by health behaviors and obesity, for women, however, the impact of DM on ADL was above all confounders for women. In Mexico, for men, DM was not associated with disability, however, for women, there was a link which could be explained by health behaviors and obesity. In Brazil, for men, DM – ADL limitation link could be fully explained by health behaviors and obesity, for women, however, DM was not associated with ADL at all. In Chile, for men, DM was not associated with ADL limitation, for women, however, there was an association between DM and ADL limitation which could not be explained by health behaviors, obesity, or comorbid medical conditions. In Cuba, for men, health behaviors and obesity fully mediated the effect of DM on ADL, for women, however, this link was mediated by comorbid medical conditions. Conclusions: Gender by place differences exist in the link between DM and disability, as well as behavioral and medical mechanisms behind such link. These findings advocate for the intersectionality approach in studying burden of illnesses such as DM.

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    Date Submitted: Apr 21, 2017

    Open Peer Review Period: May 31, 2017 - Jul 14, 2017

    Background: The See Me Smoke-Free (SMSF) mobile health (mHealth) application (app) was developed to help women quit smoking by targeting concerns about body weight, body image, and self-efficacy throu...

    Background: The See Me Smoke-Free (SMSF) mobile health (mHealth) application (app) was developed to help women quit smoking by targeting concerns about body weight, body image, and self-efficacy through cognitive behavioral techniques and guided imagery audio files addressing smoking, diet, and physical activity. A feasibility trial found associations between SMSF usage and positive treatment outcomes. This paper reports a detailed exploration of program use among those who downloaded the app, and the relationship between program use and treatment outcomes. Objective: To determine whether: 1) participants were more likely to set quit dates, be current smokers, and report higher levels of smoking at baseline than non-participants; 2) participants opened the app and listened to audio files more frequently than non-participants; and 3) participants with more app usage had a higher likelihood of smoking abstinence at follow-up. Methods: The SMSF feasibility trial was a single arm, within-subjects, prospective cohort study with assessments at baseline, 30- and 90-days post-enrollment. The SMSF app was deployed on the Google Play store for download, and basic profile characteristics were obtained for all app installers. Additional variables were assessed for study participants. Participants were prompted to use the app daily during study participation. Crude differences in baseline characteristics between trial participants and non-participants were evaluated using t-tests (continuous variables) and Fisher’s exact tests (categorical variables). Exact Poisson tests were used to assess group-level differences in mean usage rates over the full study period, using aggregate Google Analytics data on participation and usage. Negative binomial regression models were used to estimate associations of app usage with participant baseline characteristics, after adjustment for putative confounders. Associations between app usage and smoking abstinence were assessed using separate logistic regression models for each outcome measure. Results: Participants (n=151) were more likely than non-participants (n=96) to report female gender (P < 0.02) and smoking in the 30 days prior to enrollment (P < 0.0001). Participants and non-participants opened the app and updated quit dates at the same average rate (Rate ratio (RR) 0.98; 95% CI: 0.92, 1.04; P = 0.43), but participants started audio files (RR 1.07; 95% CI: 1.00, 1.13; P < 0.04) and completed audio files (RR 1.11; 95% CI: 1.03, 1.18; P < 0.003) at significantly higher rates than non-participants. Higher app usage among participants was generally associated with increased smoking cessation, and most effect sizes suggested strong associations, though generally without statistical significance. Conclusions: The current study suggests potential efficacy of the SMSF app, as increased usage was generally associated with higher smoking abstinence. A planned randomized controlled trial will assess the SMSF app’s efficacy as an intervention tool to help women quit smoking. Clinical Trial: ClinicalTrials.gov NCT02972515

  • Low- and No-Cost Strategies to Recruit Women to a Mobile Health Smoking Cessation Trial

    Date Submitted: Jan 19, 2017

    Open Peer Review Period: May 31, 2017 - Jul 14, 2017

    Background: Successful recruitment and retention of adequate numbers of participants to mobile health (mHealth) studies remains a challenge. Given that researchers must decide how to invest limited re...

    Background: Successful recruitment and retention of adequate numbers of participants to mobile health (mHealth) studies remains a challenge. Given that researchers must decide how to invest limited recruitment resources, it is important to identify the most effective recruitment strategies, defined as those that incur low costs relative to participant yield. Objective: The objective of this manuscript is to describe the development and implementation process for the recruitment phase of an mHealth intervention designed to increase smoking cessation among weight-concerned women smokers. These recruitment methods could be applicable across a range of mHealth studies. Methods: Study information was released to the media in multiple phases. First, local city and state media were contacted, followed by national women’s health media, and finally outlets in states with high smoking rates. Stories and mentions resulting from the press releases (earned media) were disseminated via existing department and new study-specific social media accounts. Strategic hashtags were used in Facebook and Twitter posts to connect with broader smoking cessation campaigns. Posts were also made to third-party Facebook smoking cessation communities and Internet classifieds sites. Results: Media coverage was documented across 75 publications and radio/television broadcasts, 35 of which were local, 39 national, and 1 international. Between March 30th and July 31st, 2015, 151 participants were successfully recruited to the study. Conclusions: Leveraging social media, and coordinating with university public affairs offices were effective and low-cost strategies to earn media coverage, and reach potential participants. Clinical Trial: Not Applicable

  • Using data cubes to construct a disease-gene-drug association network for diabetes mellitus

    Date Submitted: May 16, 2017

    Open Peer Review Period: May 19, 2017 - Jul 14, 2017

    Background: In this post-genomic big-data era, genomic approaches are increasingly used to search for potential new drugs and treatments for diseases. Large-scale data mining of biomedical literature...

    Background: In this post-genomic big-data era, genomic approaches are increasingly used to search for potential new drugs and treatments for diseases. Large-scale data mining of biomedical literature is an essential tool for investigating and predicting the relationships between causal genes and treatments of diabetes mellitus (DM). Objective: The objective of the study is to construct a disease-gene-drug association network for diabetes mellitus and predict some new associations. Methods: Based on textual data, we developed a novel, data cube–based approach for constructing a disease-gene-drug association network for DM. We used association rules to measure the associations between biological entities. Results: We obtained phenotypic, genotypic, and treatment drug data for DM from the PubMed database. After data preprocessing, we constructed the 0-D vertex cube, which we then filtered to construct three 1-D cubes consisting of 14 diseases, 23 genes, and 34 drugs. We found 194 associations between the 14 subclasses of DM and the 23 genes, 75 associations between 11 of the DM subclasses and 24 of the drugs, and 142 associations between 14 of the DM-related genes and 15 of the drugs. By applying association rules to quantify the correlation between the disease phenotypes, genes, and treatment drugs, we established three 2-D cubes and three relational networks. Finally, using the bottom-up computation algorithm, we constructed the 3-D disease-gene-drug network, which revealed 411 associations between 14 subclasses of DM, 23 genes, and 24 drugs. Based on this 3-D network, we constructed 8 optimal disease-gene-drug subnetworks of DM. Conclusions: We have implemented and validated a network-based approach to identifying and ranking the hidden associations between diseases, genes, and drugs. Our results provide new potential pathways in the search for DM treatment drugs.

  • Smartphone Apps for Gestational Diabetes: A Scoping Review Examining Functionality, Implementation, Impact and the Role of Health Literacy

    Date Submitted: May 14, 2017

    Open Peer Review Period: May 17, 2017 - Jul 12, 2017

    Background: The increasing ownership of smartphones and advances in hardware and software position these devices as cost-effective personalized tools for health promotion and management among women wi...

    Background: The increasing ownership of smartphones and advances in hardware and software position these devices as cost-effective personalized tools for health promotion and management among women with gestational diabetes mellitus (GDM). Numerous smartphone apps are available online; however, no review has documented how these apps are developed and evaluated in relation to gestational diabetes. Objective: To answer the following two research questions: (1) What is known from the existing literature about the availability, functionality, and effectiveness of smartphone apps on GDM prevention and management? And (2) What is the role of health literacy in these apps? Methods: Seven relevant electronic databases were searched for original research documents using terms related to smartphone apps, GDM, and health literacy. Selected articles were thematically categorized using a framework adapted from Arksey & O'Malley. Results: Twelve articles related to seven app/systems were included in the final analysis. Articles were classified around two themes: (1) description of the development, feasibility or usability of the apps/systems, and (2) trial protocols. Varying degrees of personalization exist in the apps for GDM and decision support systems (DSSs) can be used to generate time-efficient personalized feedback for both patients and healthcare providers. Health literacy was considered during the development or measured as an outcome by some apps. Conclusions: There is a limited body of research on smartphone apps in relation to GDM prevention and management. Smartphone apps can provide time- and cost-efficient personalized interventions for GDM. Several randomized controlled trials (RCT) have been launched recently to evaluate the effectiveness of the apps. Consideration of health literacy should be improved when developing features of the apps.

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