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JMIR Diabetes

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


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:

  • Source:; Copyright: Tsippendale; URL:; License: Public Domain (CC0).

    An Interactive Simulation to Change Outcome Expectancies and Intentions in Adults With Type 2 Diabetes: Within-Subjects Experiment


    Background: Computerized simulations are underutilized to educate or motivate patients with chronic disease. Objective: The aim of this study was to test the efficacy of an interactive, personalized simulation that demonstrates the acute effect of physical activity on blood glucose. Our goal was to test its effects on physical activity-related outcome expectancies and behavioral intentions among adults with type 2 diabetes mellitus (T2DM). Methods: In this within-subjects experiment, potential participants were emailed a link to the study website and directed through 7 tasks: (1) consent; (2) demographics, baseline intentions, and self-reported walking; (3) orientation to the diurnal glucose curve; (4) baseline outcome expectancy, measured by a novel drawing task in which participants use their mouse to draw the expected difference in the diurnal glucose curve if they had walked; (5) interactive simulation; (6) postsimulation outcome expectancy measured by a second drawing task; and (7) final measures of intentions and impressions of the website. To test our primary hypothesis that participants’ outcome expectancies regarding walking would shift toward the outcome presented in the interactive simulation, we used a paired t test to compare the difference of differences between the change in area under the curve in the simulation and participants’ two drawings. To test whether intentions to walk increased, we used paired t tests. To assess the intervention’s usability, we collected both quantitative and qualitative data on participants’ perceptions of the drawing tasks and simulation. Results: A total of 2019 individuals visited the website and 1335 (566 males, 765 females, and 4 others) provided complete data. Participants were largely late middle-aged (mean=59.8 years; standard deviation=10.5), female 56.55% (755/1335), Caucasian 77.45% (1034/1335), lower income 64.04% (855/1335) t1334=3.4, P ≤.001). Our second hypothesis, that participants’ intentions to walk in the coming week would increase, was also supported; general intention (mean difference=0.31/7, t1001=10.8, P<.001) and minutes of walking last week versus planned for coming week (mean difference=33.5 min, t1334=13.2, P<.001) both increased. Finally, an examination of qualitative feedback and drawing task data suggested that some participants had difficulty understanding the website. This led to a post-hoc subset analysis. In this analysis, effects for our hypothesis regarding outcome expectancies were markedly stronger, suggesting that further work is needed to determine moderators of the efficacy of this simulation. Conclusions: A novel interactive simulation is efficacious in changing the outcome expectancies and behavioral intentions of adults with T2DM. We discuss applications of our results to the design of mobile health (mHealth) interventions.

  • OneTouch Select Plus Simple glucose meter. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Health Care Professionals’ Clinical Perspectives on Glycemic Control and Satisfaction With a New Blood Glucose Meter With a Color Range Indicator: Online...


    Background: We previously demonstrated in patients with diabetes that displaying blood glucose results in association with color improved their ability to interpret glucose results. Objective: The objective of this study was to investigate the perceptions of health care professionals (HCPs) in specific countries about the value of color on a new glucose meter and to determine if HCP perspectives among countries differ on the value of this approach in clinical practice. Methods: A total of 180 HCPs, including 105 endocrinologists, 34 primary care physicians, 25 diabetes educators, and 16 pharmacists, were recruited from India (n=50), Russia (n=50), China (n=50), and the United States (n=30). These HCPs experienced the OneTouch Select Plus Simple glucose meter online from their own office computer using interactive demonstrations (webpages, meter simulator, and video clips). After providing demographic and current clinical practice insights, HCPs responded to questions about the utility of the color-enhanced glucose meter. Results: Mean age and years in their current professional role for the 180 HCPs was 41.3 (SD 8.1) and 13.3 (SD 6.8) years for endocrinologists, 41.3 (SD 8.3) and 14.1 (SD 6.8) years for primary care physicians, 37.5 (SD 8.7) and 12.7 (SD 6.8) years for diabetes educators, and 35.9 (SD 5.3) and 9.5 (SD 5.2) years for pharmacists. In all, 88% (44/50) of Russian and 83% (25/30) of American HCPs said their patients find it easy to recognize low, in-range, or high blood glucose results compared to 56% (28/50) of HCPs in China and 42% (21/50) in India. Regardless of country, HCPs had less confidence that their patients act on blood glucose results with 52% (26/50) in Russia, 63% (19/30) in the United States, 60% (30/50) in China, and 40% (20/50) in India responding positively. During the interactive online meter experience, HCPs from all countries responded positively to questions about a meter with color features. After reflecting on the value of this meter, most HCPs strongly agreed or agreed their patients would be more inclined to act on results using a meter with color features (Russia: 92%, 46/50; United States: 70%, 21/30; China: 98%, 49/50; India: 94%, 47/50). They also said that color was particularly useful for patients with lower numeracy or education who may struggle with interpreting results (Russia: 98%, 49/50; United States: 77%, 23/30; China: 100%, 50/50; India: 82%, 41/50). Conclusions: This multicountry online study provides evidence that HCPs had high overall satisfaction with the OneTouch Select Plus glucose meter, which uses color-coded information to assist patients with interpreting blood glucose results. This may be especially helpful in patient populations with low numeracy or literacy and limited access to health care and direct interaction with HCPs.

  • Facebook page of PilAm Go4Health (montage). Source: University of California San Francisco /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Feasible and Efficacious Mobile-Phone Based Lifestyle Intervention for Filipino Americans with Type 2 Diabetes: Randomized Controlled Trial


    Background: Filipino Americans have a high prevalence of obesity, type 2 diabetes (T2D), and cardiovascular disease compared with other Asian American subgroups and non-Hispanic whites. Mobile health (mHealth) weight loss interventions can reduce chronic disease risks, but these are untested in Filipino Americans with T2D. Objective: The objective of this study was to assess feasibility and potential efficacy of a pilot, randomized controlled trial (RCT) of a culturally adapted mHealth weight loss lifestyle intervention (Pilipino Americans Go4Health [PilAm Go4Health]) for overweight Filipino Americans with T2D. Methods: This was a 2-arm pilot RCT of the 3-month PilAm Go4Health intervention (phase 1) with an active waitlist control and 3-month follow-up (phase 2). The waitlist control received the PilAm Go4Health in phase 2, whereas the intervention group transitioned to the 3-month follow-up. PilAm Go4Health incorporated a Fitbit accelerometer, mobile app with diary for health behavior tracking (steps, food/calories, and weight), and social media (Facebook) for virtual social support, including 7 in-person monthly meetings. Filipino American adults ≥18 years with T2D were recruited from Northern California. Feasibility was measured by rates of recruitment, engagement, and retention. Multilevel regression analyses assessed within and between group differences for the secondary outcome of percent weight change and other outcomes of weight (kg), body mass index (BMI), waist circumference, fasting plasma glucose, HbA1c, and steps. Results: A total of 45 Filipino American adults were enrolled and randomized. Mean age was 58 (SD 10) years, 62% (28/45) were women, and mean BMI was 30.1 (SD 4.6). Participant retention and study completion were 100%, with both the intervention and waitlist group achieving near-perfect attendance at all 7 intervention office visits. Groups receiving the PilAm Go4Health in phase 1 (intervention group) and phase 2 (waitlist group) had significantly greater weight loss, −2.6% (−3.9 to −1.4) and −3.3% (−1.8 to −4.8), respectively, compared with the nonintervention group, resulting in a moderate to small effect sizes (d=0.53 and 0.37, respectively). In phase 1, 18% (4/22) of the intervention group achieved a 5% weight loss, whereas 82% (18/22) maintained or lost 2% to 5% of their weight and continued to maintain this weight loss in the 3-month follow-up. Other health outcomes, including waist circumference, BMI, and step counts, improved when each arm received the PilAm Go4Health, but the fasting glucose and HbA1c outcomes were mixed. Conclusions: The PilAm Go4Health was feasible and demonstrated potential efficacy in reducing diabetes risks in overweight Filipino Americans with T2D. This study supports the use of mHealth and other promising intervention strategies to reduce obesity and diabetes risks in Filipino Americans. Further testing in a full-scale RCT is warranted. These findings may support intervention translation to reduce diabetes risks in other at-risk diverse populations. Trial Registration: NCT02290184; (Archived by WebCite at

  • Source: Pixabay; Copyright: Tesa Robbins; URL:; License: Public Domain (CC0).

    Transitional Needs of Australian Young Adults With Type 1 Diabetes: Mixed Methods Study


    Background: Young adulthood is marked by transitions that impact diabetes self-management behaviors, which require ongoing diabetes education and support. Traditional diabetes education programs and services currently do not meet the needs of many young adults with type 1 diabetes mellitus (T1DM) as they continue to fall through the cracks of clinical services. Age-centered diabetes education programs and services present an opportunity for young adults to meet in a supportive environment and gain a better understanding about diabetes management. Objective: The aim of the study was to identify the health and well-being needs of Australian young adults aged between 18 and 35 years with T1DM to develop appropriate solutions to keep them engaged with diabetes self-management. Methods: In total, 13 semistructured individual interviews and self-reported surveys were obtained to understand participants’ experiences with diabetes education programs and services. Together with survey data, transcribed interviews were analyzed into themes and categories using comparative analysis to identify the health and well-being needs of young adults with T1DM during young adulthood. Results: Diabetes education and service needs for young adults with T1DM related to improving access to existing diabetes education programs and services, having credible informational resources, as well as having personalized diabetes management advice. Participants especially valued relevant and real-time information and opportunities for peer support, mostly sourced from Web-based platforms. Conclusions: There is a need for diabetes education programs and services to be age-appropriate and easily accessible, to provide relevant and credible information, and to provide opportunities for peer support to better support young adults with T1DM. These findings also support the use of diabetes education programs or services delivered online through mHealth systems in this population.

  • Woman using the HCAI while eating a meal. Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Fully Automated Conversational Artificial Intelligence for Weight Loss: Longitudinal Observational Study Among Overweight and Obese Adults


    Background: Type 2 diabetes is the most expensive chronic disease in the United States. Two-thirds of US adults have prediabetes or are overweight and at risk for type 2 diabetes. Intensive in-person behavioral counseling can help patients lose weight and make healthy behavior changes to improve their health outcomes. However, with the shortage of health care providers and associated costs, such programs do not adequately service all patients who could benefit. The health care system needs effective and cost-effective interventions that can lead to positive health outcomes as scale. This study investigated the ability of conversational artificial intelligence (AI), in the form of a standalone, fully automated text-based mobile coaching service, to promote weight loss and other health behaviors related to diabetes prevention. This study also measured user acceptability of AI coaches as alternatives to live health care professionals. Objective: The objective of this study was to evaluate weight loss, changes in meal quality, and app acceptability among users of the Lark Weight Loss Health Coach AI (HCAI), with the overarching goal of increasing access to compassionate health care via mobile health. Lessons learned in this study can be applied when planning future clinical trials to evaluate HCAI and when designing AI to promote weight loss, healthy behavior change, and prevention and self-management of chronic diseases. Methods: This was a longitudinal observational study among overweight and obese (body mass index ≥25) participants who used HCAI, which encourages weight loss and healthy diet choices through elements of cognitive behavioral therapy. Weight loss, meal quality, physical activity, and sleep data were collected through user input and, for sleep and physical activity, partly through automatic detection by the user’s mobile phone. User engagement was assessed by duration and amount of app use. A 4-question in-app user trust survey assessed app usability and acceptability. Results: Data were analyzed for participants (N=70) who met engagement standards set forth by the Centers for Disease Control and Prevention criteria for Diabetes Prevention Program, a clinically proven weight loss program focused on preventing diabetes. Weight loss (standard error of the mean) was 2.38% (0.69%) of baseline weight. The average duration of app use was 15 (SD 1.0) weeks, and users averaged 103 sessions each. Predictors of weight loss included duration of AI use, number of counseling sessions, and number of meals logged. Percentage of healthy meals increased by 31%. The in-app user trust survey had a 100% response rate and positive results, with a satisfaction score of 87 out of 100 and net promoter score of 47. Conclusions: This study showed that use of an AI health coach is associated with weight loss comparable to in-person lifestyle interventions. It can also encourage behavior changes and have high user acceptability. Research into AI and its application in telemedicine should be pursued, with clinical trials investigating effects on weight, health behaviors, and user engagement and acceptability.

  • Source: Pixabay; Copyright: alphalight1; URL:; License: Public Domain (CC0).

    A Novel Approach to Identifying Barriers and Facilitators in Raising a Child With Type 1 Diabetes: Qualitative Analysis of Caregiver Blogs


    Background: With rising incidence of type 1 diabetes (T1D) diagnoses among children and the high levels of distress experienced by the caregivers of these children, caregiver support is becoming increasingly important. Historically, relatively few support resources have existed. Increasing use of the Internet, and blogs in particular, has seen a growth of peer support between caregivers of children with T1D. However, little is known about the type and quality of information shared on T1D caregiver blogs. At the same time, the information on such blogs offers a new window into what challenges and successes caregivers experience in helping to manage their children’s T1D. Objective: The purpose of this study was to (1) analyze blogs of caregivers to children with T1D to better understand the challenges and successes they face in raising a child with T1D, and (2) assess the blogs for the presence of unsafe or inaccurate clinical information or advice. Methods: An inductive thematic qualitative study was conducted of three blogs authored by caregivers of children living with T1D, which included 140 unique blog posts and 663 associated comments. Two physician investigators evaluated the blogs for presence of clinical or medical misinformation. Results: Five major themes emerged: (1) the impact of the child’s diagnosis, (2) the burden of intense self-management experienced in caring for a child with T1D, (3) caregivers’ use of technology to ease their fear of hypoglycemia and impacts that device alarms associated with this technology have on caregiver burden, (4) caregivers’ perceptions of frequently missed or delayed diagnosis of T1D and the frustration this causes, and (5) the resilience that caregivers develop despite the burdens they experience. Misinformation was exceedingly rare and benign when it did occur. Conclusions: Blog analysis represents a novel approach to understand the T1D caregiver’s experience. This qualitative study found many challenges that caregivers face in raising a child with T1D. Despite the many barriers caregivers face in managing their children’s T1D, they find support through advocacy efforts and peer-to-peer blogging. Blogs provide a unique avenue for support, with only rare and benign findings of medical misinformation, and may be a resource that diabetes care providers can consider offering to families for support.

  • Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Website to Promote Physical Activity in People With Type 2 Diabetes Living in Remote or Rural Locations: Feasibility Pilot Randomized Controlled Trial


    Background: Research supports the use of Web-based interventions to promote physical activity in diabetes management. However, previous interventions have found poor levels of engagement or have not included health professionals and people with diabetes in the design of the tool. Objective: To develop and explore the feasibility and indicative effect of a Web-based physical activity promotion intervention in people diagnosed with type 2 diabetes living in remote or rural locations. Methods: A qualitative approach using focus groups that included patients with diabetes and health professionals were run to identify key concepts, ideas, and features, which resulted in the design of a physical activity website. This site was tested using a quantitative approach with a qualitative 6-month pilot study that adopted a three-armed approach. Participants were randomized into three groups: a control group who received written diabetes-specific physical activity advice; an information Web group, a Web-based group who received the information online; and an intervention Web group, an interactive Web-based group who received online information plus interactive features, such as an activity log, personalized advice, and goal setting. Results: A website was designed based on patient and health professional ideas for effective physical activity promotion. This website was tested with 31 participants, 61% (19/31) male, who were randomized into the groups. Website log-ins decreased over time: 4.5 times in month 1, falling to 3 times in month 6. Both the information Web group—mean 134.6 (SD 123.9) to mean 154.9 (SD 144.2) min—and the control group—mean 118.9 (SD 103.8) to mean 126.1 (SD 93.4) min, d=0.07—increased time spent in moderate-to-vigorous physical activity, but this decreased in the intervention Web group—mean 131.9 (SD 126.2) to mean 116.8 (SD 107.4) min. Conclusions: Access to online diabetes-specific physical information was effective in promoting physical activity in people with type 2 diabetes; access to interactive features was not associated with increases in activity. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN): 96266587; (Archived by WebCite at

  • Source: iStock by Getty Images; Copyright: Pilin_Petunyia; URL:; License: Licensed by the authors.

    Functionality, Implementation, Impact, and the Role of Health Literacy in Mobile Phone Apps for Gestational Diabetes: Scoping Review


    Background: The increasing ownership of mobile phones 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 mobile phone apps are available online; however, to our knowledge, no review has documented how these apps are developed and evaluated in relation to GDM. Objective: The objective of our review was to answer the following 2 research questions: (1) What is known from the existing literature about the availability, functionality, and effectiveness of mobile phone apps on GDM prevention and management? (2) What is the role of health literacy in these apps? Methods: We searched 7 relevant electronic databases for original research documents using terms related to mobile phone apps, GDM, and health literacy. We thematically categorized selected articles using a framework adapted from Arksey and O’Malley. Results: We included 12 articles related to 7 apps or systems in the final analysis. We classified articles around 2 themes: (1) description of the development, feasibility, or usability of the apps or systems, and (2) trial protocols. The degree of personalization varied among the apps for GDM, and decision support systems can be used to generate time-efficient personalized feedback for both patients and health care 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 mobile phone apps in relation to GDM prevention and management. Mobile phone apps can provide time- and cost-efficient personalized interventions for GDM. Several randomized controlled trials have been launched recently to evaluate the effectiveness of the apps. Consideration of health literacy should be improved when developing features of the apps.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Examining the Impact of a Novel Blood Glucose Monitor With Color Range Indicator on Decision-Making in Patients With Type 1 and Type 2 Diabetes and its...


    Background: Many patients struggle to interpret and respond appropriately to the numerical blood glucose results displayed on their meter, with many regularly taking no action or self-care adjustment for out-of-range results. We recently reported that a glucose meter that provides automatic onscreen information using a color range indicator (ColorSure Technology) improved the ability of patients to categorize their blood glucose results. Objective: The objective of this study was to examine how ColorSure Technology (or color) affected patient decision making on blood glucose results and how patient numeracy levels influenced such decisions. Methods: We invited 103 subjects (56 with type 2 diabetes and 47 with type 1 diabetes) to a face-to-face in-clinic visit in a diabetes care center and showed them glucose results with or without color via interactive computer or paper logbook exercises. Before participating in these exercises, subjects completed surveys on numeracy and their understanding of blood glucose information. Results: Subjects preferentially acted on high glucose results shown with color (55%, 57/103) compared to results without color (45%, 46/103; P=.001). When shown identical pairs of results, subjects preferentially acted on results shown with color (62%, 64/103) compared to results without color (16%, 16/103) (P<.001). Subjects more accurately identified days of the week in which results were low, in range, or high when reviewing logbooks with color (83%, 85/103) than without color (68%, 70/103; P=.012). Subjects with lower numeracy were more likely to consider taking action for high glucose results shown with color (59%, 18/31) than without color (41%, 13/31) and preferentially would take action on results shown with color (71%, 22/31) compared to results without color (16%, 5/31). Conclusions: Insulin- and noninsulin-using subjects were each more inclined to act when glucose results were shown with color, and associating glucose results with color was viewed as particularly beneficial by subjects with lower numeracy.

  • Source: Shutterstock; Copyright: Monkey Business Images; URL:; License: Licensed by JMIR.

    Mutual Involvement in Families With Type 2 Diabetes Through Web-Based Health Care Solutions: Quantitative Survey Study of Family Preferences, Challenges, and...


    Background: Type 2 diabetes (T2D) is a prevalent chronic disease that affects not just patients but entire families. Both the patient and the rest of the family may benefit from gaining knowledge about the disease and from supportive interfamilial interaction. The Internet is becoming a widely-used resource for health information, so a Web-based solution could potentially promote awareness and knowledge on how to manage T2D as a family, while also providing support for the family. Objective: We aim to assess the usage of online diabetes information by patients with T2D and their relatives, and explore the families’ needs and preferences regarding online information on diabetes. Methods: A quantitative self-reported questionnaire survey was performed with Danish families that had at least one family member diagnosed with T2D. The survey consisted of 36 closed questions on demographics, usage of the Internet, preferences in the source of information, interest in online information on six problem domains within family life related to T2D, preferences towards the delivery format of online information, and peer-to-peer communication. Two open-ended questions were also included to elicit any additional comments or suggestions about improving online information on T2D regarding family life. Results: Fifty participants from 22 families with T2D answered the questionnaire individually. Relatives (25/28, 89%) and patients (22/22, 100%) indicated that information on T2D is relevant for them, while indicating that the Internet is the first or second preferred source when in need of information on T2D (25/28, 89% vs 21/22, 95%). Only a minority of the participants indicated that they had searched the Internet to gain knowledge on T2D regarding family life (9/28, 32% vs 10/22, 46%). Also, patients were more likely to have used the Internet to gain information on T2D (P=.027). Both groups indicated a preference for watching videos or reading about T2D in relation to family life while a minority of the participants indicated an interest in peer-to-peer communication. Regarding the six problem domains, the domains Support, Knowledge, and Everyday Life were slightly more popular. These three domains were considered interesting by at least 79% (22/28) and 73% (16/22) of the relatives and patients respectively, while the domains Communication, Worries, and Roles were considered interesting by at least 46% (20/28) and 50% (11/22). Conclusions: Despite an interest in online information on T2D, there appears to be an unsatisfied need for more supportive online information on T2D aimed at Danish families with T2D. Based on family preferences, online information should focus on the six problem domains and be presented through text and videos by health care practitioners and peers. Peer-to-peer communication elements may be beneficial, but are only expected to be used by a very limited number of families.

  • Diabetic foot care. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Views of Patients on Using mHealth to Monitor and Prevent Diabetic Foot Ulcers: Qualitative Study


    Background: People with diabetes are at risk for diabetic foot ulcers (DFUs), which can lead to limb loss and a significant decrease in quality of life. Evidence suggests that mHealth can be an effective tool in diabetes self-management. mHealth presents an opportunity for the prevention and monitoring of DFUs. However, there is a paucity of research that explores its effectiveness in the DFU patient population, as well as the views and attitudes of these patients toward technology and mHealth. Objective: This study aimed to explore the views, attitudes, and experiences of a diabetic patient population with or at risk of DFUs regarding technology, mHealth, and the diabetic foot. Methods: We used a qualitative research approach using in-depth interviews with 8 patients with DFUs. Questions were structured around experience with technology, current health practices related to diabetic foot care, and thoughts on using an mHealth device that prevents and monitors DFUs. We transcribed and thematically analyzed all interviews. Results: All patients had positive responses for an mHealth intervention aimed at preventing and monitoring DFUs. We found 4 themes in the data: diversity in use of technology, feet-checking habits, 2-way communication with health care professionals (HCPs), and functionality. There were varying levels of familiarity with and dependence on technology within this patient population. These relationships correlated with distinct generations found in North America, including baby boomers and Generation X. Furthermore, we found that most patients performed daily feet checks to monitor any changes in health. However, some did not perform feet checks prior to the development of a DFU. Patients expressed interest in 2-way communication with HCPs that would allow for easier appointment scheduling, sharing of medical data, decreased number of visits, and use of alerts for when medical attention is required. Patients also identified conditions of functionality for the mHealth intervention. These included consideration of debilitating complications because of diabetes, such as retinopathy and decreased mobility; ease of use of the intervention; and implementation of virtual communities to support continued use of the intervention. Conclusions: Our patient population expressed an interest in mHealth for preventing and monitoring DFUs, although some participants were not frequent users of technology. mHealth continues to show potential in improving patient outcomes, and this study provides a foundation for designing interventions specific to a DFU population. Further research is needed to confirm these findings.

  • Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    The Effect of Telehealth on Quality of Life and Psychological Outcomes Over a 12-Month Period in a Diabetes Cohort Within the Whole Systems Demonstrator...


    Background: Much is written about the promise of telehealth and there is great enthusiasm about its potential. However, many studies of telehealth do not meet orthodox quality standards and there are few studies examining quality of life in diabetes as an outcome. Objective:  To assess the impact of home-based telehealth (remote monitoring of physiological, symptom and self-care behavior data for long-term conditions) on generic and disease-specific health-related quality of life, anxiety, and depressive symptoms over 12 months in patients with diabetes. Remote monitoring provides the potential to improve quality of life, through the reassurance it provides patients. Methods: The study focused on participant-reported outcomes of patients with diabetes within the Whole Systems Demonstrator (WSD) Telehealth Questionnaire Study, nested within a pragmatic cluster-randomized trial of telehealth (the WSD Telehealth Trial), held across 3 regions of England. Telehealth was compared with usual-care, with general practice as the unit of randomization. Participant-reported outcome measures (Short-Form 12, EuroQual-5D, Diabetes Health Profile scales, Brief State-Trait Anxiety Inventory, and Centre for Epidemiological Studies Depression Scale) were collected at baseline, short-term (4 months) and long-term (12months) follow-ups. Intention-to-treat analyses testing treatment effectiveness, were conducted using multilevel models controlling for practice clustering and a range of covariates. Analyses assumed participants received their allocated treatment and were conducted for participants who completed the baseline plus at least one follow-up assessment (n=317).  Results:  Primary analyses showed differences between telehealth and usual care were small and only reached significance for 1 scale (diabetes health profile-disinhibited eating, P=.006). The magnitude of differences between trial arms did not reach the trial-defined minimal clinically important difference of 0.3 standard deviations for most outcomes. Effect sizes (Hedge's g) ranged from 0.015 to 0.143 for Generic quality of life (QoL) measures and 0.018 to 0.394 for disease specific measures. Conclusions: Second generation home-based telehealth as implemented in the WSD evaluation was not effective in the subsample of people with diabetes. Overall, telehealth did not improve or have a deleterious effect quality of life or psychological outcomes for patients with diabetes over a 12-month period.

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  • Mixed-Methods Evaluation of the Phased Implementation of a National Telehealth Weight Management Program for Veterans

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: The burden of obesity is high among U.S. veterans yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the V...

    Background: The burden of obesity is high among U.S. veterans yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE®, a home-based 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services. Objective: Our primary aims were to establish preliminary evidence for the program to engage the priority population based on the number of patients enrolled per site as well as the program’s clinical effectiveness as demonstrated by average weight lost per patient. A secondary aim was to understand factors influencing implementation variability across demonstration sites to develop recommendations to inform the national TeleMOVE dissemination. Methods: We employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE programming at nine demonstration sites and to compare patient- and site-level measures of program uptake. Data was collected between October 1, 2009 and September 30, 2012. Twenty-eight stakeholders were recruited to provide contextual details while patient-level program outcomes were extracted from VHA patient care databases. Program stakeholders were recruited to participate in two rounds of semi-structured interviews about aspects of implementation processes, site-level contextual factors, and daily program delivery. Administrative data was used to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared to outcomes for participants enrolled in standard MOVE! at each demonstration site as well as to national averages during the first two years of program implementation. Results: Program uptake was high at two sites, delayed-high at one site, low at three sites, and three late-adopting sites declined interviews. At six months post-enrollment, mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at -5.2 lb (SD=14.4) and -5.1 lb (SD=12.2), respectively (p=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging strong communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements whereas, low-uptake sites reported less leadership support and effective communication among stakeholders. Conclusions: This evaluation of the phased implementation of a new clinical telehealth program demonstrates the value of partnership-based research in which researchers not only provide operational leaders with rapid and responsive feedback regarding the effectiveness of a new clinical program but also relevant feedback into contextual factors related to implementation to enable adaptations for national rollout of the program.

  • Experiences of using web-based and mobile technologies to support self-management of type 2 diabetes: a qualitative study

    Date Submitted: Dec 29, 2017

    Open Peer Review Period: Dec 31, 2017 - Feb 25, 2018

    Background: The prevalence of type 2 diabetes is rising, placing increasing strain on healthcare services. Web-based and mobile technologies can be an important source of information and support for p...

    Background: The prevalence of type 2 diabetes is rising, placing increasing strain on healthcare services. Web-based and mobile technologies can be an important source of information and support for people with type 2 diabetes and may go some way towards reducing complications due to mismanagement. To date, little research has been carried out to gain an insight into people’s perspectives of using such technologies in their daily management. Objective: The purpose of this study is to understand the impact of using web-based and mobile technologies to support the management of type 2 diabetes. Methods: In-depth interviews were conducted with 15 people with type 2 diabetes to explore experiences of using web-based and mobile technologies to manage their diabetes. Transcripts were analyzed using the Framework method. Results: Technology supported users to maintain individualized and tailored goals when managing their health. Seven themes were identified as important to participants when using technology to support self-management: 1) Information, 2) Understanding individual health and personal data, 3) Reaching and sustaining goals, 4) Minimizing disruption to daily life, 5) Reassurance, 6) Communicating with health professionals; and 7) Co-ordinated care. Conclusions: Patients need to be supported to manage their condition to improve well-being and prevent further diabetes related complications arising. Technologies enabled users to get an in-depth sense of how their body reacted to both lifestyle and medication factors; something much more difficult with the use of traditional ‘standardized’ information alone. It is intended that the results of this study will inform a new questionnaire designed to assess self-management in people using web-based and mobile technology to manage their health.

  • Web-based interventions for depression in individuals with diabetes: a review and discussion

    Date Submitted: Dec 19, 2017

    Open Peer Review Period: Dec 20, 2017 - Feb 14, 2018

    Background: Depression is twice as common in people with diabetes. This comorbidity worsens the course of both pathologies. Screening and treatment of depression in patients with diabetes are highly r...

    Background: Depression is twice as common in people with diabetes. This comorbidity worsens the course of both pathologies. Screening and treatment of depression in patients with diabetes are highly recommended in clinical practice guidelines. However, depression is still both under recognized and undertreated. In response to the need to find ways to enhance reach, psychological treatments have taken advantage of the benefits of Internet and/or technological devices as delivery format, delivering interventions that require considerably less (or even none) interaction time with the therapist. These kinds of treatments hold promise for effective interventions at low costs with positive results. Objective: The aims of this review were to describe web-based interventions for depression in individuals with diabetes, and discuss the procedures and findings of these studies in the light of the evidence brought by a wider range of interventions for depression and/or diabetes. Methods: A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included if they met the following selection criteria: (1) the study was published in English or Spanish language peer-reviewed journals, (2) the sample of the study was composed of individuals with diabetes, (3) the intervention targeted depression symptomatology, (4) was accessible via internet, and (5) had little to none clinician support. Results: Five research studies were identified in the review. All studies were RCTs, most studies used waitlist as control. Interventions variate in their characteristics, but most of them were clinical-assisted, had a CBT approach, used diabetes-specific topics, had a weekly modular display, used homework assignments and had some kind of adherence management strategy. These characteristics are consistent with intervention features associated with positive results in the literature. The efficacy of these studies to treat depressive symptoms supports the notion that web-based format is a suitable psychology service delivery option for diabetic individuals with depression. Conclusions: Congruently with previous research on depression treatment, web-based interventions for depression in people with diabetes have positive results. Future research should bring light to the reason why these interventions are effective and for whom, and which aspects can increase patient’s adherence. Some recommendations are: (1) to compare interventions with controls that match with nonspecific factors of the intervention (2) refine depression and diabetes distress inclusion criteria and assessment, (3) study if the need of tailoring with diabetic-specific content is associated with the presence of diabetic distress, (4) include measures of glycemic control, (5) assess other psychological outcomes, moderators, use and perception of the intervention, (6) avoid possible recruitment bias, (7) identify effective adherence management techniques and persuasive features, (8) detect which contents of the interventions are more effective, and (9) study the benefits of including peer support.