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Journal Description

JMIR Diabetes (JD, Editor-in-Chief: Caroline Richardson) is a Pubmed journal of JMIR the leading open-access journal in health informatics. JMIR Diabetes focuses 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 JD is 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 prevention and 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.


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    Mobile Clinical Decision Support System for the Management of Diabetic Patients With Kidney Complications in UK Primary Care Settings: Mixed Methods...


    Background: Attempts to utilize eHealth in diabetes mellitus (DM) management have shown promising outcomes, mostly targeted at patients; however, few solutions have been designed for health care providers. Objective: The purpose of this study was to conduct a feasibility project developing and evaluating a mobile clinical decision support system (CDSS) tool exclusively for health care providers to manage chronic kidney disease (CKD) in patients with DM. Methods: The design process was based on the 3 key stages of the user-centered design framework. First, an exploratory qualitative study collected the experiences and views of DM specialist nurses regarding the use of mobile apps in clinical practice. Second, a CDSS tool was developed for the management of patients with DM and CKD. Finally, a randomized controlled trial examined the acceptability and impact of the tool. Results: We interviewed 15 DM specialist nurses. DM specialist nurses were not currently using eHealth solutions in their clinical practice, while most nurses were not even aware of existing medical apps. However, they appreciated the potential benefits that apps may bring to their clinical practice. Taking into consideration the needs and preferences of end users, a new mobile CDSS app, “Diabetes & CKD,” was developed based on guidelines. We recruited 39 junior foundation year 1 doctors (44% male) to evaluate the app. Of them, 44% (17/39) were allocated to the intervention group, and 56% (22/39) were allocated to the control group. There was no significant difference in scores (maximum score=13) assessing the management decisions between the app and paper-based version of the app’s algorithm (intervention group: mean 7.24 points, SD 2.46 points; control group: mean 7.39, SD 2.56; t37=–0.19, P=.85). However, 82% (14/17) of the participants were satisfied with using the app. Conclusions: The findings will guide the design of future CDSS apps for the management of DM, aiming to help health care providers with a personalized approach depending on patients’ comorbidities, specifically CKD, in accordance with guidelines.

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    Secondary Impact of Social Media via Text Message Screening for Type 2 Diabetes Risk in Kuwait: Survey Study


    Background: Type 2 diabetes mellitus (T2DM) is an international problem of alarming epidemic proportions. T2DM can develop due to multiple factors, and it usually begins with prediabetes. Fortunately, this disease can be prevented by following a healthy lifestyle. However, many health care systems fail to properly educate the public on disease prevention and to offer support in embracing behavioral interventions to prevent diabetes. SMS messaging has been combined with cost-effective ways to reach out to the population at risk for medical comorbidities. To our knowledge, the use of nationwide SMS messaging in the Middle East as a screening tool to identify individuals who might be at risk of developing T2DM has not been reported in the literature. Objective: The primary aim of this study was to assess the feasibility of conducting a series of SMS messaging campaigns directed at random smartphone users in Kuwait for the detection and prevention of T2DM. It was predicted that 1% of those receiving the text message would find it relevant and participate in the study. The secondary aim of this study was to assess the incidence of participation of those who were forwarded the initial text message by family members and friends. Methods: In this study, 5 separate text message screening campaigns were launched inviting recipients to answer 6 questions to determine the risk of developing T2DM. If subjects agreed to participate, a link to the prediabetes screening test devised by the Centers for Disease Control and Prevention was automatically transmitted to their mobile devices. Those identified as high risk were invited to participate in a diabetes prevention program. Results: A total of 180,000 SMSs were sent to approximately 6% of the adult population in Kuwait. Of these, 0.14% (260/180,000) of the individuals who received the SMS agreed to participate, of whom 58.8% (153/260) completed the screening. Surprisingly, additional surveys were completed by 367 individuals who were invited via circulated SMS messages forwarded by family members and friends. Altogether, 23.3% (121/520) qualified and agreed to participate in a diabetes prevention program. The majority of those who chose to participate in the prevention program were overweight, aged 45-65 years, and reported being less physically active than those who chose not to participate (χ22=42.1, P<.001). Conclusions: Although health care screening via text messaging was found to have limited effectiveness by itself, it exhibited increased reach through shared second-party social media messaging. Despite the fact a subpopulation at possible risk of developing T2DM could be reached via text messaging, most responders were informed about the screening campaign by family and friends. Future research should be designed to tap into the benefits of social media use in health risk campaigns.

  • An iPhone image showing the main panel of the Diabits app. Source: Image created by the Authors; Copyright: Bio Conscious Technologies, Inc; URL:; License: Creative Commons Attribution (CC-BY).

    The Diabits App for Smartphone-Assisted Predictive Monitoring of Glycemia in Patients With Diabetes: Retrospective Observational Study


    Background: Diabetes mellitus, which causes dysregulation of blood glucose in humans, is a major public health challenge. Patients with diabetes must monitor their glycemic levels to keep them in a healthy range. This task is made easier by using continuous glucose monitoring (CGM) devices and relaying their output to smartphone apps, thus providing users with real-time information on their glycemic fluctuations and possibly predicting future trends. Objective: This study aims to discuss various challenges of predictive monitoring of glycemia and examines the accuracy and blood glucose control effects of Diabits, a smartphone app that helps patients with diabetes monitor and manage their blood glucose levels in real time. Methods: Using data from CGM devices and user input, Diabits applies machine learning techniques to create personalized patient models and predict blood glucose fluctuations up to 60 min in advance. These predictions give patients an opportunity to take pre-emptive action to maintain their blood glucose values within the reference range. In this retrospective observational cohort study, the predictive accuracy of Diabits and the correlation between daily use of the app and blood glucose control metrics were examined based on real app users’ data. Moreover, the accuracy of predictions on the 2018 Ohio T1DM (type 1 diabetes mellitus) data set was calculated and compared against other published results. Results: On the basis of more than 6.8 million data points, 30-min Diabits predictions evaluated using Parkes Error Grid were found to be 86.89% (5,963,930/6,864,130) clinically accurate (zone A) and 99.56% (6,833,625/6,864,130) clinically acceptable (zones A and B), whereas 60-min predictions were 70.56% (4,843,605/6,864,130) clinically accurate and 97.49% (6,692,165/6,864,130) clinically acceptable. By analyzing daily use statistics and CGM data for the 280 most long-standing users of Diabits, it was established that under free-living conditions, many common blood glucose control metrics improved with increased frequency of app use. For instance, the average blood glucose for the days these users did not interact with the app was 154.0 (SD 47.2) mg/dL, with 67.52% of the time spent in the healthy 70 to 180 mg/dL range. For days with 10 or more Diabits sessions, the average blood glucose decreased to 141.6 (SD 42.0) mg/dL (P<.001), whereas the time in euglycemic range increased to 74.28% (P<.001). On the Ohio T1DM data set of 6 patients with type 1 diabetes, 30-min predictions of the base Diabits model had an average root mean square error of 18.68 (SD 2.19) mg/dL, which is an improvement over the published state-of-the-art results for this data set. Conclusions: Diabits accurately predicts future glycemic fluctuations, potentially making it easier for patients with diabetes to maintain their blood glucose in the reference range. Furthermore, an improvement in glucose control was observed on days with more frequent Diabits use. Trial Registration:

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    Facebook as a Medium for the Support and Enhancement of Ambulatory Care for People With Diabetes: Qualitative Realist Evaluation of a Real-World Trial


    Background: There is a growing focus on the potential uses, benefits, and limitations of social media in the context of health care communication. In this study, we have sought to evaluate an initiative pioneered at a hospital in Denmark that uses Facebook to support and enhance patient-provider communication about diabetes. Objective: This paper aims to evaluate the success of the trial according to its initial objectives and to assess its potential scalability. Methods: The study was undertaken in a clinic for diabetes and hormonal diseases at a large regional hospital in Denmark. Using a realist evaluation approach, we identified 4 key components in the program theory of the initiative, which we formulated as context-mechanism-outcome configurations (eg, complex and iterative chains of causality). These configurations informed data gathering and analysis. Primary data sources were the activity and content in the Facebook group, in the form of posts, likes, and comments, and interviews with patients (n=26) and staff (n=6) at the clinic. Results: New developments in diabetes technology were the most popular posts in the forum, judged by number of likes and comments. Otherwise, information specific to the clinic received the most attention. All 4 components of the program theory were compromised to varying degrees, either as a result of failings in the anticipated mechanisms of change or contextual factors derived from the mode of implementation. Conclusions: Social media serves well as a conduit for imagining positive change, but this can be a strength and weakness when attempting to enact change via concrete interventions, where stakeholder expectations may be unreasonably high or incompatible. Nonetheless, such initiatives may possess intangible benefits difficult to measure in terms of cost-effectiveness.

  • Image of examples of possible foods from a very low-carbohydrate, ketogenic diet. Source:; Copyright: ThitareeSarmkasat; URL:; License: Licensed by the authors.

    Intervention Enhancement Strategies Among Adults With Type 2 Diabetes in a Very Low–Carbohydrate Web-Based Program: Evaluating the Impact With a Randomized...


    Background: Adults with type 2 diabetes may experience health benefits, including glycemic control and weight loss, from following a very low–carbohydrate, ketogenic (VLC) diet. However, it is unclear which ancillary strategies may enhance these effects. Objective: This pilot study aims to estimate the effect sizes of 3 intervention enhancement strategies (text messages, gifts, and breath vs urine ketone self-monitoring) that may improve outcomes of a 12-month web-based ad libitum VLC diet and lifestyle intervention for adults with type 2 diabetes. The primary intervention also included other components to improve adherence and well-being, including positive affect and mindfulness as well as coaching. Methods: Overweight or obese adults (n=44; BMI 25-45 kg/m2) with type 2 diabetes (glycated hemoglobin [HbA1c] ≥6.5%), who had been prescribed either no glucose-lowering medications or metformin alone, participated in a 12-month web-based intervention. Using a 2×2×2 randomized factorial design, we compared 3 enhancement strategies: (1) near-daily text messages about the intervention’s recommended behaviors (texts n=22 vs no texts n=22), (2) mailed gifts of diet-relevant foods and cookbooks (6 rounds of mailed gifts n=21 vs no gifts n=23), and (3) urine- or breath-based ketone self-monitoring (urine n=21 vs breath n=23). We assessed HbA1c and weight at baseline and at 4, 8, and 12 months. We evaluated whether each strategy exerted a differential impact on HbA1c and weight at 12 months against an a priori threshold of Cohen d of 0.5 or greater. Results: We retained 73% (32/44) of the participants at 12 months. The intervention, across all conditions, led to improvements in glucose control and reductions in body weight at the 12-month follow-up. In intent-to-treat (ITT) analyses, the mean HbA1c reduction was 1.0% (SD 1.6) and the mean weight reduction was 5.3% (SD 6.0), whereas among study completers, these reductions were 1.2% (SD 1.7) and 6.3% (SD 6.4), respectively, all with a P value of less than .001. In ITT analyses, no enhancement strategy met the effect size threshold. Considering only study completers, 2 strategies showed a differential effect size of at least a d value of 0.5 or greater Conclusions: Text messages, gifts of food and cookbooks, and urine-based ketone self-monitoring may potentially enhance the glycemic or weight loss benefits of a web-based VLC diet and lifestyle intervention for individuals with type 2 diabetes. Future research could investigate other enhancement strategies to help create even more effective solutions for the treatment of type 2 diabetes. Trial Registration: NCT02676648;

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    Technology-Assisted Self-Monitoring of Lifestyle Behaviors and Health Indicators in Diabetes: Qualitative Study


    Background: Self-monitoring is key to successful behavior change in diabetes and obesity, and the use of traditional paper-based methods of self-monitoring may be time-consuming and burdensome. Objective: This study aimed to explore participant experiences while using technology-assisted self-monitoring of lifestyle behaviors and health indicators among overweight or obese adults with type 2 diabetes. Methods: Qualitative data collected from the intervention group of a 6-month, three-arm (control, paper diary, and technology-assisted self-monitoring groups) randomized clinical trial were analyzed. Study participants in the intervention group monitored their diet, exercise, and weight using the LoseIt! app, and their blood glucose levels using a glucometer and the Diabetes Connect app. Semistructured group discussions were conducted at 6 weeks (n=10) from the initiation of the behavioral lifestyle intervention and again at 6 months (n=9). All group interviews were audiotaped and transcribed verbatim. Using a combination of thematic and comparative analysis approaches, two trained professionals coded the transcriptions independently and then discussed and concluded common themes for the 6-week and 6-month discussions separately. Results: The sample (n=10), which primarily involved African American participants (n=7) and female participants (n=8), had a mean age of 59.4 years. The following eight themes emerged: (1) perceived benefits of technology-assisted self-monitoring; (2) perceived ease of use (eg, barriers: technical difficulties and lack of self-discipline; facilitators: help from family, friends, and the program); (3) use of technology-assisted self-monitoring; (4) facilitators of engaging in healthy lifestyle behaviors (eg, visualization and awareness of calorie input/expenditure); (5) positive lifestyle change; (6) barriers of engaging in healthy lifestyle behaviors (eg, event influence); (7) learning curve; and (8) monitored data sharing. The first six of these themes were shared between the 6-week and 6-month timepoints, but the codes within these themes were not all the same and differed slightly between the two timepoints. These differences provide insights into the evolution of participant thoughts and perceptions on using technology for self-monitoring and subsequent behavioral lifestyle changes while participating in lifestyle interventions. The findings from the 6-week and 6-month data helped to paint a picture of participant comfort and the integration of technology and knowledge overtime, and clarified participant attitudes, difficulties, behavioral processes, and modifications, as well as health indicators that were experienced throughout the study. Conclusions: Although there were some barriers, participants were able to identify various individual and external facilitators to adjust to and engage in technology-assisted self-monitoring, and it was concluded that the technology-assisted self-monitoring approach was beneficial, safe, and feasible to use for positive lifestyle change. These patient perspectives need to be considered in future research studies when investigating the effectiveness of using technology-assisted self-monitoring, as well as in clinical practice when recommending technology-assisted self-monitoring of lifestyle behaviors and health indicators to improve health outcomes.

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    Internet-Based Lifestyle Intervention to Prevent Type 2 Diabetes Through Healthy Habits: Design and 6-Month Usage Results of Randomized Controlled Trial


    Background: Type 2 diabetes can be prevented through lifestyle changes, but sustainable and scalable lifestyle interventions are still lacking. Habit-based approaches offer an opportunity to induce long-term behavior changes. Objective: The purposes of this study were to describe an internet-based lifestyle intervention for people at risk for type 2 diabetes targeted to support formation of healthy habits and explore its user engagement during the first 6 months of a randomized controlled trial (RCT). Methods: The app provides an online store that offers more than 400 simple and contextualized habit-forming behavioral suggestions triggered by daily life activities. Users can browse, inspect, and select them; report their performances; and reflect on their own activities. Users can also get reminders, information on other users’ activities, and information on the prevention of type 2 diabetes. An unblended parallel RCT was carried out to evaluate the effectiveness of the app in comparison with routine care. User engagement is reported for the first 6 months of the trial based on the use log data of the participants, who were 18- to 70-year-old community-dwelling adults at an increased risk of type 2 diabetes. Results: Of 3271 participants recruited online, 2909 were eligible to participate in the RCT. Participants were randomized using a computerized randomization system to the control group (n=971), internet-based intervention (digital, n=967), and internet-based intervention with face-to-face group coaching (F2F+digital, n=971). Mean age of control group participants was 55.0 years, digital group 55.2 years, and F2F+digital 55.2 years. The majority of participants were female, 81.1% (787/971) in the control group, 78.3% (757/967) in the digital group, and 80.7% (784/971) in the F2F+digital group. Of the participants allocated to the digital and F2F+digital groups, 99.53% (1929/1938) logged in to the app at least once, 98.55% (1901/1938) selected at least one habit, and 95.13% (1835/1938) reported at least one habit performance. The app was mostly used on a weekly basis. During the first 6 months, the number of active users on a weekly level varied from 93.05% (1795/1929) on week 1 to 51.79% (999/1929) on week 26. The daily use activity was not as high. The digital and F2F+digital groups used the app on a median of 23.0 and 24.5 days and for 79.4 and 85.1 minutes total duration, respectively. A total of 1,089,555 habit performances were reported during the first 6 months. There were no significant differences in the use metrics between the groups with regard to cumulative use metrics. Conclusions: Results demonstrate that internet-based lifestyle interventions can be delivered to large groups including community-dwelling middle-aged and older adults, many with limited experience in digital app use, without additional user training. This intermediate analysis of use behavior showed relatively good engagement, with the percentage of active weekly users remaining over 50% at 6 months. However, we do not yet know if the weekly engagement was enough to change the lifestyles of the participants. Trial Registration: NCT03156478;

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    Evaluation of a Text Messaging Intervention to Support Self-Management of Diabetes During Pregnancy Among Low-Income, Minority Women: Qualitative Study


    Background: Given the growing burden of diabetes in underserved communities and the complexity of diabetes self-management during pregnancy, the development of interventions to support low-income pregnant women with diabetes is urgently needed. Objective: This study aims to develop and pilot test a theory-driven curriculum of SMS text messaging for diabetes support and education during pregnancy. Methods: This was a prospective pilot investigation of a novel SMS text messaging intervention offered to pregnant women with pregestational or gestational diabetes mellitus and publicly funded prenatal care. Prior work yielded a conceptual model of diabetes self-management barriers and support factors in this population, which was used to guide curriculum development along with health behavior theories. Participants received three supportive or educational one-way text messages per week during pregnancy. In-depth semistructured interviews were performed at study exit to solicit feedback on the program. Narrative data were analyzed using the constant comparative technique to identify themes and subthemes. Results: Participants (N=31 enrolled and n=26 completed both interviews) consistently reported that SMS text messaging provided enhanced motivation for diabetes self-care, reduced diabetes-related social isolation, increased perceived diabetes-associated knowledge, enhanced comfort with the health care team, and reduced logistical burdens of diabetes during pregnancy. Participants requested enhanced interactive and customizable features in future intervention iterations. Conclusions: Pregnant women with diabetes who were enrolled in this pilot study of an SMS text messaging curriculum for diabetes support described enhanced motivation, knowledge, and comfort with diabetes self-care activities as a result of the health education intervention. The next steps include enriching the interactive features of the intervention and investigating the effect of the intervention on perinatal outcomes.

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    Changes in Patient-Reported Outcome Measures With a Technology-Supported Behavioral Lifestyle Intervention Among Patients With Type 2 Diabetes: Pilot...


    Background: In the United States, more than one-third of the adult population is obese, and approximately 25.2% of those aged ≥65 years have type 2 diabetes (T2D), which is the seventh leading cause of death. It is important to measure patient-reported outcomes and monitor progress or challenges over time when managing T2D to understand patients’ perception of health and quantify the impact of disease processes or intervention effects. The evaluation of patient-reported outcome measures (PROMs) is especially important among patients with multiple chronic conditions in which clinical measures do not provide a complete picture of health. Objective: This study examined the feasibility of collecting Patient-Reported Outcome Measurement Information System (PROMIS) measures, and preliminarily evaluated changes in PROMIS scores and compared the scores with standard scores of the general US population. The parent study is a pilot randomized controlled clinical trial testing three different modes (mobile health [mHealth], paper diary, and control) of self-monitoring in a behavioral lifestyle intervention among overweight or obese patients with T2D. Methods: Patients with comorbid overweight or obesity and a diagnosis of T2D for at least 6 months were recruited from a diabetes education program. Participants were randomized to the following three groups: mHealth, paper diary, and control (standard of care) groups. Paper diary and mHealth experimental groups received additional behavioral lifestyle intervention education sessions, as well as tools to self-monitor weight, physical activity, diet, and blood glucose. All participants completed PROMIS-57 and PROMIS-Global Health (GH) version 1.0 questionnaires during visits at baseline, 3 months, and 6 months. The PROMIS-57 includes the following seven domains: anxiety, depression, fatigue, pain interference, physical function, satisfaction with participation in social roles, and sleep disturbance. The PROMIS-GH is composed of the following two domains: global mental health and global physical health. Results: A total of 26 patients (mHealth, 11; paper diary, 9; control, 6) were included in our analysis. The study sample was predominantly African American (68%) and female (57%), with a mean age of 54.7 years and a mean BMI of 37.5 kg/m2. All patients completed the PROMIS-57 and PROMIS-GH questionnaires, and we compared the mean scores of the three groups to investigate potential differences. No relevant differences were noted across the groups. However, positive trends were noted in both intervention (mHealth and paper diary) groups in the middle (month 3) and end (month 6) of the study. Conclusions: Our pilot study provides evidence for the feasibility of using PROMIS questionnaires to record important components of T2D-related symptoms among overweight or obese individuals. The results from our study support the use of PROMIS questionnaires to provide clinicians and researchers with a benchmark for assessing the overall need for symptom management and determining the success or challenges of an intervention. Clinical Trial: NCT02858648;

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    User Experiences With a Type 2 Diabetes Coaching App: Qualitative Study


    Background: Diabetes self-management apps have the potential to improve self-management in people with type 2 diabetes (T2D). Although efficacy trials provide evidence of health benefits, premature disengagement from apps is common. Therefore, it is important to understand the factors that influence engagement in real-world settings. Objective: This study aims to explore users’ real-world experiences with the My Diabetes Coach (MDC) self-management app. Methods: We conducted telephone-based interviews with participants who had accessed the MDC self-management app via their smartphone for up to 12 months. Interviews focused on user characteristics; the context within which the app was used; barriers and facilitators of app use; and the design, content, and delivery of support within the app. Results: A total of 19 adults with T2D (8/19, 42% women; mean age 60, SD 14 years) were interviewed. Of the 19 interviewees, 8 (42%) had T2D for <5 years, 42% (n=8) had T2D for 5-10 years, and 16% (n=3) had T2D for >10 years. In total, 2 themes were constructed from interview data: (1) the moderating effect of diabetes self-management styles on needs, preferences, and expectations and (2) factors influencing users’ engagement with the app: one size does not fit all. Conclusions: User characteristics, the context of use, and features of the app interact and influence engagement. Promoting engagement is vital if diabetes self-management apps are to become a useful complement to clinical care in supporting optimal self-management. Trial Registration: Australia New Zealand Clinical Trials Registry CTRN126140012296; URL

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    Web-Based and mHealth Technologies to Support Self-Management in People Living With Type 2 Diabetes: Validation of the Diabetes Self-Management and...


    Background: A growing number of web-based and mobile health (mHealth) technologies have been developed to support type 2 diabetes self-management. Little is known about individuals’ experiences with these technologies and how they support self-management. Appropriate tools are needed to understand how web-based and mHealth interventions may impact self-management. Objective: This study aimed to develop an instrument, the Diabetes Self-Management and Technology Questionnaire (DSMT-Q), to assess self-management among people living with type 2 diabetes who use web-based and mHealth technologies. Methods: A total of 36 candidate questionnaire items, drafted previously, were refined using cognitive debriefing interviews (n=8), expert consultation, and public patient involvement feedback. Item reduction steps were performed on survey data (n=250), and tests of validity and reliability were subsequently performed. Results: Following amendments, patients and experts found 21 items relevant and acceptable for inclusion in the instrument. Survey participants included 104 (41.6%) women and 146 (58.4%) men. Two subscales with high construct validity, internal consistency, and test-retest reliability were identified: “Understanding individual health and making informed decisions” and “Confidence to reach and sustain goals.” Conclusions: Analyses confirmed good psychometric properties in the DSMT-Q scales. This tool will facilitate the measurement of self-management in people living with type 2 diabetes who use web-based or mHealth technologies.

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    Diabetes Management Experience and the State of Hypoglycemia: National Online Survey Study


    Background: Hypoglycemia, or low blood sugar levels, in people with diabetes can be a serious life-threatening condition, and serious outcomes can be avoided if low levels of blood sugar are proactively detected. Although technologies exist to detect the onset of hypoglycemia, they are invasive or costly or exhibit a high incidence of false alarms. Tremors are commonly reported symptoms of hypoglycemia and may be used to detect hypoglycemic events, yet their onset is not well researched or understood. Objective: This study aimed to understand diabetic patients’ perceptions of hypoglycemic tremors, as well as their user experiences with technology to manage diabetes, and expectations from a self-management tool to ultimately inform the design of a noninvasive and cost-effective technology that detects tremors associated with hypoglycemia. Methods: A cross-sectional internet panel survey was administered to adult patients with type 1 diabetes using the Qualtrics platform in May 2019. The questions focused on 3 main constructs: (1) perceived experiences of hypoglycemia, (2) experiences and expectations about a diabetes management device and mobile app, and (3) beliefs and attitudes regarding intention to use a diabetes management device. The analysis in this paper focuses on the first two constructs. Nonparametric tests were used to analyze the Likert scale data, with a Mann-Whitney U test, Kruskal-Wallis test, and Games-Howell post hoc test as applicable, for subgroup comparisons to highlight differences in perceived frequency, severity, and noticeability of hypoglycemic tremors across age, gender, years living with diabetes, and physical activity. Results: Data from 212 respondents (129 [60.8%] females) revealed statistically significant differences in perceived noticeability of tremors by gender, whereby males noticed their tremors more (P<.001), and age, with the older population reporting lower noticeability than the young and middle age groups (P<.001). Individuals living longer with diabetes noticed their tremors significantly less than those with diabetes for ≤1 year but not in terms of frequency or severity. Additionally, the majority of our participants (150/212, 70.7%) reported experience with diabetes-monitoring devices. Conclusions: Our findings support the need for cost-efficient and noninvasive continuous monitoring technologies. Although hypoglycemic tremors were perceived to occur frequently, such tremors were not found to be severe compared with other symptoms such as sweating, which was the highest rated symptom in our study. Using a combination of tremor and galvanic skin response sensors may show promise in detecting the onset of hypoglycemic events.

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