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JMIR Diabetes
Emerging technologies, medical devices, apps, sensors, and informatics to help people with diabetes
(Toronto, Jul 16th, 2018) We are pleased to report that JMIR Diabetes (JD) has been accepted for indexing in PubMed Central and PubMed. The acceptance is the result of a rigorous scientific and technical evaluation by the US National Library's (NLM’s) Library Operations Division, which decided that the scientific and editorial character and quality of a JMIR Diabetes merits its inclusion in PMC. In making this decision NLM has considered the suitability of the journal for the NLM collection as well as the opinions of expert consultants.
JMIR Diabetes (JD, Editor-in-Chief: Caroline Richardson) is a Pubmed-indexed sister journal of JMIR (the leading open-access journal in health informatics (Impact Factor 2018: 4.945). 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.
Background: The prevalence of type 2 diabetes mellitus (T2DM) and obesity is increasing, and the way people interact with health care is evolving. People traditionally access advice and support to improve their lifestyle and learn more about the self-management of T2DM in a face-to-face setting. Although these services have a strong evidence base, they have limitations for reaching specific groups of people. Digital programs could provide a new delivery model to help more people access health education and behavior change support, but long-term data supporting these programs are limited.
Objective: The purpose of this service evaluation was to analyze the weight change of people who participated in OurPath (also known as Second Nature), a UK-based digital lifestyle change program, for either weight management or diabetes-related weight management and structured education at 6 and 12 months.
Methods: Participants either paid to access the program privately (self-funded clients) or were referred by their general practitioner to participate in the program free of charge (funded by the National Health Service). Additional follow-up support was provided to help people to maintain lifestyle changes. To retrospectively assess potential weight loss, the analysis included data from participants who submitted weight readings at baseline and 6 and 12 months after starting the program. Changes in weight after 6 and 12 months were primary outcome measures.
Results: For the 896 participants who submitted baseline and 6- and 12-month data, a significant change in mean weight of −7.12 kg (−7.50%; SD 6.37; P<.001) was observed at 6 months. Data from the same participants at 12 months showed a change in mean weight when compared with a baseline of −6.14 kg (−6.48%; SD 6.97; P<.001).
Conclusions: The data presented here had several limitations, and there were too many uncertainties to make any reliable conclusions. However, these results suggest that digital lifestyle change programs could provide a new way to help people to access nutritional advice and support to achieve weight loss. Further research into digital education and coaching platforms is needed to establish their effectiveness.
Background: Structured education for people with type 2 diabetes improves outcomes, but uptake is low globally. In the United Kingdom in 2016, only 8.3% of people who were referred to education programs attended the program. We have developed a Web-based structured education program named Healthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO), as an alternative to face-to-face courses. A Web-based program gives people more options for accessing structured education and may help improve overall uptake.
Objective: The aim was to explore the feasibility and acceptability of delivering a Web-based structured education program (named HeLP-Diabetes: Starting Out) in routine primary health care and its potential impact on self-efficacy and diabetes-related distress.
Methods: HDSO was delivered as part of routine diabetes services in primary health care in the United Kingdom, having been commissioned by local Clinical Commissioning Groups. Quantitative data were collected on uptake, use of the program, demographic characteristics, self-reported self-efficacy, and diabetes-related distress. A subsample of people with type 2 diabetes and health care professionals were interviewed about acceptability of the program.
Results: It was feasible to deliver the program, but completion rates were low: of 791 people with type 2 diabetes registered, only 74 (9.0%) completed it. Completers improved their self-efficacy (change in median score 2.5, P=.001) and diabetes-related distress (change in median score 6.0, P=.001). Interview data suggested that the course was acceptable, and that uptake and completion may be related to nonprioritization of structured education.
Conclusions: The study provides evidence of the feasibility and acceptability of a Web-based structured education. However, uptake and completion rates were low, limiting potential population impact. Further research is needed to improve completion rates, and to determine the relative effectiveness of Web-based versus face-to-face education.
Background: Women with gestational diabetes mellitus (GDM) require regular follow-ups and overall management to normalize maternal blood glucose and improve pregnancy outcomes. With the advancements made in the digital field, telemedicine is gaining popularity over traditional health care approaches in different medical fields. As for GDM, telemonitoring solutions seem to improve women’s quality of life and enhance self-management.
Objective: The aim of this study is to understand, from patients’ and health care professionals’ (HCPs) perspectives, what drives the adoption and diffusion of a telemonitoring solution (myDiabby) in a context where telemonitoring activities are still not compensated like traditional follow-ups.
Methods: The study was conducted in 12 diabetes services in France using myDiabby for monitoring and managing patients with GDM. A qualitative research approach was adopted for collecting and analyzing data. A total of 20 semistructured interviews were conducted with HCPs working in different health structures in France, and 15 semistructured interviews were conducted with patients who had been using myDiabby. Data were analyzed using a thematic analysis approach.
Results: Different determinants need to be taken into consideration when adopting an innovative health technology. By drawing on the diffusion of innovation theory, a set of factors associated with the technology (the relative advantages, compatibility, ease of use, testability, and observability of the telemedicine platform) has been identified as affecting the adoption and diffusion of telemonitoring solutions in French diabetes services. In addition, data analysis shows a set of environmental factors (the demographic situation of HCPs, the health care access in rural communities, and the economic and political context in France) that also influences the spread and adoption of telemonitoring systems in French hospitals.
Conclusions: Even though telemonitoring activities are still not remunerated as traditional follow-ups, many French HCPs support and encourage the adoption of telemonitoring systems in GDM. As for patients, telemonitoring systems are perceived as a useful and easy way to monitor their GDM. This study contributes to recognizing the value of telemonitoring interventions in managing GDM and considering the expansion of telemonitoring to other chronic conditions.
Background: Diabetes is a global epidemic affecting approximately 30 million people in the United States. The World Health Organization recommends using technology and telecommunications to improve health care delivery and disease management. The Livongo for Diabetes Program offers a remote monitoring technology with Certified Diabetes Educator outreach. Objective: The purpose of this study was to examine health outcomes measured by changes in HbA1c, time in target blood glucose range, and depression symptoms for patients enrolled in a remote digital diabetes management program in a Diabetes Center of Excellence setting. Methods: The impact of the Livongo for Diabetes Program on Hemoglobin A1c (HbA1c), blood glucose ranges, and depression screening survey results (Patient Health Questionnaire-2) were assessed over 12 months in a prospective cohort recruited from the University of South Florida Health Diabetes Home for Healthy Living. Any patient >18 years old with a diagnosis of diabetes was approached for voluntary inclusion into the program. The analysis was a pre-post design for those members enrolled in the study. Data was collected at outpatient clinic visits and remotely through the Livongo glucose meter. Results: A total of 86 adults were enrolled into the Livongo for Diabetes program, with 49% (42/86) female, an average age of 50 (SD 15) years, 56% (48/86) with type 2 diabetes mellitus, and 69% (59/86) with insulin use. The mean HbA1c drop amongst the group was 0.66% (P=.17), with all participants showing a decline in HbA1c at 12 months. A 17% decrease of blood glucose checks <70 mg/dL occurred concurrently. Participants with type 2 diabetes not using insulin had blood glucose values within target range (70-180 mg/dL) 89% of the time. Participants with type 2 diabetes using insulin were in target range 68% of the time, and type 1 diabetes 58% of the time. Average PHQ-2 scores decreased by 0.56 points during the study period. Conclusions: Participants provided with a cellular-enabled blood glucose meter with real-time feedback and access to coaching from a certified diabetes educator in an outpatient clinical setting experienced improved mean glucose values and fewer episodes of hypoglycemia relative to the start of the program.
Background: Developing countries are experiencing a shift from infectious diseases such as HIV and tuberculosis to noncommunicable diseases (NCDs) such as diabetes. Diabetes accounts for more disability-adjusted life years than any other NCD in South Africa, and research has identified a number of preventable risk factors; however, there is not enough evidence from lower resource settings as to how best to disseminate this information to the population. Today, 90% of the world’s population lives in mobile phone coverage areas, and this provides a unique opportunity to reach large populations with health information. Objective: This study aimed to investigate how potential mobile health (mHealth) platforms should be paired with diabetes risk factor education so that at-risk communities are empowered with information to prevent and manage diabetes. Methods: A Likert-style survey was distributed to commuters in the City of Johannesburg in July 2018 that explored participants’ background characteristics as well as their knowledge and awareness surrounding diabetic risk factors (such as exercise, smoking, and hypertension) and their comfort level with various information delivery methods (such as WhatsApp, short message service, and email). The grouped variables from diabetic risk factors and information delivery methods were described with mean Likert scores and then investigated for relationships with Spearman Rho correlation coefficients. Results: Background characteristics revealed that the self-reported prevalence of diabetes was twice as high in this studied commuter population than the national average. WhatsApp was the most favorable mHealth information delivery method and had a moderate correlation coefficient with diet and nutrition (0.338; P<.001) as well as a weaker correlation with physical activity (0.243; P<.001). Although not as robust as the WhatsApp correlations, each of the other information delivery methods also showed weaker, yet statistically significant, relationships with one or more of the risk factors. Conclusions: The elevated self-reported diabetes prevalence reinforces the need for diabetes risk factor education in the studied commuter population of Johannesburg. The most feasible mHealth intervention for diabetic risk factor education should focus on WhatsApp messaging while also offering content across other mHealth and traditional platforms to remove barriers to access and enhance the user experience. The content should emphasize diet and nutrition as well as physical activity while also incorporating information on secondary risk factors.
Background: Self-management is a substantial part of treatment for patients with type 2 diabetes (T2D). Modern digital technology, being small, available, and ubiquitous, might work well in supporting self-management. This study follows the process of developing a pilot implementation of an electronic health (eHealth) service for T2D self-management support in primary health care. The use of digital health, or eHealth, solutions for supporting self-management for patients with T2D is increasing. There are good examples of successful implementations that can serve as guides in the development of new solutions. However, when adding person-centered principles as a requirement, the examples are scarce. Objective: The objective of this study was to explore challenges that could impact the design of a person-centered eHealth service for T2D self-management support. The study included data collection from multiple sources, that is, interviews, observations, focus groups, and a Mentimeter (interactive presentation with polling) survey among stakeholders, representing various perspectives of T2D. Methods: A user-centered design approach was used to exploratively collect data from different sources. Data were collected from a workshop, interviews, and observations. The different data sources enabled a triangulation of data. Results: Results show that user needs related to an eHealth service for person-centered T2D self-management support are multifaceted and situated in a complex context. The two main user groups, patients and diabetes specialist nurses, express needs that both diverge and converge, which indicates that critical design decisions have to be made. There is also a discrepancy between the needs expressed by the potential users and the current work practice, suggesting more attention toward changing the organization of work to fully support a new eHealth service. Conclusions: A total of three overarching challenges—flexible access, reducing administrative tasks, and patient empowerment—each having a significant impact on design, are discussed. These challenges need to be considered and resolved through careful design decisions. Special attention has to be given to the patient user group that could greatly impact current work practice and power structures at the primary care unit. A need for further studies investigating patient needs in everyday life is identified to better support the implementation of technology that does not give specific attention to organizational perspectives but instead approach design with the patient perspective in focus.
Background:
Type 1 diabetes mellitus (T1DM) is characterized by chronic insulin deficiency and consequent hyperglycemia. Patients with T1DM require long-term exogenous insulin therapy to regulate blood glucose levels and prevent the long-term complications of the disease. Currently, there are no effective algorithms that consider the unique characteristics of T1DM patients to automatically recommend personalized insulin dosage levels.
Methods:
This research presents a model-free data-driven RL algorithm, namely Q-learning, that recommends insulin doses to regulate the blood glucose level of a T1DM patient, considering his or her state defined by glycated hemoglobin (HbA1c) levels, body mass index, engagement in physical activity, and alcohol usage. In this approach, the RL agent identifies the different states of the patient by exploring the patient’s responses when he or she is subjected to varying insulin doses. On the basis of the result of a treatment action at time step t, the RL agent receives a numeric reward, positive or negative. The reward is calculated as a function of the difference between the actual blood glucose level achieved in response to the insulin dose and the targeted HbA1c level. The RL agent was trained on 10 years of clinical data of patients treated at the Mass General Hospital.
Results:
A total of 87 patients were included in the training set. The mean age of these patients was 53 years, 59% (51/87) were male, 86% (75/87) were white, and 47% (41/87) were married. The performance of the RL agent was evaluated on 60 test cases. RL agent–recommended insulin dosage interval includes the actual dose prescribed by the physician in 53 out of 60 cases (53/60, 88%).
Conclusions:
This exploratory study demonstrates that an RL algorithm can be used to recommend personalized insulin doses to achieve adequate glycemic control in patients with T1DM. However, further investigation in a larger sample of patients is needed to confirm these findings.
Background: As digital healthcare expands to include the use of mobile devices, there are opportunities to integrate these technologies into the self-management of chronic disease. Purpose built apps for diabetes self-management are plentiful and vary in functionality; they offer capability for individuals to record, manage, display, and interpret their own data. The optimal incorporation of mobile tablets into diabetes self-care is little explored in research, and guidelines for use are scant. Objective: The purpose of this study was to examine an individual’s use of mobile devices and apps in the self-management of type 2 diabetes to establish the potential and value of this ubiquitous technology for chronic healthcare. Methods: In a 9-month intervention, 28 patients at a large multidisciplinary healthcare center were gifted internet connected Apple iPads with preinstalled apps and given digital support to use them. They were invited to take up predefined activities, which included recording their own biometrics, monitoring their diet, and traditional online information seeking. Four online surveys captured the participants’ perceptions and health outcomes throughout the study. This article reports on the qualitative analysis of the open-ended responses in all four surveys. Results: Using apps, participants self-curated small data sets that included their blood glucose level, blood pressure, weight, and dietary intake. The dynamic visualizations of the data in the form of charts and diagrams were created using apps and participants were able to interpret the impact of their choices and behaviors from the diagrammatic form of their small personal data sets. Findings are presented in four themes: (1) recording personal data; (2) modelling and visualizing the data; (3) interpreting the data; and (4) empowering and improving health. Conclusions: The modelling capability of apps using small personal data sets, collected and curated by individuals, and the resultant graphical information that can be displayed on tablet screens proves a valuable asset for diabetes self-care. Informed by their own data, individuals are well-positioned to make changes in their daily lives that will improve their health.
Background: Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials. Objective: The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources. Methods: The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers’ content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey. Results: Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again. Conclusions: The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers’ feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.
Background: The prevalence of diabetes is increasing among adults globally. Research has demonstrated that a diabetes prevention program (DPP), which focuses on developing and maintaining health-promoting lifestyle modifications, can prevent or delay the onset of type 2 diabetes among at-risk individuals. The implementation of a digitally adapted DPP has the potential to prevent prediabetes on a national and global scale by using technology and behavior change science. Objective: This study aimed to investigate the effects of a novel digital therapeutic DPP (Transform) on weight loss, body mass index (BMI), exercise frequency, and work absenteeism. Methods: This study was a secondary analysis of retrospective data of adults with prediabetes who were enrolled in the Transform DPP from December 2016 to December 2017. The program incorporates interactive mobile computing, remote monitoring, an evidence-based curriculum, behavior tracking tools, health coaching, and online peer support to prevent or delay the onset of type 2 diabetes. The analysis included data that were collected at baseline and after 4 months of the Transform DPP. Results: The sample (N=273) comprised people with prediabetes who completed 4 months of the Transform program. Participants included 70.3% women, with a mean age of 54.0 (SD 11.2) years. On average, participants decreased their weight by 13.3 lbs (6.5%) and their BMI by 1.9 kg/m2. On average, participants increased their exercise frequency by 1.7 days per week, and absenteeism was reduced by almost half a day per month. Conclusions: These results suggest that the digital therapeutic DPP (Transform) is effective at preventing type 2 diabetes through a significant reduction in body weight and an increase of physical activity. A prospective, controlled clinical study is warranted to validate these findings.
Background: Although multiple self-monitoring technologies for type 2 diabetes mellitus (T2DM) show promise for improving T2DM self-care behaviors and clinical outcomes, they have been understudied in Hispanic adult populations who suffer disproportionately from T2DM. Objective: The objective of this study was to evaluate the acceptability, feasibility, and potential integration of wearable sensors for diabetes self-monitoring among Hispanic adults with self-reported T2DM. Methods: We conducted a pilot study of T2DM self-monitoring technologies among Hispanic adults with self-reported T2DM. Participants (n=21) received a real-time continuous glucose monitor (RT-CGM), a wrist-worn physical activity (PA) tracker, and a tablet-based digital food diary to self-monitor blood glucose, PA, and food intake, respectively, for 1 week. The RT-CGM captured viewable blood glucose concentration (mg/dL) and PA trackers collected accelerometer-based data, viewable on the device or an associated tablet app. After 1 week of use, we conducted a semistructured interview with each participant to understand experiences and thoughts on integration of the data from the devices into a technology-facilitated T2DM self-management intervention. We also conducted a brief written questionnaire to understand participants’ self-reported T2DM history and past experience using digital health tools for T2DM self-management. Feasibility was measured by device utilization and objective RT-CGM, PA tracker, and diet logging data. Acceptability and potential integration were evaluated through thematic analysis of verbatim interview transcripts. Results: Participants (n=21, 76% female, 50.4 [SD 11] years) had a mean self-reported hemoglobin A1c of 7.4 [SD 1.8] mg/dL and had been diagnosed with T2DM for 7.4 [SD 5.2] years (range: 1-16 years). Most (89%) were treated with oral medications, whereas the others self-managed through diet and exercise. Nearly all participants (n=20) used both the RT-CGM and PA tracker, and 52% (11/21) logged at least one meal, with 33% (7/21) logging meals for 4 or more days. Of the 8 possible days, PA data were recorded for 7.1 [SD 1.8] days (range: 2-8), and participants averaged 7822 [SD 3984] steps per day. Interview transcripts revealed that participants felt most positive about the RT-CGM as it unveiled previously unknown relationships between lifestyle and health and contributed to changes in T2DM-related thoughts and behaviors. Participants felt generally positive about incorporating the wearable sensors and mobile apps into a future intervention if support were provided by a health coach or health care provider, device training were provided, apps were tailored to their language and culture, and content were both actionable and delivered on a single platform. Conclusions: Sensor-based tools for facilitating T2DM self-monitoring appear to be a feasible and acceptable technology among low-income Hispanic adults. We identified barriers to acceptability and highlighted preferences for wearable sensor integration in a community-based intervention. These findings have implications for the design of T2DM interventions targeting Hispanic adults.
Background: Introducing self-collected health data from patients with diabetes into consultation can be beneficial for both patients and clinicians. Such an initiative can allow patients to be more proactive in their disease management and clinicians to provide more tailored medical services. Optimally, electronic health record systems (EHRs) should be able to receive self-collected health data in a standard representation of medical data such as Fast Healthcare Interoperability Resources (FHIR), from patients systems like mobile health apps and display the data directly to their users—the clinicians. However, although Norwegian EHRs are working on implementing FHIR, no solution or graphical interface is available today to display self-collected health data. Objective: The objective of this study was to design and assess a dashboard for displaying relevant self-collected health data from patients with diabetes to clinicians. Methods: The design relied on an iterative participatory process involving workshops with patients, clinicians, and researchers to define which information should be available and how it should be displayed. The assessment is based on a case study, presenting an instance of the dashboard populated with data collected from one patient with diabetes type 1 (in-house researcher) face-to-face by 14 clinicians. We performed a qualitative analysis based on usability, functionality, and expectation by using responses to questionnaires that were distributed to the 14 clinicians at the end of the workshops and collected before the participants left. The qualitative assessment was guided by the Standards for Reporting Qualitative Research. Results: We created a dashboard permitting clinicians to assess the reliability of self-collected health data, list all collected data including medical calculations, and highlight medical situations that need to be investigated to improve the situation of the patients. The dashboard uses a combination of tables, graphs, and other visual representations to display the relevant information. Clinicians think that this type of solution will be useful during consultations every day, especially for patients living in remote areas or those who are technologically interested. Conclusions: Displaying self-collected health data during consultations is not enough for clinicians; the data reliability has to be assured and the relevant information needs to be extracted and displayed along with the data to ease the introduction during a medical encounter. The prestudy assessment showed that the system provides relevant information to meet clinicians’ need and that clinicians were eager to start using it during consultations. The system has been under testing in a medical trial since November 2018, and the first results of its assessment in a real-life situation are expected in the beginning of next year (2020).
