TY - JOUR AU - Dening, Jedha AU - Islam, Shariful Sheikh Mohammed AU - George, Elena AU - Maddison, Ralph PY - 2020/8/28 TI - Web-Based Interventions for Dietary Behavior in Adults With Type 2 Diabetes: Systematic Review of Randomized Controlled Trials JO - J Med Internet Res SP - e16437 VL - 22 IS - 8 KW - type 2 diabetes KW - dietary behavior KW - diet KW - glycemic control KW - self-management KW - eHealth KW - web-based KW - HbA1c N2 - Background: Type 2 diabetes mellitus (T2DM) is among the most prevalent noncommunicable health conditions worldwide, affecting over 500 million people globally. Diet is a key aspect of T2DM management with dietary modification shown to elicit clinically meaningful outcomes such as improved glycemic control, and reductions in weight and cardiovascular disease risk factors. Web-based interventions provide a potentially convenient and accessible method for delivering dietary education, but its effects on dietary behavior in people with T2DM are unknown. Objective: The objective of this review was to determine the effectiveness of web-based interventions on dietary behavior change and glycemic control in people with T2DM. Methods: Per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, systematic literature searches were performed using Medline, Embase, The Cochrane Library, and CINAHL to retrieve papers from January 2013 to May 2019. Randomized controlled trials of web-based interventions in adults with T2DM with reported dietary assessment were included. Population and intervention characteristics, dietary guidelines and assessments, and significant clinical outcomes were extracted. Differences between groups and within groups were assessed for dietary behavior and clinical outcomes. Results: There were 714 records screened, and five studies comprising 1056 adults were included. Studies measured dietary changes by assessing overall diet quality, changes in specific dietary components, or dietary knowledge scores. Significant improvements in dietary behavior were reported in four out of the five studies, representing healthier food choices, improvements in eating habits, reductions in carbohydrates, added sugar, sodium, saturated fat and overall fat intake, and/or increases in dietary knowledge. Three studies found significant mean reductions for hemoglobin A1c ranging from ?0.3% to ?0.8%, and/or weight ranging from ?2.3 kg to ?12.7 kg, fasting blood glucose (?1 mmol/L), waist circumference (?1 cm), and triglycerides (?60.1 mg/dL). These studies provided varied dietary recommendations from standard dietary guidelines, national health program guidelines, and a very low carbohydrate ketogenic diet. Conclusions: This review provided evidence that web-based interventions may be an effective way to support dietary behavior change in people with T2DM, potentially leading to changes in glycemic control and other clinical outcomes. However, the evidence should be viewed as preliminary as there were only five studies included with considerable heterogeneity in terms of the diets recommended, the dietary assessment measures used, the complexity of the interventions, and the modes and methods of delivery. UR - http://www.jmir.org/2020/8/e16437/ UR - http://dx.doi.org/10.2196/16437 UR - http://www.ncbi.nlm.nih.gov/pubmed/32857059 ID - info:doi/10.2196/16437 ER - TY - JOUR AU - Du, Yan AU - Dennis, Brittany AU - Rhodes, Lakel Shanae AU - Sia, Michelle AU - Ko, Jisook AU - Jiwani, Rozmin AU - Wang, Jing PY - 2020/8/28 TI - Technology-Assisted Self-Monitoring of Lifestyle Behaviors and Health Indicators in Diabetes: Qualitative Study JO - JMIR Diabetes SP - e21183 VL - 5 IS - 3 KW - technology KW - monitoring KW - lifestyle KW - diet KW - exercise KW - weight KW - glucose KW - diabetes management N2 - 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. UR - http://diabetes.jmir.org/2020/3/e21183/ UR - http://dx.doi.org/10.2196/21183 UR - http://www.ncbi.nlm.nih.gov/pubmed/32857056 ID - info:doi/10.2196/21183 ER - TY - JOUR AU - Fakih El Khoury, Cosette AU - Crutzen, Rik AU - Schols, A. Jos M. G. AU - Halfens, G. Ruud J. AU - Karavetian, Mirey PY - 2020/7/20 TI - A Dietary Mobile App for Patients Undergoing Hemodialysis: Prospective Pilot Study to Improve Dietary Intakes JO - J Med Internet Res SP - e17817 VL - 22 IS - 7 KW - mHealth KW - dietary app KW - hemodialysis diet N2 - Background: Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners. Objective: This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly. Methods: A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials. Results: A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2). Conclusions: This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately. UR - http://www.jmir.org/2020/7/e17817/ UR - http://dx.doi.org/10.2196/17817 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706698 ID - info:doi/10.2196/17817 ER - TY - JOUR AU - DeLuca, Laura AU - Toro-Ramos, Tatiana AU - Michaelides, Andreas AU - Seng, Elizabeth AU - Swencionis, Charles PY - 2020/6/4 TI - Relationship Between Age and Weight Loss in Noom: Quasi-Experimental Study JO - JMIR Diabetes SP - e18363 VL - 5 IS - 2 KW - older adults KW - DPP KW - mHealth KW - weight loss KW - lifestyle intervention KW - engagement N2 - Background: The prevalence of obesity and diabetes among middle-aged and older adults is on the rise, and with an increase in the world population of adults aged 60 years and older, the demand for health interventions across age groups is growing. Noom is an mHealth behavior change lifestyle intervention that provides users with tracking features for food and exercise logging and weighing-in as well as access to a virtual 1:1 behavior change coach, support group, and daily curriculum that includes diet-, exercise-, and psychology-based content. Limited research has observed the effect of age on a mobile health (mHealth) lifestyle intervention. Objective: The goal of the research was to analyze engagement of middle-aged and older adults using a mobile lifestyle or diabetes prevention intervention. Methods: A total of 14,767 adults (aged 35 to 85 years) received one of two curricula via an mHealth intervention in a quasi-experimental study: the Healthy Weight program (HW) by Noom (84%) or the Noom-developed Diabetes Prevention Program (DPP), recognized by the US Centers for Disease Control and Prevention (CDC). The main outcome measure was weight over time, observed at baseline and weeks 16 and 52. Results: Linear mixed modeling found age to be a significant predictor of weight at week 16 (F2,1398.4=9.20; P<.001; baseline vs week 16: ?=?.12, 95% CI ?0.18 to ?0.07), suggesting that as age increases by 1 year, weight decreased by 0.12 kg. An interaction between engagement and age was also found at week 52 (F1,14680.51=6.70; P=.01) such that engagement was more strongly associated with weight for younger versus older adults (age × engagement: ?=.02, 95% CI 0.01 to 0.04). HW users lost 6.24 (SD 6.73) kg or 5.2% of their body weight and DPP users lost 5.66 (SD 7.16) kg or 8.1% of their body weight at week 52, meeting the CDC standards for weight loss effects on health. Conclusions: Age and engagement are significant predictors of weight. Older adults lost more weight using an mHealth evidence-based lifestyle intervention compared with younger adults, despite their engagement. These preliminary findings suggest further clinical implications for adapting the program to older adults? needs. UR - http://diabetes.jmir.org/2020/2/e18363/ UR - http://dx.doi.org/10.2196/18363 UR - http://www.ncbi.nlm.nih.gov/pubmed/32497017 ID - info:doi/10.2196/18363 ER - TY - JOUR AU - Alrige, Mayda AU - Alharbey, Riad AU - Chatterjee, Samir PY - 2020/5/19 TI - The Effect of a Customized Nutrient-Profiling Approach on the Glycated Hemoglobin Levels of Patients With Type 2 Diabetes: Quasi-Experimental Study JO - J Med Internet Res SP - e15497 VL - 22 IS - 5 KW - mHealth KW - consumer health informatics KW - diet therapy KW - nutrient profiling KW - Hb A1c N2 - Background: Presently, dietary management approaches are mostly oriented toward using calorie-counting and diet-tracking tools that draw our attention away from the nutritional value of our food. To improve individuals? dietary behavior, primarily that of people with type 2 diabetes, a simple technique is needed to increase their understanding of the nutritional content of their food. Objective: This study aimed to design, develop, and evaluate a customized nutrient-profiling tool called EasyNutrition. EasyNutrition was built to introduce the new concept of nutrient profiling by applying the Intelligent Nutrition Engine, an algorithm that we developed for ranking different food recipes based on their nutritional value. This study also aimed to investigate the efficacy of EasyNutrition in lowering glycated hemoglobin (HbA1c) levels and improving dietary habits among people with type 2 diabetes. Methods: We evaluated the utility of EasyNutrition using design science research in three sequential stages. This paper has elaborated on the third stage to investigate the efficacy of EasyNutrition in managing type 2 diabetes. A quasi-experimental study was conducted in a diabetes treatment center (n=28). The intervention group utilized EasyNutrition over 3 months, whereas participants in the control group utilized the standard of care provided by the center. Dietary habits and HbA1c levels were measured to capture any change before and after experimenting with EasyNutrition. Results: The intervention group (n=9) exhibited a statistically significant change between the pre- and postexposure results of their HbA1c (t9=2.427; P=.04). Their HbA1c dropped from 8.13 to 6.72. This provided preliminary evidence of the efficacy of using a customized nutrient-profiling app in reducing HbA1c for people with type 2 diabetes. Conclusions: This study adds to the evidence base that a nutrient-profiling strategy may be a modern adjunct to diabetes dietary management. In conjunction with reliable dietary education provided by a registered dietician, EasyNutrition may have some beneficial effects to improve the dietary habits of people with type 2 diabetes. UR - https://www.jmir.org/2020/5/e15497 UR - http://dx.doi.org/10.2196/15497 UR - http://www.ncbi.nlm.nih.gov/pubmed/32427107 ID - info:doi/10.2196/15497 ER - TY - JOUR AU - van het Schip, Colette AU - Cheung, Long Kei AU - Vluggen, Stan AU - Hoving, Ciska AU - Schaper, C. Nicolaas AU - de Vries, Hein PY - 2020/4/23 TI - Spoken Animated Self-Management Video Messages Aimed at Improving Physical Activity in People With Type 2 Diabetes: Development and Interview Study JO - J Med Internet Res SP - e15397 VL - 22 IS - 4 KW - diabetes mellitus, type 2 KW - internet-based intervention KW - telemedicine KW - computer tailoring KW - self-management KW - exercise KW - animation KW - health literacy N2 - Background: Web-based tailored interventions are a promising approach to help people with type 2 diabetes successfully adopt regular physical activity. Spoken animation seems to be effective regardless of the characteristics of the user and may be a relevant strategy to communicate complex health information Objective: The objectives of our study were to evaluate (1) pretesting communication elements and user appreciation, and (2) the applied behavior change techniques of the previously designed spoken animated video messages in a tailored self-management program for people with type 2 diabetes. Methods: We conducted semistructured interviews with patients with type 2 diabetes recruited from general practices located in different socioeconomic status urban neighborhoods. Based on the pretesting key communication elements of Salazar?s model, we asked participants about the spoken animated video messages? attractiveness, comprehensibility, acceptance, believability, involvement, and relevance and to what extent the video messages motivated them to become more physically active. We also assessed participants? intention to use the spoken animated video messages and to recommend them to others. To evaluate participants? appreciation of the different applied behavior change techniques, we conducted a post hoc analysis of the qualitative data using the MAXQDA program. Transcripts were coded by 2 coders using iterative qualitative content analysis methods to uncover key health communication issues. Results: Of 23 patients who expressed an interest in participating, 17 met the inclusion criteria and 15 took part in the interviews. The positive appreciation of the comprehensibility, believability, and personalization was supported by participants? statements on behavior change techniques and other communication elements. Reinforcement of and feedback on participants? answers were positively evaluated as was the simplicity and concreteness of the spoken animated video messages. Most participants indicated reasons for not feeling motivated to increase their physical activity level, including being already sufficiently physically active and the presence of other impeding health factors. Conclusions: Spoken animated video messages should be simple, short, concrete, and without the use of medical terminology. Providing positive reinforcement, feedback on participants? answers, examples that match user characteristics, and the possibility to identify with the animation figures will enhance involvement in the health message. To connect more with patients? needs and thereby increase the perceived relevance of and motivation to use an animated video program, we suggest offering the program soon after diabetes mellitus is diagnosed. We recommend piloting behavior change techniques to identify potential resistance. UR - http://www.jmir.org/2020/4/e15397/ UR - http://dx.doi.org/10.2196/15397 UR - http://www.ncbi.nlm.nih.gov/pubmed/32324138 ID - info:doi/10.2196/15397 ER - TY - JOUR AU - Zheng, Yaguang AU - Weinger, Katie AU - Greenberg, Jordan AU - Burke, E. Lora AU - Sereika, M. Susan AU - Patience, Nicole AU - Gregas, C. Matt AU - Li, Zhuoxin AU - Qi, Chenfang AU - Yamasaki, Joy AU - Munshi, N. Medha PY - 2020/3/23 TI - Actual Use of Multiple Health Monitors Among Older Adults With Diabetes: Pilot Study JO - JMIR Aging SP - e15995 VL - 3 IS - 1 KW - mobile health KW - aged KW - lifestyle KW - self-management KW - diabetes mellitus, type 2 N2 - Background: Previous studies have reported older adults? perceptions of using health monitors; however, no studies have examined the actual use of multiple health monitors for lifestyle changes over time among older adults with type 2 diabetes (T2D). Objective: The primary aim of this study was to examine the actual use of multiple health monitors for lifestyle changes over 3 months among older adults with T2D. The secondary aim was to explore changes in caloric intake and physical activity (PA) over 3 months. Methods: This was a single-group study lasting 3 months. The study sample included participants who were aged ?65 years with a diagnosis of T2D. Participants were recruited through fliers posted at the Joslin Diabetes Center in Boston. Participants attended five 60-min, biweekly group sessions, which focused on self-monitoring, goal setting, self-regulation to achieve healthy eating and PA habits, and the development of problem-solving skills. Participants were provided with the Lose It! app to record daily food intake and devices such as a Fitbit Alta for monitoring PA, a Bluetooth-enabled blood glucose meter, and a Bluetooth-enabled digital scale. Descriptive statistics were used for analysis. Results: Of the enrolled participants (N=9), the sample was white (8/9, 89%) and female (4/9, 44%), with a mean age of 76.4 years (SD 6.0; range 69-89 years), 15.7 years (SD 2.0) of education, 33.3 kg/m2 (SD 3.1) BMI, and 7.4% (SD 0.8) hemoglobin A1c. Over the 84 days of self-monitoring, the mean percentage of days using the Lose It!, Fitbit Alta, blood glucose meter, and scale were 82.7 (SD 17.6), 85.2 (SD 19.7), 65.3 (SD 30.1), and 53.0 (SD 34.5), respectively. From baseline to completion of the study, the mean daily calorie intake was 1459 (SD 661) at week 1, 1245 (SD 554) at week 11, and 1333 (SD 546) at week 12, whereas the mean daily step counts were 5618 (SD 3654) at week 1, 5792 (SD 3814) at week 11, and 4552 (SD 3616) at week 12. The mean percentage of weight loss from baseline was 4.92% (SD 0.25). The dose of oral hypoglycemic agents or insulin was reduced in 55.6% (5/9) of the participants. Conclusions: The results from the pilot study are encouraging and suggest the need for a larger study to confirm the outcomes. In addition, a study design that includes a control group with educational sessions but without the integration of technology would offer additional insight to understand the value of mobile health in behavior changes and the health outcomes observed during this pilot study. UR - http://aging.jmir.org/2020/1/e15995/ UR - http://dx.doi.org/10.2196/15995 UR - http://www.ncbi.nlm.nih.gov/pubmed/32202506 ID - info:doi/10.2196/15995 ER - TY - JOUR AU - Summers, Charlotte AU - Curtis, Kristina PY - 2020/3/4 TI - Novel Digital Architecture of a ?Low Carb Program? for Initiating and Maintaining Long-Term Sustainable Health-Promoting Behavior Change in Patients with Type 2 Diabetes JO - JMIR Diabetes SP - e15030 VL - 5 IS - 1 KW - type 2 diabetes KW - behaviour change KW - nutrition KW - digital intervention KW - low carb KW - type 2 diabetes remission KW - eHealth UR - http://diabetes.jmir.org/2020/1/e15030/ UR - http://dx.doi.org/10.2196/15030 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130113 ID - info:doi/10.2196/15030 ER - TY - JOUR AU - Young, M. Heather AU - Miyamoto, Sheridan AU - Dharmar, Madan AU - Tang-Feldman, Yajarayma PY - 2020/3/2 TI - Nurse Coaching and Mobile Health Compared With Usual Care to Improve Diabetes Self-Efficacy for Persons With Type 2 Diabetes: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e16665 VL - 8 IS - 3 KW - mHealth KW - electronic health record KW - type 2 diabetes KW - motivational interviewing N2 - Background: Type 2 diabetes is a growing public health problem amenable to prevention and health promotion. As healthy behaviors have an impact on disease outcomes, approaches to support and sustain diabetes self-management are vital. Objective: This study aimed to evaluate the effectiveness of a nurse coaching program using motivational interviewing paired with mobile health (mHealth) technology on diabetes self-efficacy and self-management for persons with type 2 diabetes. Methods: This randomized controlled trial compared usual care with an intervention that entailed nurse health coaching and mHealth technology to track patient-generated health data and integrate these data into an electronic health record. The inclusion criteria were as follows: (1) enrolled at 1 of 3 primary care clinics, (2) aged 18 years or above, (3) living with type 2 diabetes, and (4) English-speaking. We collected outcome measures at baseline, 3 months, and 9 months. The primary outcome was diabetes self-efficacy; secondary outcomes were depressive symptoms, perceived stress, physical functioning, and emotional distress and anxiety. Linear regression mixed modeling estimated the population trends and individual differences in change. Results: We enrolled 319 participants; 287 participants completed the study (155 control and 132 intervention). The participants in the intervention group had significant improvements in diabetes self-efficacy (Diabetes Empowerment Scale, 0.34; 95% CI ?0.15,0.53; P<.01) and a decrease in depressive symptoms compared with usual care at 3 months (Patient Health Questionnaire-9; 0.89; 95% CI 0.01-1.77; P=.05), with no differences in the other outcomes. The differences in self-efficacy and depression scores between the 2 arms at 9 months were not sustained. The participants in the intervention group demonstrated a significant increase in physical activity (from 23,770 steps per week to 39,167 steps per week at 3 months and 32,601 per week at 9 months). Conclusions: We demonstrated the short-term effectiveness of this intervention; however, by 9 months, although physical activity remained above the baseline, the improvements in self-efficacy were not sustained. Further research should evaluate the minimum dose of coaching required to continue progress after active intervention and the potential of technology to provide effective ongoing automated reinforcement for behavior change. Trial Registration: ClinicalTrials.gov NCT02672176; https://clinicaltrials.gov/ct2/show/NCT02672176 UR - https://mhealth.jmir.org/2020/3/e16665 UR - http://dx.doi.org/10.2196/16665 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130184 ID - info:doi/10.2196/16665 ER - TY - JOUR AU - Fortunato, Michael AU - Harrison, Joseph AU - Oon, Leen Ai AU - Small, Dylan AU - Hilbert, Victoria AU - Rareshide, Charles AU - Patel, Mitesh PY - 2019/11/20 TI - Remotely Monitored Gamification and Social Incentives to Improve Glycemic Control Among Adults With Uncontrolled Type 2 Diabetes (iDiabetes): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e14180 VL - 8 IS - 11 KW - behavioral economics KW - gamification KW - social incentives KW - diabetes KW - glycemic control weight KW - physical activity KW - remote monitoring KW - wearable devices N2 - Background: Type 2 diabetes is a significant cause of morbidity and mortality in the United States. Lifestyle modifications including increasing physical activity and losing weight have been demonstrated to improve glycemic control. However, most patients struggle to make these changes. Many stakeholders are interested in using gamification and social incentives to increase engagement in healthy behaviors. However, these approaches often do not appropriately leverage insights from behavioral economics that could be used to address predictable barriers to behavior change. Objective: This study aimed to describe the protocol for the Influencing DIabetics to Adapt Behaviors related to Exercise and weighT by Enhancing Social incentives (iDiabetes) trial, which aimed to evaluate the effectiveness of gamification interventions that leverage insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives to improve glycemic control, promote weight loss, and increase physical activity among overweight and obese adults with type 2 diabetes. Methods: We are conducting a one-year four-arm randomized controlled trial of 361 overweight and obese patients with type 2 diabetes and a glycated hemoglobin (HbA1c) level ?8.0. Wireless weight scales and wearable devices are provided to remotely monitor weight and physical activity and transmit data to the study team. Patients are recruited by email, following which they establish a baseline measure of weight, daily step count, HbA1c level, and low-density lipoprotein cholesterol level and then repeat these measures at 6 and 12 months. The control arm receives no other interventions. Patients randomized to one of the three intervention arms are entered into a game designed using insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives. To examine predictors of strong or poor performance, participants completed validated questionnaires on a range of areas including their personality, risk preferences, and social network. Results: Enrollment of 361 patients was completed in January 2019. Results are expected in 2020. Conclusions: The iDiabetes trial represents a scalable model to remotely monitor the daily health behaviors of adults with type 2 diabetes. Results from this trial will help provide insights into how to improve management of patients with type 2 diabetes. Trial Registration: ClinicalTrials.gov NCT02961192; https://clinicaltrials.gov/ct2/show/NCT02961192 International Registered Report Identifier (IRRID): DERR1-10.2196/14180 UR - http://www.researchprotocols.org/2019/11/e14180/ UR - http://dx.doi.org/10.2196/14180 UR - http://www.ncbi.nlm.nih.gov/pubmed/31746765 ID - info:doi/10.2196/14180 ER - TY - JOUR AU - Abu-Saad, Kathleen AU - Murad, Havi AU - Barid, Rivka AU - Olmer, Liraz AU - Ziv, Arnona AU - Younis-Zeidan, Nuha AU - Kaufman-Shriqui, Vered AU - Gillon-Keren, Michal AU - Rigler, Shmuel AU - Berchenko, Yakir AU - Kalter-Leibovici, Ofra PY - 2019/10/16 TI - Development and Efficacy of an Electronic, Culturally Adapted Lifestyle Counseling Tool for Improving Diabetes-Related Dietary Knowledge: Randomized Controlled Trial Among Ethnic Minority Adults With Type 2 Diabetes Mellitus JO - J Med Internet Res SP - e13674 VL - 21 IS - 10 KW - diabetes mellitus, type 2 KW - diabetes-related dietary knowledge KW - lifestyle KW - software KW - culturally congruent care KW - ethnic minorities N2 - Background: Ethnic minority populations exhibit disproportionately high rates of type 2 diabetes mellitus (T2DM). Electronic health tools have the potential to facilitate the cultural adaptation and tailoring of T2DM education to improve the knowledge and management of diabetes mellitus (DM). Objective: This study aimed (1) to develop an adaptable Interactive Lifestyle Assessment, Counseling, and Education (I-ACE) software to support dietitian-delivered lifestyle counseling among low-socioeconomic status (SES) ethnic minority patients with T2DM and (2) to evaluate its effect on DM-related dietary knowledge and management compared with standard lifestyle advice (SLA) in a randomized controlled trial (RCT). Methods: The I-ACE software, developed in consultation with clinical dieticians, incorporates evidence-based dietary and physical activity (PA) recommendations and educational materials. The features and behavioral change techniques include quantitative lifestyle (dietary intake and PA) assessment and simulation, individually tailored education and recommendations, motivational interviewing, and goal setting. For the unblinded pilot RCT, 50 overweight or obese Arab adults (aged 40-62 years) with poorly controlled T2DM were recruited from primary care clinics and randomly assigned to receive 4 in-person, dietician-delivered counseling sessions over 6 months using either (1) the I-ACE tool (experimental arm) or (2) the SLA methods (comparison arm). All outcome assessments were face-to-face. DM-related dietary knowledge (primary outcome) was measured at baseline, 3, 6, and 12 months. Lifestyle and other parameters were measured before, during, and after the intervention. Multiple linear regression and repeated measures linear mixed models were used to compare the changes in study outcomes and explore time trends in between-group and within-group changes. Results: A total of 25 participants were enrolled in each arm, of whom 24 and 21 completed the final assessment of the primary outcome in the I-ACE and SLA arms, respectively. DM-related lifestyle knowledge increased more rapidly in the I-ACE arm than in the SLA arm (P value for study arm×time interaction=.02). Within the I-ACE arm, the mean (SE) differences in added sugar and dietary fiber intakes from baseline to 12 months were ?2.6% (SE 1.0%) of total energy (P=.03) and 2.7 (SE 0.0) g/1000 kcal (P=.003), respectively. The odds of engaging in any leisure PA at 12 months tended to be higher in the I-ACE arm versus SLA arm, but did not reach statistical significance (odds ratio 2.8; 95% CI 0.7-11.6; P=.16). Both arms exhibited significant reductions in HbA1c (P value for change over time <.001). Conclusions: The use of the I-ACE software in a 6-month, 4-session dietician-delivered lifestyle counseling intervention improved the efficiency of lifestyle education, compared with SLA, among low-SES, ethnic minority patients with T2DM. This pilot trial provides justification for conducting a large-scale trial to evaluate its effectiveness and applicability in routine clinical care among ethnically diverse populations. Trial Registration: ClinicalTrials.gov NCT01858506; https://clinicaltrials.gov/ct2/show/NCT01858506. UR - https://www.jmir.org/2019/10/e13674 UR - http://dx.doi.org/10.2196/13674 UR - http://www.ncbi.nlm.nih.gov/pubmed/31621640 ID - info:doi/10.2196/13674 ER - TY - JOUR AU - MacPherson, M. Megan AU - Merry, J. Kohle AU - Locke, R. Sean AU - Jung, E. Mary PY - 2019/09/05 TI - Effects of Mobile Health Prompts on Self-Monitoring and Exercise Behaviors Following a Diabetes Prevention Program: Secondary Analysis From a Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e12956 VL - 7 IS - 9 KW - self-monitoring KW - health behavior KW - prompts KW - mHealth KW - mobile apps KW - exercise KW - high-intensity interval training KW - reminder system N2 - Background: A number of mobile health (mHealth) apps exist that focus specifically on promoting exercise behavior. To increase user engagement, prompts, such as text messages, emails, or push notifications, are often used. To date, little research has been done to understand whether, and for how long, these prompts influence exercise behavior. Objective: This study aimed to assess the impact of prompts on mHealth self-monitoring and self-reported exercise in the days following a prompt and whether these effects differ based on exercise modality. Methods: Of the possible 99 adults at risk for developing type II diabetes who participated in a diabetes prevention program, 69 were included in this secondary analysis. Participants were randomly assigned to 1 of the following 2 exercise conditions: high-intensity interval training or moderate-intensity continuous training. In the year following a brief, community-based diabetes prevention program involving counseling and supervised exercise sessions, all participants self-monitored their daily exercise behaviors on an mHealth app in which they were sent personalized prompts at varying frequencies. mHealth self-monitoring and self-reported exercise data from the app were averaged over 1, 3, 5, and 7 days preceding and following a prompt and subsequently compared using t tests. Results: In the year following the diabetes prevention program, self-monitoring (t68=6.82; P<.001; d=0.46) and self-reported exercise (t68=2.16; P=.03; d=0.38) significantly increased in the 3 days following a prompt compared with the 3 days preceding. Prompts were most effective in the first half of the year, and there were no differences in self-monitoring or self-reported exercise behaviors between exercise modalities (P values >.05). In the first half of the year, self-monitoring was significant in the 3 days following a prompt (t68=8.61; P<.001; d=0.60), and self-reported exercise was significant in the 3 days (t68=3.7; P<.001; d=0.37), 5 days (t67=2.15; P=.04; d=0.14), and 7 days (t68=2.46; P=.02; d=0.15) following a prompt, whereas no significant changes were found in the second half of the year. Conclusions: This study provides preliminary evidence regarding the potential influence of prompts on mHealth self-monitoring and self-reported exercise and the duration for which prompts may be effective as exercise behavior change tools. Future studies should determine the optimal prompting frequency for influencing self-reported exercise behaviors. Optimizing prompt frequency can potentially reduce intervention costs and promote user engagement. Furthermore, it can encourage consumers to self-monitor using mHealth technology while ensuring prompts are sent when necessary and effective. International Registered Report Identifier (IRRID): DERR2-10.2196/11226 UR - http://mhealth.jmir.org/2019/9/e12956/ UR - http://dx.doi.org/10.2196/12956 UR - http://www.ncbi.nlm.nih.gov/pubmed/31489842 ID - info:doi/10.2196/12956 ER - TY - JOUR AU - McKinney, Pamela AU - Cox, Martin Andrew AU - Sbaffi, Laura PY - 2019/08/01 TI - Information Literacy in Food and Activity Tracking Among Parkrunners, People With Type 2 Diabetes, and People With Irritable Bowel Syndrome: Exploratory Study JO - J Med Internet Res SP - e13652 VL - 21 IS - 8 KW - activity logging KW - food logging KW - information literacy KW - irritable bowel syndrome KW - personal informatics KW - quantified self KW - running KW - self-tracking KW - type 2 diabetes N2 - Background: The tracking, or logging, of food intake and physical activity is increasing among people, and as a result there is increasing evidence of a link to improvement in health and well-being. Crucial to the effective and safe use of logging is a user?s information literacy. Objective: The aim of this study was to analyze food and activity tracking from an information literacy perspective. Methods: An online survey was distributed to three communities via parkrun, diabetes.co.uk and the Irritable Bowel Syndrome Network. Results: The data showed that there were clear differences in the logging practices of the members of the three different communities, as well as differences in motivations for tracking and the extent of sharing of said tracked data. Respondents showed a good understanding of the importance of information accuracy and were confident in their ability to understand tracked data, however, there were differences in the extent to which food and activity data were shared and also a lack of understanding of the potential reuse and sharing of data by third parties. Conclusions: Information literacy in this context involves developing awareness of the issues of accurate information recording, and how tracked information can be applied to support specific health goals. Developing awareness of how and when to share data, as well as of data ownership and privacy, are also important aspects of information literacy. UR - https://www.jmir.org/2019/8/e13652/ UR - http://dx.doi.org/10.2196/13652 UR - http://www.ncbi.nlm.nih.gov/pubmed/31373277 ID - info:doi/10.2196/13652 ER - TY - JOUR AU - Yingling, Leah AU - Allen, A. Nancy AU - Litchman, L. Michelle AU - Colicchio, Vanessa AU - Gibson, S. Bryan PY - 2019/07/16 TI - An Evaluation of Digital Health Tools for Diabetes Self-Management in Hispanic Adults: Exploratory Study JO - JMIR Diabetes SP - e12936 VL - 4 IS - 3 KW - type 2 diabetes KW - Hispanic KW - blood glucose self-monitoring KW - culturally appropriate technology KW - mobile app N2 - 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. UR - http://diabetes.jmir.org/2019/3/e12936/ UR - http://dx.doi.org/10.2196/12936 UR - http://www.ncbi.nlm.nih.gov/pubmed/31313657 ID - info:doi/10.2196/12936 ER - TY - JOUR AU - Fischer, H. Henry AU - Durfee, J. Michael AU - Raghunath, G. Silvia AU - Ritchie, D. Natalie PY - 2019/04/15 TI - Short Message Service Text Message Support for Weight Loss in Patients With Prediabetes: Pragmatic Trial JO - JMIR Diabetes SP - e12985 VL - 4 IS - 2 KW - eHealth KW - prediabetes KW - texting KW - weight loss N2 - Background: To reach all 84.1 million US adults estimated to have prediabetes warrants need for low-cost and less burdensome alternatives to the National Diabetes Prevention Program (NDPP). In a previous randomized controlled trial, we demonstrated the efficacy of a 12-month short message service text message support program called SMS4PreDM amongst individuals with prediabetes. Objective: The study aimed to evaluate the implementation and effectiveness of SMS4PreDM in a pragmatic study following dissemination in a safety net health care system. Methods: English- and Spanish-speaking patients at risk for diabetes (eg, glycated hemoglobin 5.7-6.4) were referred by their providers and offered either NDPP classes, SMS4PreDM, or both. This analysis focuses on weight change among 285 SMS4PreDM-only participants who began the year-long intervention between October 2015 and April 2017 with accompanying pre- and postweights, as compared with 1233 usual-care control patients at risk for diabetes, who were identified from electronic health records during this time but not referred. Weight outcomes included time-related mean weight change and frequency of either ?3% weight loss or gain. Mixed linear models adjusted for age, gender, race, ethnicity, preferred language, and baseline weight. A secondary analysis was stratified by language. We also assessed implementation factors, including retention and cost. Results: SMS4PreDM participants had high retention (259 of 285 patients or 91.0% completion at 12-months, ) and a time-related mean weight loss of 1.3 pounds (SE 0.74), compared with the control group?s slight mean weight gain of 0.25 pounds (SE 0.59; P=.004). Spanish-speaking SMS4PreDM participants (n=130) had a time-related mean weight loss of 1.11 pounds (SE 1.22) compared with weight gain of 0.96 pounds (SE 1.14) in Spanish-speaking controls (n=382, P<.001). English-speaking intervention participants (n=155) had a comparable time-related mean weight change (?0.89 pounds; SE 0.93) as English-speaking controls (n=828; 0.31 pounds gained; SE 0.62, P=.14). Overall, frequency of achieving ?3% weight loss was comparable between groups (54 of 285 or 19.0% of SMS4PreDM participants [95% CI 14.8-23.9] vs 266 of 1233 or 21.6% of controls [95% CI 19.3-24.0]; P=.33). Nonetheless, more controls had ?3% weight gain compared with intervention participants (337 of 1233 or 27.3% of controls [95% CI 24.9-29.9] vs 57 of 285 or 20.0% of SMS4PreDM participants [95% CI 16.8-25.1]; P=.01). SMS4PreDM delivery costs were US $100.92 per participant. Conclusions: Although SMS4PreDM was relatively low cost to deliver and demonstrated high retention, weight loss outcomes may not be sufficient to serve as a population health strategy. UR - http://diabetes.jmir.org/2019/2/e12985/ UR - http://dx.doi.org/10.2196/12985 UR - http://www.ncbi.nlm.nih.gov/pubmed/30985289 ID - info:doi/10.2196/12985 ER - TY - JOUR AU - Mason, E. Ashley AU - Saslow, Laura AU - Moran, J. Patricia AU - Kim, Sarah AU - Wali, K. Priyanka AU - Abousleiman, Hiba AU - Hartman, Alison AU - Richler, Robert AU - Schleicher, Samantha AU - Hartogensis, Wendy AU - Epel, S. Elissa AU - Hecht, Frederick PY - 2019/02/20 TI - Examining the Effects of Mindful Eating Training on Adherence to a Carbohydrate-Restricted Diet in Patients With Type 2 Diabetes (the DELISH Study): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e11002 VL - 8 IS - 2 KW - treatment adherence and compliance KW - mind-body therapies KW - diabetes mellitus KW - diet, ketogenic KW - mindfulness N2 - Background: Diet patterns have a profound influence on glycemic control for individuals with type 2 diabetes mellitus (T2DM), and craving-related eating is an important obstacle to dietary adherence. A growing body of research suggests that carbohydrate-restricted (CR) diets can improve glycemic control and reduce medication dependence in T2DM. However, limited data speak to the effects of long-term adherence to CR diets. Mindful eating training has been shown to reduce craving-related eating in overweight populations but has yet to be examined as a behavioral support for dietary adherence in T2DM. This trial examines behavioral mechanisms, particularly craving-related eating, through which mindful eating training might improve adherence to CR dietary recommendations in T2DM. This will clarify the importance of focusing on craving-related eating in the optimization of dietary adherence interventions. Objective: The aim of this trial is to determine whether providing training in mindful eating increases adherence to a CR dietary recommendation in T2DM. Methods: We are randomizing 60 participants to receive a CR diet with or without mindful eating training (12-week group intervention) and are following participants for 12 weeks after intervention completion. We hypothesize that participants who receive mindful eating training (relative to those who do not) will demonstrate greater adherence to the CR diet. Results: Our primary outcome is change in craving-related eating, as assessed using an ecological momentary assessment mobile phone?based platform. Secondary behavioral pathway outcomes include changes in stress-related eating, impulsivity, glycemic control, weight change, dietary adherence, and resumption of dietary adherence after dietary nonadherence. Conclusions: This theory-driven trial will shed light on the impact of mindfulness training on mechanisms that may impact dietary adherence in T2DM. Trial Registration: ClinicalTrials.gov NCT03207711; https://clinicaltrials.gov/ct2/show/NCT03207711 (Archived by WebCite at http://www.webcitation.org/73pXscwaU)  UR - http://www.researchprotocols.org/2019/2/e11002/ UR - http://dx.doi.org/10.2196/11002 UR - http://www.ncbi.nlm.nih.gov/pubmed/30545813 ID - info:doi/10.2196/11002 ER - TY - JOUR AU - Brooksbank, Katriona AU - O'Donnell, Joanne AU - Corbett, Vicky AU - Shield, Sarah AU - Ainsworth, Rachel AU - Shearer, Ross AU - Montgomery, Susan AU - Gallagher, Andrew AU - Duncan, Hannah AU - Hamilton, Lorna AU - Laszlo, Valerie AU - Noone, Rhonda AU - Baxendale, Anna AU - Blane, David AU - Logue, Jennifer PY - 2019/02/15 TI - Discussing Weight Management With Type 2 Diabetes Patients in Primary Care Using the Small Talk Big Difference Intervention: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e12162 VL - 8 IS - 2 KW - obesity KW - primary care KW - medical education N2 - Background: Guidelines for the management of type 2 diabetes universally recommend that adults with type 2 diabetes and obesity be offered individualized interventions to encourage weight loss. Yet despite the existing recommendations, provision of weight management services is currently patchy around the United Kingdom and where services are available, high attrition rates are often reported. In addition, individuals often fail to take up services, that is, after discussion with a general practitioner or practice nurse, individuals are referred to the service but do not attend for an appointment. Qualitative research has identified that the initial discussion raising the issue of weight, motivating the patient, and referring to services is crucial to a successful outcome from weight management. Objective: Our aim was to evaluate the effectiveness of an Internet-based training program and practice implementation toolkit with or without face-to-face training for primary care staff. The primary outcome is the change in referral rate of patients with type 2 diabetes to National Health Service adult weight management programs, 3 months pre- and postintervention. Methods: We used the Behavior Change Wheel to develop an intervention for staff in primary care consisting of a 1-hour Internet-based eLearning package covering the links between obesity, type 2 diabetes, and the benefits of weight management, the treatment of diabetes in patients with obesity, specific training in raising the issue of weight, local services and referral pathways, overview of weight management components/ evidence base, and the role of the referrer. The package also includes a patient pamphlet, a discussion tool, a practice implementation checklist, and an optional 2.5-hour face-to-face training session. We have randomly assigned 100 practices in a 1:1 ratio to either have immediate access to all the resources or have access delayed for 4 months. An intention-to-treat statistical analysis will be performed. Results: Recruitment to the study is now complete. We will finalize follow-up in 2018 and publish in early 2019. Conclusions: This protocol describes the development and randomized evaluation of the effectiveness of an intervention to improve referral and uptake rates of weight management programs for adults with type 2 diabetes. At a time when many new dietary and pharmacological weight management interventions are showing large clinical benefits for people with type 2 diabetes, it is vital that primary care practitioners are willing, skilled, and able to discuss weight and make appropriate referrals to services. Trial Registration: ClinicalTrials.gov NCT03360058; https://clinicaltrials.gov/ct2/show/NCT03360058 (Archived by WebCite at http://www.webcitation.org/74HI8ULfn) International Registered Report Identifier (IRRID): DERR1-10.2196/12162 UR - http://www.researchprotocols.org/2019/2/e12162/ UR - http://dx.doi.org/10.2196/12162 UR - http://www.ncbi.nlm.nih.gov/pubmed/30767902 ID - info:doi/10.2196/12162 ER - TY - JOUR AU - Höchsmann, Christoph AU - Infanger, Denis AU - Klenk, Christopher AU - Königstein, Karsten AU - Walz, P. Steffen AU - Schmidt-Trucksäss, Arno PY - 2019/02/13 TI - Effectiveness of a Behavior Change Technique?Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial JO - JMIR Serious Games SP - e11444 VL - 7 IS - 1 KW - behavior change KW - exercise adherence KW - gamification KW - intrinsic motivation KW - mhealth KW - mobile phone game KW - physical activity KW - type 2 diabetes N2 - Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales ?interest/enjoyment? (+2.0 (SD 1.9) points, P<.001) and ?perceived competence? (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 UR - http://games.jmir.org/2019/1/e11444/ UR - http://dx.doi.org/10.2196/11444 UR - http://www.ncbi.nlm.nih.gov/pubmed/30758293 ID - info:doi/10.2196/11444 ER - TY - JOUR AU - Wu, Xinghan AU - Guo, Xitong AU - Zhang, Zhiwei PY - 2019/01/15 TI - The Efficacy of Mobile Phone Apps for Lifestyle Modification in Diabetes: Systematic Review and Meta-Analysis JO - JMIR Mhealth Uhealth SP - e12297 VL - 7 IS - 1 KW - smartphone KW - mobile applications KW - diabetes mellitus KW - lifestyle KW - physical activity KW - diet KW - behavior therapy N2 - Background: Diabetes and related complications are estimated to cost US $727 billion worldwide annually. Type 1 diabetes, type 2 diabetes, and gestational diabetes are three subtypes of diabetes that share the same behavioral risk factors. Efforts in lifestyle modification, such as daily physical activity and healthy diets, can reduce the risk of prediabetes, improve the health levels of people with diabetes, and prevent complications. Lifestyle modification is commonly performed in a face-to-face interaction, which can prove costly. Mobile phone apps provide a more accessible platform for lifestyle modification in diabetes. Objective: This review aimed to summarize and synthesize the clinical evidence of the efficacy of mobile phone apps for lifestyle modification in different subtypes of diabetes. Methods: In June 2018, we conducted a literature search in 5 databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, and PsycINFO). We evaluated the studies that passed screening using The Cochrane Collaboration?s risk of bias tool. We conducted a meta-analysis for each subtype on the mean difference (between intervention and control groups) at the posttreatment glycated hemoglobin (HbA1c) level. Where possible, we analyzed subgroups for short-term (3-6 months) and long-term (9-12 months) studies. Heterogeneity was assessed using the I2 statistic. Results: We identified total of 2669 articles through database searching. After the screening, we included 26 articles (23 studies) in the systematic review, of which 18 studies (5 type 1 diabetes, 11 type 2 diabetes, and 2 prediabetes studies) were eligible for meta-analysis. For type 1 diabetes, the overall effect on HbA1c was statistically insignificant (P=.46) with acceptable heterogeneity (I2=39%) in the short-term subgroup (4 studies) and significant heterogeneity between the short-term and long-term subgroups (I2=64%). Regarding type 2 diabetes, the overall effect on HbA1c was statistically significant (P<.01) in both subgroups, and when the 2 subgroups were combined, there was virtually no heterogeneity within and between the subgroups (I2 range 0%-2%). The effect remained statistically significant (P<.01) after adjusting for publication bias using the trim and fill method. For the prediabetes condition, the overall effect on HbA1c was statistically insignificant (P=.67) with a large heterogeneity (I2=65%) between the 2 studies. Conclusions: There is strong evidence for the efficacy of mobile phone apps for lifestyle modification in type 2 diabetes. The evidence is inconclusive for the other diabetes subtypes. UR - http://mhealth.jmir.org/2019/1/e12297/ UR - http://dx.doi.org/10.2196/12297 UR - http://www.ncbi.nlm.nih.gov/pubmed/30664494 ID - info:doi/10.2196/12297 ER - TY - JOUR AU - Griauzde, Dina AU - Kullgren, T. Jeffrey AU - Liestenfeltz, Brad AU - Ansari, Tahoora AU - Johnson, H. Emily AU - Fedewa, Allison AU - Saslow, R. Laura AU - Richardson, Caroline AU - Heisler, Michele PY - 2019/01/09 TI - A Mobile Phone-Based Program to Promote Healthy Behaviors Among Adults With Prediabetes Who Declined Participation in Free Diabetes Prevention Programs: Mixed-Methods Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e11267 VL - 7 IS - 1 KW - autonomous motivation KW - behavioral change KW - mHealth KW - mobile phone KW - prediabetes KW - prevention KW - type 2 diabetes mellitus N2 - Background: Despite evidence that Diabetes Prevention Programs (DPPs) can delay or prevent progression to type 2 diabetes mellitus (T2DM), few individuals with prediabetes enroll in offered programs. This may be in part because many individuals with prediabetes have low levels of autonomous motivation (ie, motivation that arises from internal sources) to prevent T2DM. Objective: This study aims to examine the feasibility and acceptability of a mobile health (mHealth) intervention designed to increase autonomous motivation and healthy behaviors among adults with prediabetes who previously declined participation free DPPs. In addition, the study aims to examine changes in autonomous motivation among adults offered 2 versions of the mHealth program compared with an information-only control group. Methods: In this 12-week, parallel, 3-arm, mixed-methods pilot randomized controlled trial, participants were randomized to (1) a group that received information about prediabetes and strategies to prevent T2DM (control); (2) a group that received a mHealth app that aims to increase autonomous motivation among users (app-only); or (3) a group that received the app plus a physical activity tracker and wireless-enabled digital scale for self-monitoring (app-plus). Primary outcome measures included rates of intervention uptake (number of individuals enrolled/number of individuals assessed for eligibility), retention (number of 12-week survey completers/number of participants), and adherence (number of device-usage days). The secondary outcome measure was change in autonomous motivation (measured using the Treatment Self-Regulation Questionnaire), which was examined using difference-in-difference analysis. Furthermore, we conducted postintervention qualitative interviews with participants. Results: Overall, 28% (69/244) of eligible individuals were randomized; of these, 80% (55/69) completed the 12-week survey. Retention rates were significantly higher among app-plus participants than participants in the other 2 study arms combined (P=.004, ?2). No significant differences were observed in adherence rates between app-only and app-plus participants (43 days vs 37 days; P=.34). Among all participants, mean autonomous motivation measures were relatively high at baseline (6.0 of 7.0 scale), with no statistically significant within- or between-group differences in follow-up scores. In qualitative interviews (n=15), participants identified reasons that they enjoyed using the app (eg, encouraged self-reflection), reasons that they did not enjoy using the app (eg, did not consider personal circumstances), and strategies to improve the intervention (eg, increased interpersonal contact). Conclusions: Among individuals with prediabetes who did not engage in free DPPs, this mHealth intervention was feasible and acceptable. Future work should (1) examine the effectiveness of a refined intervention on clinically relevant outcomes (eg, weight loss) among a larger population of DPP nonenrollees with low baseline autonomous motivation and (2) identify other factors associated with DPP nonenrollment, which may serve as additional potential targets for interventions. Trial Registration: ClinicalTrials.gov NCT03025607; https://clinicaltrials.gov/ct2/show/NCT03025607 (Archived by WebCite at http://www.webcitation.org/73cvaSAie) UR - http://mhealth.jmir.org/2019/1/e11267/ UR - http://dx.doi.org/10.2196/11267 UR - http://www.ncbi.nlm.nih.gov/pubmed/30626566 ID - info:doi/10.2196/11267 ER - TY - JOUR AU - Weatherall, James AU - Paprocki, Yurek AU - Meyer, M. Theresa AU - Kudel, Ian AU - Witt, A. Edward PY - 2018/06/05 TI - Sleep Tracking and Exercise in Patients With Type 2 Diabetes Mellitus (Step-D): Pilot Study to Determine Correlations Between Fitbit Data and Patient-Reported Outcomes JO - JMIR Mhealth Uhealth SP - e131 VL - 6 IS - 6 KW - Fitbit charge HR KW - type 2 diabetes mellitus KW - sleep KW - health outcomes KW - health behaviors N2 - Background: Few studies assessing the correlation between patient-reported outcomes and patient-generated health data from wearable devices exist. Objective: The aim of this study was to determine the direction and magnitude of associations between patient-generated health data (from the Fitbit Charge HR) and patient-reported outcomes for sleep patterns and physical activity in patients with type 2 diabetes mellitus (T2DM). Methods: This was a pilot study conducted with adults diagnosed with T2DM (n=86). All participants wore a Fitbit Charge HR for 14 consecutive days and completed internet-based surveys at 3 time points: day 1, day 7, and day 14. Patient-generated health data included minutes asleep and number of steps taken. Questionnaires assessed the number of days of exercise and nights of sleep problems per week. Means and SDs were calculated for all data, and Pearson correlations were used to examine associations between patient-reported outcomes and patient-generated health data. All respondents provided informed consent before participating. Results: The participants were predominantly middle-aged (mean 54.3, SD 13.3 years), white (80/86, 93%), and female (50/86, 58%). Use of oral T2DM medication correlated with the number of mean steps taken (r=.35, P=.001), whereas being unaware of the glycated hemoglobin level correlated with the number of minutes asleep (r=?.24, P=.04). On the basis of the Fitbit data, participants walked an average of 4955 steps and slept 6.7 hours per day. They self-reported an average of 2.0 days of exercise and 2.3 nights of sleep problems per week. The association between the number of days exercised and steps walked was strong (r=.60, P<.001), whereas the association between the number of troubled sleep nights and minutes asleep was weaker (r=.28, P=.02). Conclusions: Fitbit and patient-reported data were positively associated for physical activity as well as sleep, with the former more strongly correlated than the latter. As extensive patient monitoring can guide clinical decisions regarding T2DM therapy, passive, objective data collection through wearables could potentially enhance patient care, resulting in better patient-reported outcomes. UR - http://mhealth.jmir.org/2018/6/e131/ UR - http://dx.doi.org/10.2196/mhealth.8122 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/mhealth.8122 ER - TY - JOUR AU - Kaka, Bashir AU - Maharaj, Sooknunan Sonill PY - 2018/05/07 TI - Effect of Rebound Exercises and Circuit Training on Complications Associated with Type 2 Diabetes: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e124 VL - 7 IS - 5 KW - diabetes KW - musculoskeletal pain KW - exercise N2 - Background: The incidence of type 2 diabetes mellitus, a chronic lifestyle disease, and its complications are on the rise. Exercise has been documented as being effective in the management of musculoskeletal pain, depression, and reduction of hyperglycemia in diabetic patients. However, there is no consensus regarding the types of exercise that reduce musculoskeletal pain and depression and improve quality of life as well as respiratory function among individuals with type 2 diabetes. Objective: The objective of this study is to determine the effects of rebound and circuit training on musculoskeletal pain, blood glucose level, cholesterol level, quality of life, depression, and respiratory parameters in patients with type 2 diabetes mellitus. Methods: A total of 70 participants are expected to be recruited in this single blind randomized controlled trial. Computer-generated random numbers will be used to randomize the participants into 3 groups, namely, the rebound exercise group, the circuit exercise group, and the control group. Measurements will be taken at baseline and at the end of the 8 weeks of the study. Participants? musculoskeletal pain will be assessed using the visual analog scale, quality of life will be assessed using the SF 12 Health Survey Questionnaire, depression using the Beck Depression Inventory, respiratory parameters using the spirometer, and biochemical parameters such as glucose level and cholesterol level using the glucometer. Data will be analyzed using descriptive statistics and inferential statistics of multivariate analysis of variance between the groups and paired t test within the group. Alpha will be set at .05. Results: The results of this study will identify the effectiveness of rebound exercise and circuit training, compared with the control, in the management of type 2 diabetes mellitus and on quality of life, musculoskeletal pain, depression, glycemic control, cholesterol level, as well as improvement in respiratory function. Conclusions: Though different additional strategies such as exercise and dietary and lifestyle modifications exist for the control of type 2 diabetes, they are mostly applied for the control of glucose level. No strategies have been identified for the control of complications associated with diabetes such as musculoskeletal pain, depression, and reduction in quality of life. Trial Registration: Clinicaltrials.gov NCT03200795; https://clinicaltrials.gov/ct2/show/NCT03200795 (Archived by WebCite at http://www.webcitation.org/6mBgcj6z7) UR - http://www.researchprotocols.org/2018/5/e124/ UR - http://dx.doi.org/10.2196/resprot.8827 UR - http://www.ncbi.nlm.nih.gov/pubmed/29735476 ID - info:doi/10.2196/resprot.8827 ER - TY - JOUR AU - Lunde, Pernille AU - Nilsson, Blakstad Birgitta AU - Bergland, Astrid AU - Kværner, Jorunn Kari AU - Bye, Asta PY - 2018/05/04 TI - The Effectiveness of Smartphone Apps for Lifestyle Improvement in Noncommunicable Diseases: Systematic Review and Meta-Analyses JO - J Med Internet Res SP - e162 VL - 20 IS - 5 KW - smartphone KW - telemedicine KW - noncommunicable diseases KW - lifestyle KW - diet KW - exercise N2 - Background: Noncommunicable diseases (NCDs) account for 70% of all deaths in a year globally. The four main NCDs are cardiovascular diseases, cancers, chronic pulmonary diseases, and diabetes mellitus. Fifty percent of persons with NCD do not adhere to prescribed treatment; in fact, adherence to lifestyle interventions is especially considered as a major challenge. Smartphone apps permit structured monitoring of health parameters, as well as the opportunity to receive feedback. Objective: The aim of this study was to review and assess the effectiveness of app-based interventions, lasting at least 3 months, to promote lifestyle changes in patients with NCDs. Methods: In February 2017, a literature search in five databases (EMBASE, MEDLINE, CINAHL, Academic Research Premier, and Cochrane Reviews and Trials) was conducted. Inclusion criteria was quantitative study designs including randomized and nonrandomized controlled trials that included patients aged 18 years and older diagnosed with any of the four main NCDs. Lifestyle outcomes were physical activity, physical fitness, modification of dietary habits, and quality of life. All included studies were assessed for risk of bias using the Cochrane Collaboration`s risk of bias tool. Meta-analyses were conducted for one of the outcomes (glycated hemoglobin, HbA1c) by using the estimate of effect of mean post treatment with SD or CI. Heterogeneity was tested using the I2 test. All studies included in the meta-analyses were graded. Results: Of the 1588 records examined, 9 met the predefined criteria. Seven studies included diabetes patients only, one study included heart patients only, and another study included both diabetes and heart patients. Statistical significant effect was shown in HbA1c in 5 of 8 studies, as well in body weight in one of 5 studies and in waist circumference in one of 3 studies evaluating these outcomes. Seven of the included studies were included in the meta-analyses and demonstrated significantly overall effect on HbA1c on a short term (3-6 months; P=.02) with low heterogeneity (I2=41%). In the long term (10-12 months), the overall effect on HbA1c was statistical significant (P=.009) and without heterogeneity (I2=0%). The quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation was low for short term and moderate for long term. Conclusions: Our review demonstrated limited research of the use of smartphone apps for NCDs other than diabetes with a follow-up of at least 3 months. For diabetes, the use of apps seems to improve lifestyle factors, especially to decrease HbA1c. More research with long-term follow-up should be performed to assess the effect of smartphone apps for NCDs other than diabetes. UR - http://www.jmir.org/2018/5/e162/ UR - http://dx.doi.org/10.2196/jmir.9751 UR - http://www.ncbi.nlm.nih.gov/pubmed/29728346 ID - info:doi/10.2196/jmir.9751 ER - TY - JOUR AU - Wang, Jing AU - Cai, Chunyan AU - Padhye, Nikhil AU - Orlander, Philip AU - Zare, Mohammad PY - 2018/04/10 TI - A Behavioral Lifestyle Intervention Enhanced With Multiple-Behavior Self-Monitoring Using Mobile and Connected Tools for Underserved Individuals With Type 2 Diabetes and Comorbid Overweight or Obesity: Pilot Comparative Effectiveness Trial JO - JMIR Mhealth Uhealth SP - e92 VL - 6 IS - 4 KW - self-monitoring KW - diabetes KW - obesity KW - mobile health KW - behavior change KW - connected health KW - patient-generated health data KW - lifestyle KW - patient engagement KW - comparative effectiveness trial N2 - Background: Self-monitoring is a cornerstone of behavioral lifestyle interventions for obesity and type 2 diabetes mellitus. Mobile technology has the potential to improve adherence to self-monitoring and patient outcomes. However, no study has tested the use of a smartphone to facilitate self-monitoring in overweight or obese adults with type 2 diabetes mellitus living in the underserved community. Objective: The aim of this study was to examine the feasibility of and compare preliminary efficacy of a behavioral lifestyle intervention using smartphone- or paper-based self-monitoring of multiple behaviors on weight loss and glycemic control in a sample of overweight or obese adults with type 2 diabetes mellitus living in underserved communities. Methods: We conducted a randomized controlled trial to examine the feasibility and preliminary efficacy of a behavioral lifestyle intervention. Overweight or obese patients with type 2 diabetes mellitus were recruited from an underserved minority community health center in Houston, Texas. They were randomly assigned to one of the three groups: (1) behavior intervention with smartphone-based self-monitoring, (2) behavior intervention with paper diary-based self-monitoring, and (3) usual care group. Both the mobile and paper groups received a total of 11 face-to-face group sessions in a 6-month intervention. The mobile group received an Android-based smartphone with 2 apps loaded to help them record their diet, physical activity, weight, and blood glucose, along with a connected glucometer, whereas the paper group used paper diaries for these recordings. Primary outcomes of the study included percentage weight loss and glycated hemoglobin (HbA1c) changes over 6 months. Results: A total of 26 patients were enrolled: 11 in the mobile group, 9 in the paper group, and 6 in the control group. We had 92% (24/26) retention rate at 6 months. The sample is predominantly African Americans with an average age of 56.4 years and body mass index of 38.1. Participants lost an average of 2.73% (mobile group) and 0.13% (paper group) weight at 6 months, whereas the control group had an average 0.49% weight gain. Their HbA1c changed from 8% to 7 % in mobile group, 10% to 9% in paper group, and maintained at 9% for the control group. We found a significant difference on HbA1c at 6 months among the 3 groups (P=.01). We did not find statistical group significance on percentage weight loss (P=.20) and HbA1c changes (P=.44) overtime; however, we found a large effect size of 0.40 for weight loss and a medium effect size of 0.28 for glycemic control. Conclusions: Delivering a simplified behavioral lifestyle intervention using mobile health?based self-monitoring in an underserved community is feasible and acceptable and shows higher preliminary efficacy, as compared with paper-based self-monitoring. A full-scale randomized controlled trial is needed to confirm the findings in this pilot study. Trial Registration: ClinicalTrials.gov NCT02858648; https://clinicaltrials.gov/ct2/show/NCT02858648 (Archived by WebCite at http://www.webcitation.org/6ySidjmT7) UR - http://mhealth.jmir.org/2018/4/e92/ UR - http://dx.doi.org/10.2196/mhealth.4478 UR - http://www.ncbi.nlm.nih.gov/pubmed/29636320 ID - info:doi/10.2196/mhealth.4478 ER - TY - JOUR AU - Berman, A. Mark AU - Guthrie, L. Nicole AU - Edwards, L. Katherine AU - Appelbaum, J. Kevin AU - Njike, Y. Valentine AU - Eisenberg, M. David AU - Katz, L. David PY - 2018/02/14 TI - Change in Glycemic Control With Use of a Digital Therapeutic in Adults With Type 2 Diabetes: Cohort Study JO - JMIR Diabetes SP - e4 VL - 3 IS - 1 KW - type 2 diabetes KW - mobile health KW - mHealth KW - lifestyle medicine KW - mobile apps KW - digital therapeutics N2 - Background: Intensive lifestyle change can treat and even reverse type 2 diabetes. Digital therapeutics have the potential to deliver lifestyle as medicine for diabetes at scale. Objective: This 12-week study investigates the effects of a novel digital therapeutic, FareWell, on hemoglobin A1c (HbA1c) and diabetes medication use. Methods: Adults with type 2 diabetes and a mobile phone were recruited throughout the United States using Facebook advertisements. The intervention aim was to effect a sustainable shift to a plant-based dietary pattern and regular exercise by advancing culinary literacy and lifestyle skill acquisition. The intervention was delivered by an app paired with specialized human support, also delivered digitally. Health coaching was provided every 2 weeks by telephone, and a clinical team was available for participants requiring additional support. Participants self-reported current medications and HbA1c at the beginning and end of the 12-week program. Self-efficacy related to managing diabetes and maintaining dietary changes was assessed via survey. Engagement was recorded automatically through the app. Results: We enrolled 118 participants with a baseline HbA1c >6.5%. Participants were 81.4% female (96/118) and resided in 38 US states with a mean age of 50.7 (SD 9.4) years, baseline body mass index of 38.1 (SD 8.8) kg/m2, and baseline HbA1c of 8.1% (SD 1.6). At 12 weeks, 86.2% (94/109) of participants were still using the app. Mean change in HbA1c was ?0.8% (97/101, SD 1.3, P<.001) for those reporting end-study data. For participants with a baseline HbA1c >7.0% who did not change medications midstudy, HbA1c change was ?1.1% (67/69, SD 1.4, P<.001). The proportion of participants with an end-study HbA1c <6.5% was 28% (22/97). After completion of the intervention, 17% (16/97) of participants reported a decrease in diabetic medication while 8% (8/97) reported an increase. A total of 57% (55/97) of participants achieved a composite outcome of reducing HbA1c, reducing diabetic medication use, or both; 92% (90/98) reported greater confidence in their ability to manage their diabetes compared to before the program, and 91% (89/98) reported greater confidence in their ability to maintain a healthy dietary pattern. Participants engaged with the app an average of 4.3 times per day. We observed a significantly greater decrease in HbA1c among participants in the highest tertile of app engagement compared to those in the lowest tertile of app engagement (P=.03). Conclusions: Clinically meaningful reductions in HbA1c were observed with use of the FareWell digital therapeutic. Greater glycemic control was observed with increasing app engagement. Engagement and retention were both high in this widely distributed sample. UR - http://diabetes.jmir.org/2018/1/e4/ UR - http://dx.doi.org/10.2196/diabetes.9591 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291074 ID - info:doi/10.2196/diabetes.9591 ER - TY - JOUR AU - Osborn, Y. Chandra AU - van Ginkel, R. Joost AU - Marrero, G. David AU - Rodbard, David AU - Huddleston, Brian AU - Dachis, Jeff PY - 2017/11/29 TI - One Drop | Mobile on iPhone and Apple Watch: An Evaluation of HbA1c Improvement Associated With Tracking Self-Care JO - JMIR Mhealth Uhealth SP - e179 VL - 5 IS - 11 KW - type 1 diabetes KW - type 2 diabetes KW - mobile health KW - mobile phone KW - smartwatch KW - glycated hemoglobin A1c KW - HbA1c KW - glycemic control KW - self-care behavior N2 - Background: The One Drop | Mobile app supports manual and passive (via HealthKit and One Drop?s glucose meter) tracking of self-care and glycated hemoglobin A1c (HbA1c). Objective: We assessed the HbA1c change of a sample of people with type 1 diabetes (T1D) or type 2 diabetes (T2D) using the One Drop | Mobile app on iPhone and Apple Watch, and tested relationships between self-care tracking with the app and HbA1c change. Methods: In June 2017, we identified people with diabetes using the One Drop | Mobile app on iPhone and Apple Watch who entered two HbA1c measurements in the app 60 to 365 days apart. We assessed the relationship between using the app and HbA1c change. Results: Users had T1D (n=65) or T2D (n=191), were 22.7% (58/219) female, with diabetes for a mean 8.34 (SD 8.79) years, and tracked a mean 2176.35 (SD 3430.23) self-care activities between HbA1c entries. There was a significant 1.36% or 14.9 mmol/mol HbA1c reduction (F=62.60, P<.001) from the first (8.72%, 71.8 mmol/mol) to second HbA1c (7.36%, 56.9 mmol/mol) measurement. Tracking carbohydrates was independently associated with greater HbA1c improvement (all P<.01). Conclusions: Using One Drop | Mobile on iPhone and Apple Watch may favorably impact glycemic control. UR - http://mhealth.jmir.org/2017/11/e179/ UR - http://dx.doi.org/10.2196/mhealth.8781 UR - http://www.ncbi.nlm.nih.gov/pubmed/29187344 ID - info:doi/10.2196/mhealth.8781 ER - TY - JOUR AU - Hansel, Boris AU - Giral, Philippe AU - Gambotti, Laetitia AU - Lafourcade, Alexandre AU - Peres, Gilbert AU - Filipecki, Claude AU - Kadouch, Diana AU - Hartemann, Agnes AU - Oppert, Jean-Michel AU - Bruckert, Eric AU - Marre, Michel AU - Bruneel, Arnaud AU - Duchene, Emilie AU - Roussel, Ronan PY - 2017/11/08 TI - A Fully Automated Web-Based Program Improves Lifestyle Habits and HbA1c in Patients With Type 2 Diabetes and Abdominal Obesity: Randomized Trial of Patient E-Coaching Nutritional Support (The ANODE Study) JO - J Med Internet Res SP - e360 VL - 19 IS - 11 KW - e-health KW - nutrition KW - type 2 diabetes N2 - Background: The prevalence of abdominal obesity and type 2 diabetes mellitus (T2DM) is a public health challenge. New solutions need to be developed to help patients implement lifestyle changes. Objective: The objective of the study was to evaluate a fully automated Web-based intervention designed to help users improve their dietary habits and increase their physical activity. Methods: The Accompagnement Nutritionnel de l?Obésité et du Diabète par E-coaching (ANODE) study was a 16-week, 1:1 parallel-arm, open-label randomized clinical trial. Patients with T2DM and abdominal obesity (n=120, aged 18-75 years) were recruited. Patients in the intervention arm (n=60) had access to a fully automated program (ANODE) to improve their lifestyle. Patients were asked to log on at least once per week. Human contact was limited to hotline support in cases of technical issues. The dietetic tool provided personalized menus and a shopping list for the day or the week. Stepwise physical activity was prescribed. The control arm (n=60) received general nutritional advice. The primary outcome was the change of the dietary score (International Diet Quality Index; DQI-I) between baseline and the end of the study. Secondary endpoints included changes in body weight, waist circumference, hemoglobin A1c (HbA1c) and measured maximum oxygen consumption (VO2 max). Results: The mean age of the participants was 57 years (standard deviation [SD] 9), mean body mass index was 33 kg/m² (SD 4), mean HbA1c was 7.2% (SD 1.1), and 66.7% (80/120) of participants were women. Using an intention-to-treat analysis, the DQI-I score (54.0, SD 5.7 in the ANODE arm; 52.8, SD 6.2 in the control arm; P=.28) increased significantly in the ANODE arm compared to the control arm (+4.55, SD 5.91 vs -1.68, SD 5.18; between arms P<.001). Body weight, waist circumference, and HbA1c changes improved significantly in the intervention. Conclusions: Among patients with T2DM and abdominal obesity, the use of a fully automated Web-based program resulted in a significant improvement in dietary habits and favorable clinical and laboratory changes. The sustainability of these effects remains to be determined. Trial Registration: ClinicalTrials.gov NCT02343107; http://clinicaltrials.gov/ct2/show/NCT02343107 (Archived by WebCite at http://www.webcitation.org/6uVMKPRzs) UR - http://www.jmir.org/2017/11/e360/ UR - http://dx.doi.org/10.2196/jmir.7947 UR - http://www.ncbi.nlm.nih.gov/pubmed/29117929 ID - info:doi/10.2196/jmir.7947 ER - TY - JOUR AU - Connelly, Jenni AU - Kirk, Alison AU - Masthoff, Judith AU - MacRury, Sandra PY - 2017/10/19 TI - A Website to Promote Physical Activity in People With Type 2 Diabetes Living in Remote or Rural Locations: Feasibility Pilot Randomized Controlled Trial JO - JMIR Diabetes SP - e26 VL - 2 IS - 2 KW - blood glucose KW - diabetes KW - physical activity KW - rural KW - virtual trainer KW - Web based N2 - 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; http://www.isrctn.com/ISRCTN96266587 (Archived by WebCite at http://www.webcitation.org/6tzX6YesZ) UR - http://diabetes.jmir.org/2017/2/e26/ UR - http://dx.doi.org/10.2196/diabetes.6669 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291091 ID - info:doi/10.2196/diabetes.6669 ER - TY - JOUR AU - Lentferink, J. Aniek AU - Oldenhuis, KE Hilbrand AU - de Groot, Martijn AU - Polstra, Louis AU - Velthuijsen, Hugo AU - van Gemert-Pijnen, EWC Julia PY - 2017/08/01 TI - Key Components in eHealth Interventions Combining Self-Tracking and Persuasive eCoaching to Promote a Healthier Lifestyle: A Scoping Review JO - J Med Internet Res SP - e277 VL - 19 IS - 8 KW - telemedicine KW - review KW - health promotion KW - remote sensing technology N2 - Background: The combination of self-tracking and persuasive eCoaching in automated interventions is a new and promising approach for healthy lifestyle management. Objective: The aim of this study was to identify key components of self-tracking and persuasive eCoaching in automated healthy lifestyle interventions that contribute to their effectiveness on health outcomes, usability, and adherence. A secondary aim was to identify the way in which these key components should be designed to contribute to improved health outcomes, usability, and adherence. Methods: The scoping review methodology proposed by Arskey and O?Malley was applied. Scopus, EMBASE, PsycINFO, and PubMed were searched for publications dated from January 1, 2013 to January 31, 2016 that included (1) self-tracking, (2) persuasive eCoaching, and (3) healthy lifestyle intervention. Results: The search resulted in 32 publications, 17 of which provided results regarding the effect on health outcomes, 27 of which provided results regarding usability, and 13 of which provided results regarding adherence. Among the 32 publications, 27 described an intervention. The most commonly applied persuasive eCoaching components in the described interventions were personalization (n=24), suggestion (n=19), goal-setting (n=17), simulation (n=17), and reminders (n=15). As for self-tracking components, most interventions utilized an accelerometer to measure steps (n=11). Furthermore, the medium through which the user could access the intervention was usually a mobile phone (n=10). The following key components and their specific design seem to influence both health outcomes and usability in a positive way: reduction by setting short-term goals to eventually reach long-term goals, personalization of goals, praise messages, reminders to input self-tracking data into the technology, use of validity-tested devices, integration of self-tracking and persuasive eCoaching, and provision of face-to-face instructions during implementation. In addition, health outcomes or usability were not negatively affected when more effort was requested from participants to input data into the technology. The data extracted from the included publications provided limited ability to identify key components for adherence. However, one key component was identified for both usability and adherence, namely the provision of personalized content. Conclusions: This scoping review provides a first overview of the key components in automated healthy lifestyle interventions combining self-tracking and persuasive eCoaching that can be utilized during the development of such interventions. Future studies should focus on the identification of key components for effects on adherence, as adherence is a prerequisite for an intervention to be effective. UR - http://www.jmir.org/2017/8/e277/ UR - http://dx.doi.org/10.2196/jmir.7288 UR - http://www.ncbi.nlm.nih.gov/pubmed/28765103 ID - info:doi/10.2196/jmir.7288 ER - TY - JOUR AU - Martinez, Mark AU - Park, Bin Su AU - Maison, Isaac AU - Mody, Vicky AU - Soh, Sungkon Lewis AU - Parihar, Singh Harish PY - 2017/07/11 TI - iOS Appstore-Based Phone Apps for Diabetes Management: Potential for Use in Medication Adherence JO - JMIR Diabetes SP - e12 VL - 2 IS - 2 KW - diabetes KW - telemedicine KW - blood glucose self-monitoring glucose monitoring KW - mobile applications KW - self-care KW - mobile health N2 - Background: Currently, various phone apps have been developed to assist patients. Many of these apps are developed to assist patients in the self-management of chronic diseases such as diabetes. It is essential to analyze these various apps to understand the key features that would potentially be instrumental in helping patients successfully achieve goals in disease self-management. Objective: The objective of this study was to conduct a review of all the available diabetes-related apps in the iOS App Store to evaluate which diabetic app is more interactive and offers a wide variety of operations such as monitoring glucose, water, carbohydrate intake, weight, body mass index (BMI), medication, blood pressure (BP) levels, reminders or push notifications, food database, charts, exercise management, email, sync between devices, syncing data directly to the prescribers, and other miscellaneous functions such as (Twitter integration, password protection, retina display, barcode scanner, apple watch functionality, and cloud syncing). Methods: Data was gathered using the iOS App Store on an iPad. The search term ?diabetes? resulted in 1209 results. Many of the results obtained were remotely related to diabetes and focused mainly on diet, exercise, emergency services, refill reminders, providing general diabetes information, and other nontherapeutic options. We reviewed each app description and only included apps that were meant for tracking blood glucose levels. All data were obtained in one sitting by one person on the same device, as we found that carrying out the search at different times or on different devices (iPhones) resulted in varying results. Apps that did not have a feature for tracking glucose levels were excluded from the study. Results: The search resulted in 1209 results; 85 apps were retained based on the inclusion criteria mentioned above. All the apps were reviewed for average customer ratings, number of reviews, price, and functions. Of all the apps surveyed, 18 apps with the highest number of user ratings were used for in-depth analysis. Of these 18 apps, 50% (9/18) also had a medication adherence function. Our analysis revealed that the Diabetes logbook used by the mySugr app was one of the best; it differentiated itself by introducing fun as a method of increasing adherence. Conclusions: A large variation was seen in patient ratings of app features. Many patient reviewers desired simplicity of app functions. Glucose level tracking and email features potentially helped patients and health care providers manage the disease more efficiently. However, none of the apps could sync data directly to the prescribers. Additional features such as graph customization, availability of data backup, and recording previous entries were also requested by many users. Thus, the use of apps in disease management and patient and health-care provider involvement in future app refinement and development should be encouraged. UR - http://diabetes.jmir.org/2017/2/e12/ UR - http://dx.doi.org/10.2196/diabetes.6468 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291096 ID - info:doi/10.2196/diabetes.6468 ER - TY - JOUR AU - Haste, Anna AU - Adamson, J. Ashley AU - McColl, Elaine AU - Araujo-Soares, Vera AU - Bell, Ruth PY - 2017/07/07 TI - Web-Based Weight Loss Intervention for Men With Type 2 Diabetes: Pilot Randomized Controlled Trial JO - JMIR Diabetes SP - e14 VL - 2 IS - 2 KW - weight loss KW - Web-based intervention KW - feasibility studies KW - pilot RCT KW - randomized controlled trial KW - pilot projects KW - type 2 diabetes KW - diabetes mellitus, type 2 KW - men KW - men's health KW - process evaluation N2 - Background: Rising obesity levels remain a major public health concern due to the clear link with several comorbidities such as diabetes. Diabetes now affects 6% of the UK population. Modest weight loss of 5% to 10% has been shown to be associated with significant reductions in blood sugar, lipid, and blood pressure levels. Men have been shown to be attracted to programs that do not require extensive face-to-face time commitments, illustrating the potential audience available for health behavior change via the Web. Objective: The objective of our study was to evaluate the feasibility and acceptability of a Web-based weight loss intervention in men with type 2 diabetes. Methods: We conducted a pilot, parallel 2-arm, individually randomized controlled trial with embedded process evaluation. Participants were randomly assigned in a one-to-one ratio to the usual care group or the 12-month Web-based weight loss intervention, including dietitian and exercise expert feedback. Face-to-face recruitment and assessment were performed by the researcher unblinded. Data collected included weight, height, body mass index (BMI), and waist circumference, together with an audit trail of eligibility, recruitment, retention, and adherence rates. A process evaluation (website use data and qualitative interviews) monitored adherence, acceptability, and feasibility of the intervention. Results: General practice database searches achieved the recruitment target (n=61) for the population of men with type 2 diabetes, of whom 66% (40/61) completed 3-month follow-up measurements. By 12 months, the retention rate was 52% (32/61), with 12 of the 33 men allocated to the intervention group still active on the website. The intervention was seen as acceptable by the majority of participants. We gained insights about acceptability and use of the website from the parallel process evaluation. Conclusions: Recruitment to the Web-based weight loss intervention was successful. Results are descriptive, but there were positive indications of increased weight loss (in kilograms and as a percentage), and reduced waist circumference and BMI for the intervention group from 3 to 12 months, in comparison with control. This research adds to the evidence base in relation to incorporating a Web-based weight loss intervention within the UK National Health Service (NHS). NHS weight loss services are struggling to provide sufficient referrals. Therefore, alternative modes of delivery, with the potential to reduce health professional input and time per patient while still enabling individual and tailored care, need to be investigated to identify whether they can be effective and thus benefit the NHS. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 48086713; http://www.isrctn.com/ISRCTN48086713 (Archived by WebCite at http://www.webcitation.org/6rO4xSlhI) UR - http://diabetes.jmir.org/2017/2/e14/ UR - http://dx.doi.org/10.2196/diabetes.7430 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291100 ID - info:doi/10.2196/diabetes.7430 ER - TY - JOUR AU - Bian, R. Rachel AU - Piatt, A. Gretchen AU - Sen, Ananda AU - Plegue, A. Melissa AU - De Michele, L. Mariana AU - Hafez, Dina AU - Czuhajewski, M. Christina AU - Buis, R. Lorraine AU - Kaufman, Neal AU - Richardson, R. Caroline PY - 2017/03/27 TI - The Effect of Technology-Mediated Diabetes Prevention Interventions on Weight: A Meta-Analysis JO - J Med Internet Res SP - e76 VL - 19 IS - 3 KW - diabetes mellitus, type 2 KW - weight reduction programs KW - technology KW - meta-analysis KW - prediabetic state N2 - Background: Lifestyle interventions targeting weight loss, such as those delivered through the Diabetes Prevention Program, reduce the risk of developing type 2 diabetes. Technology-mediated interventions may be an option to help overcome barriers to program delivery, and to disseminate diabetes prevention programs on a larger scale. Objective: We conducted a meta-analysis to evaluate the effect of such technology-mediated interventions on weight loss. Methods: In this meta-analysis, six databases were searched to identify studies reporting weight change that used technology to mediate diet and exercise interventions, and targeted individuals at high risk for developing type 2 diabetes. Studies published between January 1, 2002 and August 4, 2016 were included. Results: The search identified 1196 citations. Of those, 15 studies met the inclusion criteria and evaluated 18 technology-mediated intervention arms delivered to a total of 2774 participants. Study duration ranged from 12 weeks to 2 years. A random-effects meta-analysis showed a pooled weight loss effect of 3.76 kilograms (95% CI 2.8-4.7; P<.001) for the interventions. Several studies also reported improved glycemic control following the intervention. The small sample sizes and heterogeneity of the trials precluded an evaluation of which technology-mediated intervention method was most efficacious. Conclusions: Technology-mediated diabetes prevention programs can result in clinically significant amounts of weight loss, as well as improvements in glycaemia in patients with prediabetes. Due to their potential for large-scale implementation, these interventions will play an important role in the dissemination of diabetes prevention programs. UR - http://www.jmir.org/2017/3/e76/ UR - http://dx.doi.org/10.2196/jmir.4709 UR - http://www.ncbi.nlm.nih.gov/pubmed/28347972 ID - info:doi/10.2196/jmir.4709 ER - TY - JOUR AU - McKenzie, L. Amy AU - Hallberg, J. Sarah AU - Creighton, C. Brent AU - Volk, M. Brittanie AU - Link, M. Theresa AU - Abner, K. Marcy AU - Glon, M. Roberta AU - McCarter, P. James AU - Volek, S. Jeff AU - Phinney, D. Stephen PY - 2017/03/07 TI - A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes JO - JMIR Diabetes SP - e5 VL - 2 IS - 1 KW - type 2 diabetes KW - ketosis KW - Hb A1c KW - weight loss KW - mobile health N2 - Background: Type 2 diabetes (T2D) is typically managed with a reduced fat diet plus glucose-lowering medications, the latter often promoting weight gain. Objective: We evaluated whether individuals with T2D could be taught by either on-site group or remote means to sustain adequate carbohydrate restriction to achieve nutritional ketosis as part of a comprehensive intervention, thereby improving glycemic control, decreasing medication use, and allowing clinically relevant weight loss. Methods: This study was a nonrandomized, parallel arm, outpatient intervention. Adults with T2D (N=262; mean age 54, SD 8, years; mean body mass index 41, SD 8, kg·m?2; 66.8% (175/262) women) were enrolled in an outpatient protocol providing intensive nutrition and behavioral counseling, digital coaching and education platform, and physician-guided medication management. A total of 238 participants completed the first 10 weeks. Body weight, capillary blood glucose, and beta-hydroxybutyrate (BOHB) levels were recorded daily using a mobile interface. Hemoglobin A1c (HbA1c) and related biomarkers of T2D were evaluated at baseline and 10-week follow-up. Results: Baseline HbA1c level was 7.6% (SD 1.5%) and only 52/262 (19.8%) participants had an HbA1c level of <6.5%. After 10 weeks, HbA1c level was reduced by 1.0% (SD 1.1%; 95% CI 0.9% to 1.1%, P<.001), and the percentage of individuals with an HbA1c level of <6.5% increased to 56.1% (147/262). The majority of participants (234/262, 89.3%) were taking at least one diabetes medication at baseline. By 10 weeks, 133/234 (56.8%) individuals had one or more diabetes medications reduced or eliminated. At follow-up, 47.7% of participants (125/262) achieved an HbA1c level of <6.5% while taking metformin only (n=86) or no diabetes medications (n=39). Mean body mass reduction was 7.2% (SD 3.7%; 95% CI 5.8% to 7.7%, P<.001) from baseline (117, SD 26, kg). Mean BOHB over 10 weeks was 0.6 (SD 0.6) mmol·L?1 indicating consistent carbohydrate restriction. Post hoc comparison of the remote versus on-site means of education revealed no effect of delivery method on change in HbA1c (F1,260=1.503, P=.22). Conclusions: These initial results indicate that an individualized program delivered and supported remotely that incorporates nutritional ketosis can be highly effective in improving glycemic control and weight loss in adults with T2D while significantly decreasing medication use. UR - http://diabetes.jmir.org/2017/1/e5/ UR - http://dx.doi.org/10.2196/diabetes.6981 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291062 ID - info:doi/10.2196/diabetes.6981 ER - TY - JOUR AU - Saslow, R. Laura AU - Mason, E. Ashley AU - Kim, Sarah AU - Goldman, Veronica AU - Ploutz-Snyder, Robert AU - Bayandorian, Hovig AU - Daubenmier, Jennifer AU - Hecht, M. Frederick AU - Moskowitz, T. Judith PY - 2017/02/13 TI - An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial JO - J Med Internet Res SP - e36 VL - 19 IS - 2 KW - eHealth KW - diet KW - weight loss KW - type 2 diabetes mellitus N2 - Background: Type 2 diabetes is a prevalent, chronic disease for which diet is an integral aspect of treatment. In our previous trial, we found that recommendations to follow a very low-carbohydrate ketogenic diet and to change lifestyle factors (physical activity, sleep, positive affect, mindfulness) helped overweight people with type 2 diabetes or prediabetes improve glycemic control and lose weight. This was an in-person intervention, which could be a barrier for people without the time, flexibility, transportation, social support, and/or financial resources to attend. Objective: The aim was to determine whether an online intervention based on our previous recommendations (an ad libitum very low-carbohydrate ketogenic diet with lifestyle factors; ?intervention?) or an online diet program based on the American Diabetes Associations? ?Create Your Plate? diet (?control?) would improve glycemic control and other health outcomes among overweight individuals with type 2 diabetes. Methods: In this pilot feasibility study, we randomized overweight adults (body mass index ?25) with type 2 diabetes (glycated hemoglobin [HbA1c] 6.5%-9.0%) to a 32-week online intervention based on our previous recommendations (n=12) or an online diet program based around a plate method diet (n=13) to assess the impact of each intervention on glycemic control and other health outcomes. Primary and secondary outcomes were analyzed by mixed-effects linear regression to compare outcomes by group. Results: At 32 weeks, participants in the intervention group reduced their HbA1c levels more (estimated marginal mean [EMM] ?0.8%, 95% CI ?1.1% to ?0.6%) than participants in the control group (EMM ?0.3%, 95% CI ?0.6% to 0.0%; P=.002). More than half of the participants in the intervention group (6/11, 55%) lowered their HbA1c to less than 6.5% versus 0% (0/8) in the control group (P=.02). Participants in the intervention group lost more weight (EMM ?12.7 kg, 95% CI ?16.1 to ?9.2 kg) than participants in the control group (EMM ?3.0 kg, 95% CI ?7.3 to 1.3 kg; P<.001). A greater percentage of participants lost at least 5% of their body weight in the intervention (10/11, 90%) versus the control group (2/8, 29%; P=.01). Participants in the intervention group lowered their triglyceride levels (EMM ?60.1 mg/dL, 95% CI ?91.3 to ?28.9 mg/dL) more than participants in the control group (EMM ?6.2 mg/dL, 95% CI ?46.0 to 33.6 mg/dL; P=.01). Dropout was 8% (1/12) and 46% (6/13) for the intervention and control groups, respectively (P=.07). Conclusions: Individuals with type 2 diabetes improved their glycemic control and lost more weight after being randomized to a very low-carbohydrate ketogenic diet and lifestyle online program rather than a conventional, low-fat diabetes diet online program. Thus, the online delivery of these very low-carbohydrate ketogenic diet and lifestyle recommendations may allow them to have a wider reach in the successful self-management of type 2 diabetes. Trial Registration: ClinicalTrials.gov NCT01967992; https://clinicaltrials.gov/ct2/show/NCT01967992 (Archived by WebCite at http://www.webcitation.org/6o0fI9Mkq) UR - http://www.jmir.org/2017/2/e36/ UR - http://dx.doi.org/10.2196/jmir.5806 UR - http://www.ncbi.nlm.nih.gov/pubmed/28193599 ID - info:doi/10.2196/jmir.5806 ER - TY - JOUR AU - Agboola, Stephen AU - Jethwani, Kamal AU - Lopez, Lenny AU - Searl, Meghan AU - O?Keefe, Sandra AU - Kvedar, Joseph PY - 2016/11/18 TI - Text to Move: A Randomized Controlled Trial of a Text-Messaging Program to Improve Physical Activity Behaviors in Patients With Type 2 Diabetes Mellitus JO - J Med Internet Res SP - e307 VL - 18 IS - 11 KW - type 2 diabetes KW - text messaging KW - mobile phones KW - physical activity KW - engagement KW - pedometers N2 - Background: Text messages are increasingly being used because of the low cost and the ubiquitous nature of mobile phones to engage patients in self-care behaviors. Self-care is particularly important in achieving treatment outcomes in type 2 diabetes mellitus (T2DM). Objective: This study examined the effect of personalized text messages on physical activity, as measured by a pedometer, and clinical outcomes in a diverse population of patients with T2DM. Methods: Text to Move (TTM) incorporates physical activity monitoring and coaching to provide automated and personalized text messages to help patients with T2DM achieve their physical activity goals. A total of 126 English- or Spanish-speaking patients with glycated hemoglobin A1c (HbA1c) >7 were enrolled in-person to participate in the study for 6 months and were randomized into either the intervention arm that received the full complement of the intervention or a control arm that received only pedometers. The primary outcome was change in physical activity. We also assessed the effect of the intervention on HbA1c, weight, and participant engagement. Results: All participants (intervention: n=64; control: n=62) were included in the analyses. The intervention group had significantly higher monthly step counts in the third (risk ratio [RR] 4.89, 95% CI 1.20 to 19.92, P=.03) and fourth (RR 6.88, 95% CI 1.21 to 39.00, P=.03) months of the study compared to the control group. However, over the 6-month follow-up period, monthly step counts did not differ statistically by group (intervention group: 9092 steps; control group: 3722 steps; RR 2.44, 95% CI 0.68 to 8.74, P=.17). HbA1c decreased by 0.07% (95% CI ?0.47 to 0.34, P=.75) in the TTM group compared to the control group. Within groups, HbA1c decreased significantly from baseline in the TTM group by ?0.43% (95% CI ?0.75 to ?0.12, P=.01), but nonsignificantly in the control group by ?0.21% (95% CI ?0.49 to 0.06, P=.13). Similar changes were observed for other secondary outcomes. Conclusion: Personalized text messaging can be used to improve outcomes in patients with T2DM by employing optimal patient engagement measures. UR - http://www.jmir.org/2016/11/e307/ UR - http://dx.doi.org/10.2196/jmir.6439 UR - http://www.ncbi.nlm.nih.gov/pubmed/27864165 ID - info:doi/10.2196/jmir.6439 ER - TY - JOUR AU - Rhyner, Daniel AU - Loher, Hannah AU - Dehais, Joachim AU - Anthimopoulos, Marios AU - Shevchik, Sergey AU - Botwey, Henry Ransford AU - Duke, David AU - Stettler, Christoph AU - Diem, Peter AU - Mougiakakou, Stavroula PY - 2016/05/11 TI - Carbohydrate Estimation by a Mobile Phone-Based System Versus Self-Estimations of Individuals With Type 1 Diabetes Mellitus: A Comparative Study JO - J Med Internet Res SP - e101 VL - 18 IS - 5 KW - diabetes mellitus, type 1 KW - carbohydrate counting KW - computer vision systems KW - food recognition KW - meal assessment KW - mobile phone KW - food volume estimation N2 - Background: Diabetes mellitus is spreading throughout the world and diabetic individuals have been shown to often assess their food intake inaccurately; therefore, it is a matter of urgency to develop automated diet assessment tools. The recent availability of mobile phones with enhanced capabilities, together with the advances in computer vision, have permitted the development of image analysis apps for the automated assessment of meals. GoCARB is a mobile phone-based system designed to support individuals with type 1 diabetes during daily carbohydrate estimation. In a typical scenario, the user places a reference card next to the dish and acquires two images using a mobile phone. A series of computer vision modules detect the plate and automatically segment and recognize the different food items, while their 3D shape is reconstructed. Finally, the carbohydrate content is calculated by combining the volume of each food item with the nutritional information provided by the USDA Nutrient Database for Standard Reference. Objective: The main objective of this study is to assess the accuracy of the GoCARB prototype when used by individuals with type 1 diabetes and to compare it to their own performance in carbohydrate counting. In addition, the user experience and usability of the system is evaluated by questionnaires. Methods: The study was conducted at the Bern University Hospital, ?Inselspital? (Bern, Switzerland) and involved 19 adult volunteers with type 1 diabetes, each participating once. Each study day, a total of six meals of broad diversity were taken from the hospital?s restaurant and presented to the participants. The food items were weighed on a standard balance and the true amount of carbohydrate was calculated from the USDA nutrient database. Participants were asked to count the carbohydrate content of each meal independently and then by using GoCARB. At the end of each session, a questionnaire was completed to assess the user?s experience with GoCARB. Results: The mean absolute error was 27.89 (SD 38.20) grams of carbohydrate for the estimation of participants, whereas the corresponding value for the GoCARB system was 12.28 (SD 9.56) grams of carbohydrate, which was a significantly better performance ( P=.001). In 75.4% (86/114) of the meals, the GoCARB automatic segmentation was successful and 85.1% (291/342) of individual food items were successfully recognized. Most participants found GoCARB easy to use. Conclusions: This study indicates that the system is able to estimate, on average, the carbohydrate content of meals with higher accuracy than individuals with type 1 diabetes can. The participants thought the app was useful and easy to use. GoCARB seems to be a well-accepted supportive mHealth tool for the assessment of served-on-a-plate meals. UR - http://www.jmir.org/2016/5/e101/ UR - http://dx.doi.org/10.2196/jmir.5567 UR - http://www.ncbi.nlm.nih.gov/pubmed/27170498 ID - info:doi/10.2196/jmir.5567 ER - TY - JOUR AU - Arambepola, Carukshi AU - Ricci-Cabello, Ignacio AU - Manikavasagam, Pavithra AU - Roberts, Nia AU - French, P. David AU - Farmer, Andrew PY - 2016/04/19 TI - The Impact of Automated Brief Messages Promoting Lifestyle Changes Delivered Via Mobile Devices to People with Type 2 Diabetes: A Systematic Literature Review and Meta-Analysis of Controlled Trials JO - J Med Internet Res SP - e86 VL - 18 IS - 4 KW - Diabetes mellitus, type 2 KW - mobile health KW - text messaging KW - systematic review KW - diet KW - physical activity KW - self-care N2 - Background: Brief automated messages have the potential to support self-management in people with type 2 diabetes, but their effect compared with usual care is unclear. Objective: To examine the effectiveness of interventions to change lifestyle behavior delivered via automated brief messaging in patients with type 2 diabetes. Methods: A systematic literature review of controlled trials examined the impact of interventions, delivered by brief messaging, and intended to promote lifestyle change in people with type 2 diabetes, on behavioral and clinical outcomes. Bibliographic databases searched included Medline, Embase, CINAHL, PsycINFO, and ISI WoK. Two reviewers independently screened citations. We extracted information on study risk of bias, setting (high versus low- and middle-income countries) and intervention characteristics (including use of theory and behavior-change techniques). Outcome measures included acceptability of the interventions and their impact on 1) determinants of lifestyle behavior (knowledge about diabetes, self-efficacy, attitudes towards self-management), 2) lifestyle behavior (diet, physical activity), and 3) clinical and patient-reported outcomes. Where possible, we pooled data using random-effects meta-analyses to obtain estimates of effect size of intervention compared to usual care. Results: We identified 15 trials (15 interventions) meeting our inclusion criteria. Most interventions were delivered via short message service text messaging (n=12) and simultaneously targeted diet and physical activity (n=11). Nine interventions consisted of unidirectional messages, whereas six consisted of bidirectional messages, with patients receiving automated tailored feedback based on self-reported data. The acceptability of the interventions, and their impact on lifestyle behavior and its determinants, were examined in a low proportion of trials, with heterogeneous results being observed. In 13 trials (1155 patients) where data were available, there was a difference in glycated hemoglobin of -0.53% (95% CI -0.59% to -0.47%) between intervention groups compared to usual care. In five trials (406 patients) there was a non-significant difference in body mass index of -0.25 kg/m2 (95% CI -1.02 to 0.52). Interventions based on unidirectional messages produced similar effects in the outcomes examined, compared to those based on bidirectional messages. Interventions conducted in low- and middle-income countries showed a greater impact than those conducted in high-income countries. In general, trials were not free of bias and did not use explicit theory. Conclusions: Automated brief messages strategies can improve health outcomes in people with type 2 diabetes. Larger, methodologically robust trials are needed to confirm these positive results. UR - http://www.jmir.org/2016/4/e86/ UR - http://dx.doi.org/10.2196/jmir.5425 UR - http://www.ncbi.nlm.nih.gov/pubmed/27095386 ID - info:doi/10.2196/jmir.5425 ER - TY - JOUR AU - Wayne, Noah AU - Cercone, Nick AU - Li, Jiye AU - Zohar, Ariel AU - Katz, Joel AU - Brown, Patrick AU - Ritvo, Paul PY - 2016/04/06 TI - Data Mining of a Remote Behavioral Tracking System for Type 2 Diabetes Patients: A Prospective Cohort Study JO - JMIR Diabetes SP - e1 VL - 1 IS - 1 KW - diabetes mellitus, type 2 KW - health coaching KW - mhealth KW - telehealth KW - data mining N2 - Background: Complications from type 2 diabetes mellitus can be prevented when patients perform health behaviors such as vigorous exercise and glucose-regulated diet. The use of smartphones for tracking such behaviors has demonstrated success in type 2 diabetes management while generating repositories of analyzable digital data, which, when better understood, may help improve care. Data mining methods were used in this study to better understand self-monitoring patterns using smartphone tracking software. Objective: Associations were evaluated between the smartphone monitoring of health behaviors and HbA1c reductions in a patient subsample with type 2 diabetes who demonstrated clinically significant benefits after participation in a randomized controlled trial. Methods: A priori association-rule algorithms, implemented in the C language, were applied to app-discretized use data involving three primary health behavior trackers (exercise, diet, and glucose monitoring) from 29 participants who achieved clinically significant HbA1c reductions. Use was evaluated in relation to improved HbA1c outcomes. Results: Analyses indicated that nearly a third (9/29, 31%) of participants used a single tracker, half (14/29, 48%) used two primary trackers, and the remainder (6/29, 21%) of the participants used three primary trackers. Decreases in HbA1c were observed across all groups (0.97-1.95%), but clinically significant reductions were more likely with use of one or two trackers rather than use of three trackers (OR 0.18, P=.04). Conclusions: Data mining techniques can reveal relevant coherent behavior patterns useful in guiding future intervention structure. It appears that focusing on using one or two trackers, in a symbolic function, was more effective (in this sample) than regular use of all three trackers. UR - http://diabetes.jmir.org/2016/1/e1/ UR - http://dx.doi.org/10.2196/diabetes.4506 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291054 ID - info:doi/10.2196/diabetes.4506 ER - TY - JOUR AU - Morton, Katie AU - Sutton, Stephen AU - Hardeman, Wendy AU - Troughton, Jacqui AU - Yates, Tom AU - Griffin, Simon AU - Davies, Melanie AU - Khunti, Kamlesh AU - Eborall, Helen PY - 2015/12/15 TI - A Text-Messaging and Pedometer Program to Promote Physical Activity in People at High Risk of Type 2 Diabetes: The Development of the PROPELS Follow-On Support Program JO - JMIR mHealth uHealth SP - e105 VL - 3 IS - 4 KW - physical activity KW - mHealth KW - text messaging KW - pedometer KW - tailoring KW - type 2 diabetes KW - intervention development N2 - Background: Mobile technologies for health (mHealth) represent a promising strategy for reducing type 2 diabetes (T2DM) risk. The PROPELS trial investigates whether structured group-based education alone or supplemented with a follow-on support program combining self-monitoring with pedometers and tailored text-messaging is effective in promoting and maintaining physical activity among people at high risk of T2DM. Objective: This paper describes the iterative development of the PROPELS follow-on support program and presents evidence on its acceptability and feasibility. Methods: We used a modified mHealth development framework with four phases: (1) conceptualization of the follow-on support program using theory and evidence, (2) formative research including focus groups (n=15, ages 39-79 years), (3) pre-testing focus groups using a think aloud protocol (n=20, ages 52-78 years), and (4) piloting (n=11). Analysis was informed by the constant comparative approach, with findings from each phase informing subsequent phases. Results: The first three phases informed the structure, nature, and content of the follow-on support program, including the frequency of text messages, the need for tailored content and two-way interaction, the importance of motivational messages based on encouragement and reinforcement of affective benefits (eg, enjoyment) with minimal messages about weight and T2DM risk, and the need for appropriate language. The refined program is personalized and tailored to the individual?s perceived confidence, previous activity levels, and physical activity goals. The pilot phase indicated that the program appeared to fit well with everyday routines and was easy to use by older adults. Conclusions: We developed a feasible and innovative text messaging and pedometer program based on evidence and behavior change theory and grounded in the experiences, views, and needs of people at high diabetes risk. A large scale trial is testing the effectiveness of this 4-year program over and above structured group education alone. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 83465245; http://www.controlled-trials.com/ISRCTN83465245/83465245 (Archived by WebCite at http://www.webcitation.org/6dfSmrVAe) UR - http://mhealth.jmir.org/2015/4/e105/ UR - http://dx.doi.org/10.2196/mhealth.5026 UR - http://www.ncbi.nlm.nih.gov/pubmed/26678750 ID - info:doi/10.2196/mhealth.5026 ER - TY - JOUR AU - Holmen, Heidi AU - Torbjørnsen, Astrid AU - Wahl, Klopstad Astrid AU - Jenum, Karen Anne AU - Småstuen, Cvancarova Milada AU - Årsand, Eirik AU - Ribu, Lis PY - 2014/12/11 TI - A Mobile Health Intervention for Self-Management and Lifestyle Change for Persons With Type 2 Diabetes, Part 2: One-Year Results From the Norwegian Randomized Controlled Trial RENEWING HEALTH JO - JMIR mHealth uHealth SP - e57 VL - 2 IS - 4 KW - self-care KW - mobile applications KW - cellular phone KW - telemedicine KW - counseling KW - motivational interviewing KW - diabetes mellitus, type 2 KW - hemoglobin A1c protein, human N2 - Background: Self-management is crucial in the daily management of type 2 diabetes. It has been suggested that mHealth may be an important method for enhancing self-management when delivered in combination with health counseling. Objective: The objective of this study was to test whether the use of a mobile phone?based self-management system used for 1 year, with or without telephone health counseling by a diabetes specialist nurse for the first 4 months, could improve glycated hemoglobin A1c (HbA1c) level, self-management, and health-related quality of life compared with usual care. Methods: We conducted a 3-arm prospective randomized controlled trial involving 2 intervention groups and 1 control group. Eligible participants were persons with type 2 diabetes with an HbA1c level ?7.1% (?54.1 mmol/mol) and aged ?18 years. Both intervention groups received the mobile phone?based self-management system Few Touch Application (FTA). The FTA consisted of a blood glucose?measuring system with automatic wireless data transfer, diet manual, physical activity registration, and management of personal goals, all recorded and operated using a diabetes diary app on the mobile phone. In addition, one intervention group received health counseling based on behavior change theory and delivered by a diabetes specialist nurse for the first 4 months after randomization. All groups received usual care by their general practitioner. The primary outcome was HbA1c level. Secondary outcomes were self-management (heiQ), health-related quality of life (SF-36), depressive symptoms (CES-D), and lifestyle changes (dietary habits and physical activity). Data were analyzed using univariate methods (t test, ANOVA) and multivariate linear and logistic regression. Results: A total of 151 participants were randomized: 51 to the FTA group, 50 to the FTA-health counseling (FTA-HC) group, and 50 to the control group. Follow-up data after 1 year were available for 120 participants (79%). HbA1c level decreased in all groups, but did not differ between groups after 1 year. The mean change in the heiQ domain skills and technique acquisition was significantly greater in the FTA-HC group after adjusting for age, gender, and education (P=.04). Other secondary outcomes did not differ between groups after 1 year. In the FTA group, 39% were substantial users of the app; 34% of the FTA-HC group were substantial users. Those aged ?63 years used the app more than their younger counterparts did (OR 2.7; 95% CI 1.02-7.12; P=.045). Conclusions: The change in HbA1c level did not differ between groups after the 1-year intervention. Secondary outcomes did not differ between groups except for an increase in the self-management domain of skill and technique acquisition in the FTA-HC group. Older participants used the app more than the younger participants did. UR - http://mhealth.jmir.org/2014/4/e57/ UR - http://dx.doi.org/10.2196/mhealth.3882 UR - http://www.ncbi.nlm.nih.gov/pubmed/25499872 ID - info:doi/10.2196/mhealth.3882 ER -