Digital diabetes education isn’t worth the paper it’s written on, or is it?

Research drives improvements to frontline healthcare. The evidence it generates is at the core of medical innovations, pathways and treatments.

Our brand new Behind the Science feature will tackle the latest developments, discussions and approaches and what they mean to healthcare professionals working in diabetes care.

We ask experts to delve deeper into their speciality, providing a unique approach and insight into their work. This month’s article is written by X-PERT’s Chief Executive Dr Trudi Deakin and Digital Health Lead Matthew Whitaker. 

Benefit and guidance for structured diabetes education (SDE)

Self-management of long-term conditions, such as diabetes, is of paramount importance, particularly given the minimal time individuals spend with healthcare professionals.

Guidance published by the National Institute for Health and Care Excellence (NICE) lists attendance at SDE courses as a key priority for the management of type 2 diabetes. It is recommended that SDE should be offered to all adults with type 2 diabetes at and around the time of diagnosis, with annual reinforcement and review (1).

Traditionally, SDE is delivered in a group capacity, where it has been shown to be a cost effective (2) means of improving health and wellbeing of attendees (3). SDE courses, such as those provided by X-PERT Health and DESMOND, a

re effective as they promote peer interaction, in an adult learning environment. Discovery learning plays an important role by encouraging participants to draw on their past experiences and develop the knowledge, understanding and confidence to make informed decisions regarding diabetes self-management. This, in addition to personalised goal setting, immediate feedback and reinforcement facilitates a successful group learning experience.

Limitations with group-based SDE

Despite the many benefits of people with diabetes attending SDE, group-based interventions clearly are not for everyone. Data from the 2018-19 National Diabetes Audit Report suggests that despite 73.3% of those newly diagnosed with diabetes in England in 2017 being offered SDE, only 12.4% attended within 12 months (4). The number for completion, albeit not available, will inevitably be even lower, although it is likely these numbers are exaggerated due to under-reporting.

Accessibility to group education could be a barrier to attendance. DESMOND’s group programme runs as a one whole or two half day(s); X-PERT Health’s last six weeks, one two and a half hour session each week. Such time commitments, for some, may be impractical, particularly for those in full time employment or mobility issues.

The rationale for digital SDE

The National Health Service (NHS) has recognised these accessibility barriers and have proposed that digital SDE could be suitable for those who cannot/will not attend group programmes. It was agreed in 2018 that up to 25% of Diabetes Treatment and Care Transformation Funding allocated to SDE can be used to commission a digital means of delivery. In addition, the 2019 NHS Long Term Plan (5) has placed an emphasis on digital education and self-management in two of the five diabetes long term highlights.

Clearly digital diabetes education is on the NHS agenda, with digital solutions actively being appraised and commissioned. One such example is the recent digital extension of The Healthier You: NHS Diabetes Prevention Programme (NDPP). Initially created to provide face-to-face support, the programmes successes have led to discussions on how it can be made more widely available. One means of achieving this is through digital interventions, which led to the digital version of the NDPP being piloted across eight areas and in up to 5,000 individuals (6). The results of this, and the decision on whether there will be a mass roll out, are eagerly being awaited.

Digital interventions may include: wearable technologies that monitor activity and heart rate; digital platforms that supply educational content and/or access to trained health coaches; access to online support groups and forums; educational games and platforms that give users the ability to track key health markers and self-determined goals. Such interventions may be more convenient and offer more flexibility than group based SDE. They can also reach significantly more people, in a fraction of the time.

Research on digital health interventions suggest that health technologies, when combined with standard care, can improve glycaemic control (HbA1c) in those with type 2 diabetes to a greater extent that standard care alone (7, 8). Improvements in HbA1c have been seen at 12 months when digital interventions are trialled in primary care, in England (9). To maximise the chances of success, it is essential that users are fully engaged and one way to achieve this is to ensure that referring healthcare professionals receive awareness training so that they can discuss the content and benefits with potential participants. .

Although, digital SDE could be perceived as being inappropriate for some individuals for economic or ethnic reasons, research does not support this conclusion, with the overwhelming majority of people in these populations owning smart phones with internet access (10).

Digital SDE recommendations

It is recommended that digital education should incorporate motivational reminder functionalities, such as text messages or nudging. One review suggested text messages to be a low cost, impactful way to improve glycaemic control remotely, in those with type 2 diabetes (11). This is supported by the Cabinet Office’s MINDSPACE initiative, which aims to influence behaviour change by utilising psychology theories on engagement and nudging (12). In addition to this, research conducted on adults with type 2 diabetes aimed at determining what they want from digital interventions suggests: the inclusion of functions to allow tracking such as physical activity and health markers; data is presented visually; access to personalised coaching; reminders for self-care; integrations with other devices/wearables; on-going encouragement, motivation and education; tools to help users deal with stress and negative emotions (13).

Thus, the most useful digital interventions are considered to be those that combine self-directed education with personalised health coach access and with integration with other devices. For example, one way to support self-care and decision making would be for continuous glucose monitors to provide immediate feedback informing the participant how carbohydrate intake and/or physical activity have impacted on blood glucose levels. This information would develop a better understanding and confidence for improved diabetes self-management and such innovations should be prioritised for future developments in digital SDE.

Conclusion: to digitalise or not?

Digital SDE may be extremely valuable in improving accessibility and the health and wellbeing of people with type 2 diabetes. Extending the reach of SDE to include digital offerings expands the choice available for those living with diabetes recognising that one size doesn’t fit all. Some individuals will enjoy and benefit more from group-based approaches whereas others will thieve from supported self-directed digital learning. Provider organisations should embrace the existing and emerging evidence and offer a choice of group or digital SDE to their population with type 2 diabetes.

1. Type 2 diabetes in adults: management (2015) NICE guideline NG28, recommendation 1.2.1 (key priority for implementation).
2. Teljeur C, Moran PS, Walshe S, Smith SM, Cianci F, Murphy L, et al. Economic evaluation of chronic disease self-management for people with diabetes: a systematic review. Diabetic Medicine. 2017;34(8):1040-9.
3. Odgers-Jewell K, Ball LE, Kelly JT, Isenring EA, Reidlinger DP, Thomas R. Effectiveness of group-based self-management education for individuals with Type 2 diabetes: a systematic review with meta-analyses and meta-regression. Diabetic Medicine. 2017;34(8):1027-39.
4. NHS Digital. National Diabetes Audit Report 1 – Care Processes and Treatment Targets 2018-19, Short Report 2019 [cited 2020 Jan 27]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/report-1–care-processes-and-treatment-targets-2018-19-short-report.
5. NHS. The NHS Long Term Plan v1 January 2019 [cited 2020 Jan 30]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
6. NHS. NHS Diabetes Prevention Programme – digital stream [cited 2020 Jan 31]. Available from: https://www.england.nhs.uk/diabetes/digital-innovations-to-support-diabetes-outcomes/nhs-diabetes-prevention-programme-digital-stream/
7. Yoshida Y. et al. Effect of Health Information Technologies on Glycemic Control Among Patients with Type 2 Diabetes. Current Diabetes Reports. 2018; 18(12):130
8. Kebede MM. et al. Effectiveness of Digital Interventions for Improving Glycemic Control in Persons with Poorly Controlled Type 2 Diabetes: A Systematic Review, Meta-analysis, and Meta-regression Analysis. Diabetes Technology & Therapeutics. 2018; 20(11): 767-782
9. Murray E. et al. Web-based self-management support for people with type 2 diabetes (HeLP-Diabetes): randomised controlled trial in English primary care. BMJ. 2017; 7(9): e016009
10. Stockman M.C et al. Mobile Health and Technology Usage by Patients in the Diabetes, Nutrition, and Weight Management Clinic at an Urban Academic Medical Center. Diabetes Technol Ther. 2019; 21(7): 400-405
11. Haider R. et al. Mobile phone text messaging in improving glycaemic control for patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes Research and Clinical Practice. 2019; 150: 27-37
12. Dolan P, et al. MINDSPACE Influencing behaviour through public policy. Institute for Government 2010 [cited 2020 Feb 3]. Available from: https://www.instituteforgovernment.org.uk/sites/default/files/publications/MINDSPACE.pdf
13. Baptista S. et al. What Do Adults with Type 2 Diabetes Want from the “Perfect” App? Results from the Second Diabetes MILES: Australia (MILES-2) Study. Diabetes Technology & Therapeutics. 2019; 21(7):393-399