Text Messaging Cuts New Diabetes Cases by Almost 40%

September 12, 2013

A new study conducted in southeast India has shown that sending text messages via mobile telephone seems to be an effective way of preventing the development of type 2 diabetes in at-risk men. Those who received the short messaging service (SMS), which consisted of 2 to 3 messages sent twice a week for around 2 years, were 36% less likely to develop diabetes.

The findings were reported online in Lancet Diabetes and Endocrinology by Ambady Ramachandran, MD, of India Diabetes Research Foundation, Chennai, India, and colleagues.

"This is one of the first studies in the world to show that mobile technology can have an impact on clinical outcomes; it's concrete evidence to show we could prevent diabetes," Dr. Ramachandran told Medscape Medical News.

And senior author Desmond Johnston, FMedSci, from Imperial College London, United Kingdom, said: “We've known for years that you can prevent type 2 diabetes by modifying your lifestyle, but the problem is how to support people to do that. Frequent personal contact with a doctor is effective, but it's very costly to provide. We've shown that you can achieve similar results using mobile phone messaging, which is a very low-cost solution."

And he added in the Imperial College statement, "We plan to carry out more studies in other populations, but there's no reason why this strategy shouldn't work anywhere else in the world."

Caroline Free, MD, of the London School of Hygiene and Tropical Medicine, United Kingdom, agrees. "If the results of this trial are replicated in other settings, mobile phone messaging could be a practical and affordable way to deliver lifestyle advice to delay or prevent the onset of type 2 diabetes in many different populations," she writes in an accompanying editorial.

Texts Cheap and Easy; Computer-Generated

Dr. Ramachandran said that it has been proven that primary prevention works in type 2 diabetes — for example, in studies in Finland and in the US Diabetes Prevention Program (DPP) and the Indian Diabetes Prevention Program (IDPP). But these trials were "labor intensive" and therefore costly, he explained. "We wanted to see whether we could use a cost-effective method of motivating people to change their lifestyle."

The penetration of mobile phones in India is high, and sending SMS is "very cheap," hence the decision to use this method of communication, he noted. Other studies have shown a benefit of text messaging, for example, in adherence to HIV medication and for smoking cessation, he said.

The research team screened around 8000 men aged 25 to 55 years working at 10 industrial organizations in southeast India between August 2009 and November 2012. They had to have a body mass index (BMI) of at least 23 and positive family history of diabetes, own a mobile phone, and be able to read and understand text messages in English.

The researchers selected 537 participants with impaired glucose tolerance as determined by an oral glucose tolerance test for inclusion in the study. They were randomly assigned to a mobile phone messaging intervention (n = 271) or to standard care (n = 266). At baseline, all of the men received personalized education and motivation regarding healthy lifestyle principles and written information about diet and physical activity; the prescribed lifestyle changes were similar to those used in the IDPP.

The text messages were sent from 7:00 am to 9:00 am and from 5:00 pm to 9:00 pm. The schedule was determined by polling the individuals as to preferred times to receive the SMS.

The texts were computer-generated and sent automatically; they were designed to prompt physical activity ― stating, for example, "Use stairs instead of a lift [elevator]" ― and to encourage healthy eating ― "Avoid snacks while watching TV; you may overeat."

The 60 to 80 different messages were created and sent cyclically, so that participants would not be likely to receive the same message in a 6-month period. Participants were assessed every 6 months, and the 2-year follow-up for the study "was long," Dr. Fine notes in her editorial. Satisfaction was also high, with more than 95% of participants saying they liked the text messaging.

Just 11 People Need to Receive Texts to Prevent 1 Case

The primary outcome of the study was the cumulative incidence of type 2 diabetes at 2 years: 50 (18%) of the participants in the SMS group developed type 2 diabetes compared with 73 (27%) in the control group (hazard ratio, 0.64; P = .015). The number needed to treat to prevent 1 case of diabetes was 11.

Secondary outcomes included BMI, waist circumference, systolic and diastolic blood pressure, lipid profile, total dietary energy intake, and physical-activity score.

Assessment of dietary intake and physical activity was done via questionnaires. There was no effect of the text message intervention on BMI, waist circumference, blood pressure, or serum cholesterol and triglyceride levels, but HDL cholesterol was significantly higher in those who received the SMS. Total dietary energy intake was also lower in the text message group than in the control group, but physical-activity scores did not differ.

Dr. Ramachandran told Medscape Medical News that it has previously been shown that simply changing the diet can be enough to prevent development of diabetes "even without a change in BMI." However, he suspects that there was some increase in physical activity in those receiving the texts, but "we just need a more sensitive method to demonstrate this."

Dr. Free also notes in her editorial that the mechanism of action for the reduction in diabetes seen "is worthy of further investigation," although she, too, notes that this phenomenon has been observed before, without evident reductions in body weight or without increase in exercise, in face-to-face lifestyle-modification trials.

Another remaining challenge is to identify an easier way of screening participants for such trials in the first place, say both doctors. "Robust systems will need to be adopted to identify and recruit individuals at high risk of type 2 diabetes," Dr. Fine observes.

Nevertheless, this trial demonstrates proof of principle, said Dr. Ramachandran, who noted that his team is now conducting another study of text messaging for the prevention of diabetes, this time including 30% to 40% women.

Huge Benefits to Delaying Onset of Diabetes

Dr. Fine says that text messaging needs to be further assessed in women and in a range of countries, and the cost-effectiveness needs to be established.

Dr. Ramachandran and colleagues say that mobile phone messaging is "likely to be low cost," and therefore its use in large prevention programs "warrants assessment, especially because the benefits of prevention or delaying of onset of type 2 diabetes can persist for up to 20 years.

"Furthermore, benefits extend to other cardiovascular risk factors and possibly to cardiovascular events," they conclude.

The authors and editorialist have disclosed no relevant financial relationships.

Lancet Diabetes Endocrinol. Published online September 11, 2013. Full article, Editorial


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