Text Messages Improve Blood Glucose Control in Diabetes

Pam Harrison

September 03, 2019

PARIS — A simple, low-cost automated text messaging program modestly improves glycemic control over usual care in patients with type 2 diabetes and coronary heart disease (CHD), a multicenter randomized trial carried out in China suggests.

"Mobile phones are pervasive and widely used to schedule alerts and reminders, highlighting the potential for mobile health technology to circumvent the practical barriers of traditional healthcare visits," say Xiqian Huo, MD, Fuwai Hospital, Beijing, China, and colleagues.

"The results of this study have the potential to be clinically relevant in daily practice, especially among patients with poorly controlled diabetes mellitus, where the benefit was the greatest," they stress.

The study was presented by Huo at ESC Congress 2019 and simultaneously published online in Circulation: Cardiovascular Quality and Outcomes.

"This study has important public health implications since patients with CHD and diabetes are at high risk for diabetes-related complications and death," she indicated.

CHAT-DM Study Conducted in China

The Cardiovascular Health and Texting –Diabetes Mellitus (CHAT-DM) study involved 502 participants with both diabetes and CHD who were recruited from 34 hospitals in China between August 2016 and April 2017.

The text messages were developed by a multidisciplinary team and included information about diabetes and CHD, glucose monitoring and control, blood pressure control, adherence to medication, physical activity, and lifestyle recommendations.

"Participants in the intervention group received six messages per week during the 6-month study period in addition to standard treatment," the investigators observe, "[while] the control group received two thank you text messages...per month, as well as standard treatment."

The primary outcome was change in glycated hemoglobin (HbA1c) from baseline to study end. Investigators also assessed the proportion of patients who achieved a target HbA1c < 7% as well as other secondary endpoints.

Mean HbA1c was only 7.0% at baseline and mean fasting blood glucose level was 8.3 mmol/L.

As Huo pointed out to Medscape Medical News, the study team sent educational messages to those in the text messaging group alerting them on both how to monitor glucose as well as detailing the glycemic control targets.

"Patients therefore would be aware of the safe monitoring borderlines," she noted in an email.

Greater HbA1c Reductions in Text Group for Those Initially Above Target

At 6 months, significantly greater reductions in HbA1c occurred in the text messaging group, at –0.2%, compared with controls, at +0.1% (P = .003), study authors report.

HbA1c levels were also significantly lower in the text messaging group, at 6.7%, compared with controls, at 7.2%, they add.

And more patients in the text messaging group achieved an HbA1c < 7% at 6 months compared with controls (69.3% vs 52.6%; P = .004).

Similarly, larger reductions in fasting blood glucose levels from baseline were seen in the text messaging group, at –0.5 mmol/L, compared with +0.1 mmol/L in the usual care group (P = .011).

But text messages to participants who already had low HbA1c levels at baseline did not further reduce HbA1c levels, which remained stable throughout the study and, indeed, were not different from HbA1c levels in control patients.

On the other hand, "for patients with HbA1c levels in excess of 7.5% at baseline, there was a meaningful and significant reduction in HbA1c," Huo added.

Secondary outcomes including systolic blood pressure, body mass index, low-density lipoprotein cholesterol, and self-reported levels of physical activity did not differ between the two groups after the 6-month study period.

Easy to Understand, Unique Text Messages

Importantly, almost all participants in the text messaging group indicated the messages were easy to understand and useful.

Participants in the intervention group received approximately 155 text messages about managing their disease during the study, all of which were unique (no repeated messages), the authors note.

And almost all of the text message recipients indicated they would be willing to continue to receive text messages to help them manage their disease.

As Huo noted in an ESC statement, Chinese people tend to prefer receiving direct and structured counseling rather than indirect approaches.

"[This meant that] motivational messages were practical with real-life examples instead of abstract theories," she added.

For example, participants in the intervention group might be told that if they were afraid of testing blood glucose because it hurt, they were to try to take a blood sample on the sides of their fingertips or rotate the use of their fingers to help minimize the pain.

If patients were forgetting to take their medications, they were told to try to set an alarm on their cell phone to remind them it was time to take their medication and/or inject insulin.

For physical activity, text message recipients were told to try walking briskly — that it was good for their heart and would help control their glucose levels.

"Lifestyle advice such as strict dietary control may have contributed to glycemic improvements, together with reminders to monitor blood glucose regularly," Huo acknowledged.

Huo has reported no relevant financial relationships.

Cir Cardiovasc Qual Outcomes. Published online August 31, 2019. Full text

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