The messages are pretty innocuous—“Eat your veggies!"; "Don’t let hump day get you down! Log in now!”; "For best results, take your medication at the same time of day"–and depending on my mood, I see them as encouraging or annoying. (Full disclosure: I have type 2 diabetes and I attribute using the app with helping me lose 10 pounds in the last 9 months.)
But the real stumper is whether or not they change my behavior, a question also posed by researchers who are trying to harness cell phone technology to improve diabetes care.
“With 92% of the population in the US carrying cell phones, the technology is ubiquitous,” says Janice Miller, a diabetes educator and assistant professor at the School of Nursing at Thomas Jefferson. “People can carry messages to a restaurant or wherever they go.”
Miller authored a 2016 pilot study that sent simple text messages to 20 patients with uncontrolled diabetes.
Text messages, reminding participants to eat healthy, exercise and to make an appointment for a retinopathy exam were blasted out three times weekly over a three-month interval.
At the end of the test period, patients saw a drop in their A1C readings from an average of 9.46 to 8.63. More were up to date on their retinopathy screenings and showed improvement in diabetes self-care behaviors. Eighty-six percent made changes in their food choices, while almost three-quarters had increased their label reading to check nutrition choices and improved their adherence to their medication schedule.
More than half of participants increased their physical activity and about half had increased their monitoring of blood glucose.
In an exit survey, patients praised the “frequent reminders to take care of my diabetes” and “learned information I would never have sought out in a book.”
Why the messaging was successful isn’t precisely clear, but Miller has several theories.
“First, there is a novelty to it,” she said. “There also may have been a selection bias, that people who opted into the program may have wanted to make changes in the first place.”
She also said that the messages, which were non-threatening and timely (on St. Patrick’s Day, for example, she reminded people to “Go green today and load up on salads") made people comfortable rather than seeing them as messages from the “diabetes police.”
So far, the largest study of text messaging for diabetes prevention was completed in India, where one million residents opted to receive twice weekly text messages.
Diabetes prevention is particularly important in India, where 66 million people have type 2 diabetes and are four times more likely to develop the disease than in the United States. Although the reasons for this increased susceptibility remains unclear, possible culprits include genetics, a transfer to a Western diet, and low birth weights among Indian children, says Nalini Saligram, CEO of Arogya World, who ran the massive text-messaging study in conjunction with Northwestern University Feinberg School of Medicine in Chicago, Illinois.
In the study, researchers compared composite scores of an experimental group’s fruit, vegetable and fat intake and exercise with that of a control group who did not receive text messages. Both groups showed improvement in their health behaviors, but about 40% more people improved their behavior as a result of texts. Participants who received texts increased fruit and vegetable consumption and reduced fat consumption.
Sample texts included, “High blood sugar from diabetes can cause problems in your eyes, kidneys, heart, feet and nerves” and “Small changes in the way you eat can help you avoid diabetes. Eat more vegetables and fruits. Eat less rice and roti.”
Several earlier studies have found that text messaging can be a worthwhile investment for helping people treat diabetes. In 2014, University of Chicago conducted a six-month texting study of people diagnosed with type 1 or type 2 diabetes. Educational text messages were sent with daily reminders to check blood sugar as well as nutrition and exercise tips. After six months, patients showed improved glycemic control and an 8.8% reduction in health care costs.
Another study published in the Journal of Medical Internet Research examined the motivation, intention and triggers to action of TExT-MED (Trial to Examine Text Messaging for Emergency Department patient with Diabetes), an automated text message based program tailored to low-income, urban Latinos with diabetes. Text messaging was particularly effective when it cued specific behaviors such as medication reminders or challenged patients to take a specific action.
Many mobile apps include text messaging as part of their service, says Molly McElwee-Malloy, head of Patient Engagement / Director of Marketing at TypeZero Technologies and a media spokesperson for the American Association of Diabetes Educators.
“There has been lots of research on interventions via email, telephone, text and contacts with patients on weekly and biweekly basis to see how effective it is,” says McElwee-Malloy. She notes that “more than 50% of care for diabetes is behavior—taking medication at a proper time, adherence to diet, following an exercise regimen or taking insulin,” which makes it ideal for regular reminder services.
Among the apps using text messaging available to American consumers is the Care4Life app, developed with the American Diabetes Association. The app, which can be accessed from the App Store, allows users to track food, exercise, medication and glucose readings and sends recipes and reminders via text messaging.
Other services that combine online/in person can be found at the CDC site for diabetes prevention.
Miller hopes to find financing for a longer and larger text messaging study in the future, while Saligram’s group is planning future interventions via text message to address prevention of complications from diabetes.
“I genuinely believe that text messages that are simple, short and easy to read can influence increased healthful behaviors,” said Saligram. “Treatment for chronic diseases like diabetes and heart disease is really difficult, so prevention is very important.”