EXECUTIVE SUMMARY

  • The digital world offers a wide array of health tools to improve the participation of patients with diabetes in diabetes self-management education and support (DSMES).
  • DSMES provides knowledge, proficiency, and resources to assist people with diabetes in integrating newfound skills and understanding toward effective management of this complex condition psychologically, biologically, and physically.
  • Four imperative times in management a person with diabetes should receive DSMES include: 1) at diabetes diagnosis, 2) when an annual assessment shows the patient needs further education, 3) when diabetes-related complications manifest, and 4) during transitions of care (healthcare or personal care).
  • The AADE7 model focuses on behavioral changes through encouraging patient-driven goals to achieve optimal clinical and health outcomes.
  • Tools include Food and Drug Administration-approved and American Diabetes Association-recognized digital programs as well as those from partners in the pharmaceutical industry.
  • Short message services have been shown to have high patient acceptance and lead to significant reductions in hemoglobin A1c.
  • The effect of social media has been explored and shows great promise for encompassing the seven self-care behaviors, including healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks.

The purpose of this article is to discuss the use of digital health tools to improve participation in diabetes self-management education and support (DSMES). Daily schedules and responsibilities might hinder a person from receiving DSMES; thus, only a small number of people with diabetes receive DSMES despite the clear benefits of the much-needed education. With advances in technology and digital health tools, such as mobile applications (apps) and text messaging programs, individuals seeking further knowledge and training relating to diabetes management can achieve their specific goals at their own time and pace. Various apps, short message service (SMS) programs, and organizations on social media platforms have integrated the Association of Diabetes Care and Education Specialists’ ADCES7 Self-Care Behaviors (formerly known as the American Association of Diabetes Educators’ AADE7 Self-Care Behaviors model) as the backbone of the DSMES delivery.

The COVID-19 pandemic has changed how healthcare services are being delivered, including the delivery of DSMES. Many digital health resources are available for people who are looking for DSMES materials in addition to the traditional in-person sessions. Considering the widespread use of mobile technological tools, digital health resources are a practical solution to enhance the incorporation of DSMES to help people with diabetes optimize the management of the condition.

Introduction

Gaining basic information on diabetes self-care and initiating the necessary behavioral modifications needed for achieving target hemoglobin A1c (HbA1c) levels can be extremely overwhelming. The pressure and challenges are especially real during the initial months after being diagnosed. DSMES provides knowledge, proficiency, and resources to assist people with diabetes in integrating newfound skills and understanding toward effective management of this complex condition psychologically, biologically, and physically. There are four imperative times during the course of a patient’s diabetes management when they should be receiving DSMES: 1) at diabetes diagnosis, 2) when an annual assessment shows a patient needs further education, 3) when diabetes-related complications manifest, and 4) during transitions of care (healthcare or personal care).1

The Centers for Disease Control and Prevention (CDC) reported that only 6.8% of privately insured people with newly diagnosed diabetes participated in diabetes self-management training within the first year of their diagnosis.2 These findings confirmed the assertion that DSMES had not been incorporated into routine clinical practice.2 A 2016 report, also conducted by the CDC, revealed that 62% of nonmetropolitan counties were lacking DSMES programs.3 For the nonmetropolitan counties offering DSMES services, there was an average of 1.4 programs per county.3 There are numerous barriers to DSMES participation, including:2,3

  • access barriers (e.g., insurance coverage, inadequate knowledge among primary care providers, and physician referral requirements/lack of primary care referrals);
  • availability barriers (e.g., transportation, availability in the person’s primary language, lack of awareness about the availability of DSMES, and the distance to available classes);
  • barriers associated with people with diabetes (e.g., lack of readiness to change behaviors, socioeconomic status, employment, and ethnicity/culture).

For some people with diabetes, life schedules and responsibilities are significant barriers to partaking in classes. Classes may be offered during the day while people are at work. After-work classes may be inconvenient, interfering with family responsibilities, such as cooking family meals, meetings after work, or attending children’s events.

As Certified Diabetes Care and Education Specialists (CDCES), it is within our responsibilities to find other means and opportunities for our clients so they will be able to receive the essential diabetes education and support for the effective management of the condition, especially now that the use of digital health and technology increasingly has become more prevalent for the purposes of health education and maintenance, providing a platform to increase the access to DSMES.

The COVID-19 pandemic has increased the demand for technology-based platforms to maintain high-quality healthcare delivery, including the delivery of DSMES. Web-based programs and mobile applications have been recommended as viable options for patients with diabetes to self-select the best method in meeting their preferences and needs in diabetes education amid the pandemic.

Advances in technology have granted diabetes care and education specialists (DCES) opportunities to deliver diabetes education efficiently in new formats and platforms for reaching and benefiting a large population. According to the Pew Research Center, in 2019, 85% of Americans owned a smartphone.4 Mobile technology and digital health are excellent sources for people with diabetes to learn about their chronic conditions at their own pace. These tools have been shown to be effective in providing support and improving glycemic management among individuals with type 2 diabetes.5 Those engaged in mobile communities have noted improved quality of life and diabetes self-care measures in comparison to non-users. The online community is highly accessible, convenient, and available at any moment; therefore, it is an excellent source for DSMES. The role of technology in healthcare digital health is growing vastly, thus mobile applications, text messaging programs, and social media can be a solution to enhance DSMES delivery and participation.

The purpose of this review article is to discuss the facets of various interfaces available to individuals with diabetes needing DSMES through incorporating the AADE7 Self-Care Behaviors (AADE7)/ADCES7 Self-Care Behaviors (ADCES7) model. This model focuses on behavioral changes through encouraging patient-driven goals to achieve optimal clinical and health outcomes.

The AADE7 model has been a well-documented and widely used evidence-based framework mirrored by the curriculum supported by the CDC DSMES program and promoted by the American Diabetes Association (ADA) and American Geriatric Society (AGS). This is a tool supporting DCES in conducting assessments, delivering diabetes education, and evaluating people with diabetes and diabetes education programs.6,7 As a result, this review also uses this model as a template for discussing the aforementioned digital platforms used to deliver DSMES. By highlighting the evolving means by which diabetes education can be disseminated, DCES can further advocate for the progressive improvement in diabetes education delivery while navigating barriers that hinder DSMES participation.

Note: In 2019, the American Association of Diabetes Educators (AADE) changed its name to the Association of Diabetes Care and Education Specialists (ADCES); subsequently, in 2020, the AADE7 Self-Care Behaviors (AADE7) model was changed to the ADCES7 Self-Care Behavioral (ADCES7) model with identical contents. Throughout this review article, the name AADE7 model is being used because the literature had been published and the digital health products had been released before the name change occurred.

Applications (Apps)

With the prevalence of diabetes rising every year, finding cost-effective, accessible, and interactive means to offer DSMES is crucial.8 Diabetes mobile applications can be an answer for some people with diabetes getting access to DSMES beyond the walls of healthcare facilities or hospitals.

In a study, researchers analyzed a mobile app using AADE7 as the backbone and discovered that this app covers four out of seven elements in the AADE7 model: monitoring, healthy eating, being active, and taking medications.9 However, more work is needed to incorporate healthy coping, problem solving, and reducing risks.9

Despite the imbalance in self-care behavior representation, a systematic review found a 0.5% reduction in HbA1c through app usage.8,9 Thus, the use of diabetes mobile applications potentially can lead to meaningful increases in the use of diabetes education.

Although there are numerous media that aid chronic condition management, each application offers unique advantages that serve individuals living with diabetes. BlueStar, a Food and Drug Administration (FDA)-approved type 2 diabetes application, is free to use after the initial registration with an access code.10

Clinical evidence has supported its effectiveness by demonstrating a 1.7% to 2.0% HbA1c reduction, 58% cost savings from emergency room and hospital visits, and two times the number of medication modifications and dose adjustments as a result of the app has helped clinicians manage diabetes.11

BlueStar helps keep track of blood glucose readings, daily meals, physical activities, and medication lists and schedules, as well as provides reminders. When blood glucose readings are entered, automated messages offer inspiration and guidance on how to handle hypoglycemia or hyperglycemia.

BlueStar also has collaborated with the AADE/ADCES to present brief educational content. The application offers videos, recipes for various meals, and numerous other resources for people with diabetes to manage their condition.12 Questions are sent to a DCES for inquiries, and reports regarding the information entered into BlueStar can be sent to healthcare providers for review before follow-up visits.10

As another FDA-approved digital program, Livongo integrates individual coaching and health behavioral support with personalized data collection.13,14 The program blends information from various sources (e.g., weather and location) with inputs from supplied proprietary electronic devices (e.g., glucometer and scale) equipped with wireless connectivity.

Users receive reminders through the provided device(s) and/or mobile applications to monitor chronic conditions (e.g., diabetes), increase or change activities (e.g., swim rather than walk because of inclement weather), or alter dietary intake.14

System analysis of collected data prompts interventions for tailored advice, education, and support through email, text, or phone if clinical outcomes from lifestyle modifications and medications are not within target ranges.

This approach covered by Medicare, Medicaid, and commercial insurance has reduced an average HbA1c by 0.7% in the first four months of use, with a further reduction in HbA1c by 0.9% after the first year.13-15

One Drop is the first ADA-recognized digital platform, providing accessible diabetes education. People with diabetes may register for a nine-week or six-month course package focusing on type 2 and gestational diabetes, respectively.16,17

With a business model consisting of subscription-based Bluetooth-enabled diabetes monitoring supply packages, users have access to one-on-one, 24-hour virtual support from an ADA-certified diabetes coach.17 The associated mobile application consolidates blood glucose, diet, and symptom tracking as supplemental data the coach may use to develop stress management and healthy lifestyle strategies.

This platform also formats schedules and reminders to promote regular exercise, meals, and medication adherence.18

One Drop continues to improve on its current platform with the 2018 release of Predictive Insights, a program that provides eight-hour blood glucose forecasts for people with type 2 diabetes not on insulin, in addition to maintaining a blog to keep subscribers up-to-date with topics ranging from fitness, healthcare, medication, and technology related to diabetes.16,17

The MySugr platform assimilates various capacities of electronic tools to increase user satisfaction while monitoring the management of diabetes. App developers advocate customers tracking daily activities with their proprietary blood glucose checking/monitoring supplies by allocating points for each recorded diabetes management practice (e.g., administering medications, consuming food and carbohydrates, and remaining in target ranges for vital signs, ketones, and HbA1c) or completing their physical activity “challenge.”19

Using a game-style platform, users can earn points by taming a cartoon “monster” that represents their type 2 diabetes. Points are tallied every day.

By upgrading the account to the pro version, participants may receive additional recommendations on carbohydrate and nutrition analysis by uploading images of their snacks/meals and receiving instructions from healthcare providers regarding basal rate insulin administration.20,21

Similar to One Drop, MySugr also offers additional information on living with diabetes, the healthcare industry, and nutrition through its online platform.

Partnered with pharmaceutical manufacturer Sanofi and Verily (the healthcare division of Google), Onduo is another online virtual diabetes clinic offering education approved by the ADCES.22,23 A variety of health specialists (DCES, personal trainers, registered dieticians, etc.) are available 24 hours per day, seven days a week, to assist individuals older than 18 years of age with type 2 diabetes.24 In addition to permitting enrolled users to couple photographs of meals with blood glucose readings, the program may allow select individuals to qualify to acquire an FDA-approved continuous glucose monitor (CGM).

Glucose Buddy is a diabetes management app that has been discussed in the ADA’s Diabetes Forecast magazine as well as in several other websites and magazines. App users can keep records of blood glucose readings, physical activities, medications, and food consumption with the use of a nutrition database throughout the day.24,25

This app also captures trends and displays charts regarding the individual’s HbA1c, blood glucose, blood pressure, weight, etc., making the outcomes easier for people with diabetes to monitor. Reports can be generated to print for healthcare providers, and users can join a community network for support and to stay motivated. More features can be accessed when participants upgrade their accounts to the premium version.25,26

Health2Sync was named one of the “Best Diabetes Apps of 2019” by Healthline.27 This app was developed to support and empower individuals to increase access to medical resources.

The app helps to easily keep records of medications, food, weight, physical activity, blood pressure, mood, and blood glucose.27 The consumer’s diary can be seen in table form to help determine what may have caused shifts in blood glucose trends. Data entered for blood glucose, blood pressure, and weight then can be organized into tables and charts to see if trends are reaching target goals.28 Health2Sync’s Partners function delivers individualized advice and reminders contingent upon uploaded user data.28 Healthcare providers, friends, and family can be invited as partners to assist in monitoring trends and providing support and recommendations.29 Records can be saved as PDF or Excel files and shared and emailed directly from the app to healthcare providers.29

There is a vast number of technological resources available that can benefit individuals living with diabetes. ADCES and DHX Labs (an independent nonprofit organization evaluating mobile health app user experience and security) have worked together to develop a collection of health applications for ADCES members.

The Diabetes Advanced Network Access (DANA) app delivers information to help diabetes care and education specialists navigate the growing technology and make up-to-date recommendations.30

The aforementioned platforms are only a few examples of applications now available for people with diabetes to use. Each program integrates a minimum of five out of seven components in the AADE7. Similar to the study discussed previously, the usual backbone of healthy eating, being active, monitoring, and taking medications were included. (See Table 1.)

Table 1. Mobile Applications on DSMES and AADE7 Self-Care Behaviors

 

Healthy Eating

Being Active

Monitoring

Taking Medication

Problem Solving

Healthy Coping

Reducing Risks

BlueStar

 

Glucose Buddy

 

 

Health2Sync

 

Livongo

 

MySugr

   

Onduo

 

   

One Drop

   

DSMES: diabetes self-management education and support; AADE: American Association of Diabetes Educators

indicates the resource addresses this behavior

 

 

Despite the increase in the number and variety of mobile applications aiding diabetes education and management, many lack a key component allowing users to adequately adhere to the AADE7’s reducing risks recommendations. Future development and progression of mobile applications should encourage DCES to better incorporate notifications that proactively minimize the prevalence and severity of low and high blood glucose readings. Aside from applications, text messaging programs can be a valuable asset as well.

Short Message Service

Text messaging, also known as short message service (SMS), is another avenue to provide DSMES because mobile phone possession is so widespread. In New Zealand, a three-month study was conducted to establish usefulness and patient satisfaction with the Self-Management Support for Blood Glucose (SMS4BG) text messaging diabetes program.31

The program consisted of two weekly messages providing emotional support, diabetes perceptions, and education. Participants also had the choice to customize their daily routine by adding reminders to check their blood glucose and participate in optional modules about stress management, nutrition, being active, and insulin.31

At the end of the study, interview responses showed that 100% of the 39 participants found SMS4BG to be useful, and they felt the messages were culturally and age-appropriate.31 Aside from showing patient satisfaction with the program, there also was a significant reduction in HbA1c when compared to baseline.31 Further studies are needed to establish the effectiveness of SMS as a means to deliver DSMES.31

MyAgileLife is a six-month text-messaging program created by healthcare providers and scientists from Keck School of Medicine at the University of Southern California (USC).32 Three text messages are sent every day regarding various educational topics: monitoring blood glucose, effective use of medications, tips on nutrition and active lifestyle, cardiovascular health, and ways to reduce complications.32 The program can be customized by choosing when to receive messages and if users want reminders up to five times daily about when to take medications, monitor blood glucose, and participate in physical activity.32 The program also is very interactive, allowing individuals to text whenever they have questions or need help and support. A clinical study directed by the USC team found that MyAgileLife minimized admissions to the hospital and emergency room, decreased blood glucose levels, improved patient medication use, and increased the development of crucial management behaviors.32

Care4Life is a diabetes program developed by Voxiva, in partnership with the ADA, that provides DSMES three different ways: text messages, a mobile application, and an online platform.33,34 This program focuses on eight areas to provide sources of support and motivate learning: blood glucose, exercise, weight, medications, nutrition, blood pressure, step counting, and medical appointments.

Care4Life includes quiz questions, informative videos, and short passages to read. The program also can be personalized by setting text message reminders for upcoming medical appointments, when to check blood glucose, time to take medications, and how often blood pressure should be measured. The users have access to a nutrition finder and can set goals for weight loss, exercise frequency, and daily steps. Care4Life allows participants to document what they do so they can keep track of their adherence, monitoring, and goal attainment.33,34

MyAgileLife and Care4Life have incorporated six out of the seven AADE7 Self-Care Behaviors. (See Table 2.) Both programs are highly educational, customizable, and interactive tools to provide DSMES. Last, but not least, Facebook and Twitter are two forms of social media that also have the potential to support, motivate, and further inform individuals about their diabetes.

Table 2. Text Message DSMES and AADE7 Self-Care Behaviors

 

Healthy Eating

Being Active

Monitoring

Taking Medication

Problem Solving

Healthy Coping

Reducing Risks

MyAgileLife

 

Care4Life

 

DSMES: diabetes self-management education and support; AADE: American Association of Diabetes Educators

indicates the resource addresses this behavior

Social Media

Approximately 81% of U.S. adults had access to the internet in 2017, and 74.9% of these individuals used the internet prior to other resources in their most recent health-related information inquiry.35,36 Social media sites, such as Facebook and Twitter, have the potential to provide widely accessible interactions, support, communications, and education to users at low costs and at any time or place they choose.37,38

As of July 2018, there were 2.2 billion and 336 million active monthly users of Facebook and Twitter, respectively.39 At the moment, studies analyzing the effectiveness of social media in conveying diabetes self-management education and support are inadequate; therefore, more evidence is necessary to show the benefits to which online communities can lead.40

Social media has the potential to decrease the burden of participants attending programs in person, benefiting individuals lacking time or access. This vast network can deliver the support and education that is so crucial for people with diabetes in making the imperative behavioral changes.41

To learn about which components of the AADE7 Self-Care Behaviors were fulfilled, Facebook and Twitter pages from five prominent, diabetes-focused organizations and institutions have been explored. The ADA, ADCES, Joslin Diabetes Center, diaTribe, and Taking Control of Your Diabetes (TCOYD) all present posts on their social media accounts that encompass the seven self-care behaviors.40-44

Aside from discussing AADE7 Self-Care Behaviors and diabetes education as a whole, the five organizations discuss other crucial topics. For example, the ADA presents advocacy, diabetes risk questionnaires to raise awareness, spotlights on individuals taking actions to make a difference in diabetes, personal and inspiring stories of people living with diabetes, question and answer (Q&A) events that could be joined either online or by telephone, fundraisers, donations, and research.40

TCOYD exhibits posts bringing awareness to upcoming diabetes conferences and workshops around the United States, promising technology, personal diabetes experiences, stress tests, and more.41

Joslin Diabetes Center highlights the stories of their Team Joslin runners for the Boston Marathon, personal diabetes experiences, and individuals making the change.43 Joslin also shows material about children’s education events, such as the Teddy Bear Clinic, research recruitment, fundraising campaigns, advocacy, educational programs, and various other informative posts.42

The ADCES displays their annual conference, live video Q&A sessions, published research articles, the diabetes prevention program, the ADA risk questionnaire, healthcare technology, advocacy, insurance information, training (e.g., lifestyle coach), and articles that assist healthcare professionals to deliver optimal diabetes management guidance.42

The social media accounts of the five organizations and institutions integrated all seven AADE7 Self-Care Behaviors. (See Table 3.) With the internet being highly accessible worldwide and social media being used actively daily, users will be able to receive education and support. They also will have the chance to look into the personal stories and lives of individuals with similar challenges and those who are working to make a difference in the diabetes world.

Table 3. Facebook and Twitter DSMES and AADE7 Self-Care Behaviors

 

Healthy Eating

Being Active

Monitoring

Taking Medication

Problem Solving

Healthy Coping

Reducing Risks

American Diabetes Association

American Association
of Diabetes Educators

diaTribe

Joslin Diabetes Center

Taking Control
of Your Diabetes

DSMES: diabetes self-management education and support; AADE: American Association of Diabetes Educators

indicates the resource addresses this behavior

The AADE launched the DANA technology app and website in 2018, serving as an excellent clearinghouse for online diabetes technology support for people with diabetes, their families, and their providers.31

The DANA technology is offered as a member benefit. The site includes educational programs to review useful resources for providers and resources for those who take care of people with diabetes. This platform has a good chance of becoming a one-stop shop for all things related to diabetes management. However, since diabetes is a chronic condition, innovation and improvement of the already established tools and methods of DSMES must continue, since individuals living with diabetes for more than two years often decrease or have no participation in digital health communities.45

Summary

Delivering effective DSMES is crucial for the staggering 34.1 million U.S. adults with diabetes, comprising 13.0% of the adult population, reported in 2018.46 Ideally, people with diabetes would receive DSMES in the hospital, clinic, or in-class programs directly in person with CDCES and healthcare providers.

For those having difficulty achieving optimal glycemic management, finding readily available means to receive daily education beyond the traditional settings is imperative. Mobile applications, SMS, and social media are readily accessible and easy-to-use resources that provide some or even all seven components of the AADE7/ADCES7 Self-Care Behaviors. These three different avenues may need more research to provide higher-quality evidence to show their effectiveness in motivating lifestyle modifications, leading to improved diabetes management outcomes (e.g., reduced HbA1c levels, improved blood pressure management, increased medication adherence, and reduced incidence of diabetes-related complications).

Although the current digital health platforms have been used to deliver DSMES, the lack of interoperable electronic health records (EHRs) hinders a large-scale implementation of digital-health interventions. For example, the available digital health apps do not integrate with EHRs for sharing users’ health-related data and behavioral patterns with healthcare providers for making timely clinical decisions. One of the goals in EHR evolution perhaps should focus on connecting patients’ health-related data for improving the quality of healthcare delivery.

Despite the limitations, these technology-based platforms exhibit great potential for those who struggle in keeping their blood glucose levels within the recommended ranges as the result of the lack of appropriate diabetes education resources. As we move to patient-centered diabetes education and support models, additional resource platforms to support self-management behaviors will continue to motivate and encourage patients in taking the best-supported approach possible to manage their diabetes, leading to a life with the highest quality possible and free of diabetes-related complications.

Acknowledgments

Thanks to Elyssa Valencerina, PharmD, and Cynthia Yee, PharmD, for capturing information in support of drafting this review paper.

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