¡Sí, Yo Puedo Vivir Sano con Diabetes! A Self-Management Randomized Controlled Pilot Trial for Low-Income Adults with Type 2 Diabetes in Mexico City

Are e-Health Interventions Effective in Reducing Diabetes-Related Distress and Depression in Patients with Type 2 Diabetes? A Systematic Review with Meta-Analysis

Background: e-Health refers to any health care service delivered through the internet or related technologies, to improve quality of life. Despite the increasing use of e-health interventions to manage type 2 diabetes (T2D), there is a lack of evidence about the effectiveness on diabetes distress and depression, which are common issues in those living with T2D. Purpose: To synthesize and determine the effects of e-health interventions on diabetes distress and depression among patients with T2D. Methods: We systematically searched PubMed, Scopus, Cochrane CENTRAL, and Web of Science for randomized controlled trials (RCTs), non-RCTs and observational cohort studies for the effects of e-health interventions on diabetes distress and depression in patients with T2D up to September 14, 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 recommendations were followed. The risk of bias was assessed according to the Risk-of-Bias 2 tool (RCTs), the Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I) (non-RCTs) and the National Institute of Health tool (observational). The standardized mean difference (SMD) and its related 95% confidence intervals (CIs) were estimated with the DerSimonian-Laird method through random-effect models. A pooled raw mean difference (MD) meta-analysis was conducted for RCTs comparing the effects of e-health versus control on diabetes distress screening to display the clinical impact. Results: A total of 41 studies (24 RCTs, 14 non-RCTs, and 3 observational) involving 8,667 individuals were included. The pooled SMD for the effect of e-health versus the control group on diabetes distress was -0.14 (95% CI = -0.24 to -0.04; I2 = 23.9%; n = 10 studies), being -0.06 (95% CI = -0.15 to 0.02; I2 = 7.8%; n = 16 studies) for depression. The pooled raw MD on diabetes distress screening showed a reduction of -0.54 points (95% CI = -0.81 to -0.27; I2 = 85.1%; n = 7 studies). Conclusion: e-Health interventions are effective in diminishing diabetes distress among adults with T2D, inducing clinically meaningful reductions.

Effect of Physical Exercise Programs Based on Mobile Health and Ecological Momentary Assessment on the Physical and Mental Health, Cognitive Functions, and Social Environment of Adults in Developing Countries: A Systematic Review

Background and Objectives: Although there is strong evidence of the positive effects of physical exercise on health, adherence to face-to-face exercise programs in the adult population is low, identifying several barriers that hinder their practice. There is research that demonstrates the viability of physical exercise programs with the use of Mobile Health in Ecological Momentary Assessment (EMA) mode, which contributes to overcoming many reported barriers. To synthesize the methodological characteristics and health effects of physical exercise programs based on mobile health in EMA modality in adults in developing countries. Materials and Methods: This systematic review was conducted according to guidelines established by the PRISMA statement in APA PsycArticles and CINAHL databases by EBSCOhost, Cochrane Library, PubMed, and Web of Science for articles published between 2008 and March 2024. Results: Telephone counseling on clinical-behavioral factors is believed to reduce morbidity and mortality in developed countries, but this aspect is not explored in developing countries. We included nine randomized controlled trials with a total of 4394 male and female participants aged 18 to 60 years. The interventions were mainly carried out by text messages, lasting between 20 to 80 min per session, 3 to 5 days per week, and most were carried out over 12 months. The interventions on the variables of physical activity, nutrition, and medical assessments showed significant effects, and variables such as quality of life and anthropometric measurements were not significant in most studies. Conclusions: This systematic review included studies from different developing countries, the most common diseases being diabetes, overweight, obesity, and hypertension. All the studies used mobile devices as the technology, finding a profile of the adults studied, as well as the characteristics of exercise programs based on mobile health in EMA modality.

The effectiveness of diabetes self-management education intervention on glycaemic control and cardiometabolic risk in adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

Diabetes mellitus (DM) poses a significant challenge to public health. Effective diabetes self-management education (DSME) interventions may play a pivotal role in the care of people with type 2 diabetes mellitus (T2DM) in low- and middle-income countries (LMICs). A specific up-to-date systematic review is needed to assess the effect of DSME interventions on glycaemic control, cardiometabolic risk, self-management behaviours, and psychosocial well-being among T2DM across LMICs. The MEDLINE, Embase, CINAHL, Global Health, and Cochrane databases were searched on 02 August 2022 and then updated on 10 November 2023 for published randomised controlled trials (RCTs) and quasi-experimental studies. The quality of the studies was assessed, and a random-effect model was used to estimate the pooled effect of diabetes DSME intervention. Heterogeneity (I2) was tested, and subgroup analyses were performed. Egger's regression test and funnel plots were used to examine publication bias. The risk of bias of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trial (RoB 2). The overall assessment of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. A total of 5893 articles were retrieved, and 44 studies (n = 11838) from 21 LMICs met the inclusion criteria. Compared with standard care, pooled analysis showed that DSME effectively reduced the HbA1c level by 0.64% (95% CI: 0.45% to 0.83%) and 1.27% (95% CI: -0.63% to 3.17%) for RCTs and quasi-experimental design studies, respectively. Further, the findings showed an improvement in cardiometabolic risk reduction, diabetes self-management behaviours, and psychosocial well-being. This review suggests that ongoing support alongside individualised face-to-face intervention delivery is favourable for improving overall T2DM management in LMICs, with a special emphasis on countries in the lowest income group.

Digitally Delivered Interventions to Improve Nutrition Behaviors Among Resource-Poor and Ethnic Minority Groups With Type 2 Diabetes: Systematic Review

BACKGROUND

Resource-poor individuals, such as those with a low income, are disproportionately affected by diabetes and unhealthy eating patterns that contribute to poor disease self-management and prognosis. Digitally delivered interventions have the potential to address some of the barriers to healthy eating experienced by this group. However, little is known about their effectiveness in disadvantaged populations.

OBJECTIVE

This systematic review is conducted to assess the effectiveness of digitally delivered interventions in improving nutritional behaviors and nutrition-related health outcomes among disadvantaged people with type 2 diabetes (T2D).

METHODS

MEDLINE complete, Global Health, Embase, CINAHL complete, Informit Health, IEEE Xplore, and Applied Science and Technology Source databases were searched for studies published between 1990 and 2022 on digitally delivered nutrition interventions for disadvantaged people with T2D. Two reviewers independently assessed the studies for eligibility and determined the study quality using the Cochrane Risk-of-Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 was used to identify behavior change techniques used in the design of interventions.

RESULTS

Of the 2434 identified records, 10 (0.4%), comprising 947 participants, met the eligibility criteria and were included in the review. A total of 2 digital platforms, web and messaging services (eg, SMS text messaging interventions or multimedia messaging service), were used to deliver interventions. Substantial improvements in dietary behaviors were reported in 5 (50%) of the 10 studies, representing improvements in healthier food choices or increases in dietary knowledge and skills or self-efficacy. Of the 10 studies, 7 (70%) examined changes in blood glucose levels, of which 4 (57%) out of 7 achieved significant decreases in hemoglobin A1C levels ranging from 0.3% to 1.8%. The most frequently identified behavior change techniques across all studies were instruction on how to perform the behavior, information about health consequences, and social support.

CONCLUSIONS

This review provided some support for the efficacy of digitally delivered interventions in improving healthy eating behaviors in disadvantaged people with T2D, an essential dietary prerequisite for changes in clinical metabolic parameters. Further research is needed into how disadvantaged people with T2D may benefit more from digital approaches and to identify the specific features of effective digital interventions for supporting healthy behaviors among disadvantaged populations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020149844; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149844.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions have shown promising results for the management of type 2 diabetes, but a comparison of the effectiveness and implementation of the different modes is not currently available. Therefore, this study aimed to compare the effectiveness of SMS, smartphone application, and website-based interventions on improving glycaemia in adults with type 2 diabetes and report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis, we searched CINAHL, Cochrane Central, Embase, MEDLINE, and PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) that examined the effectiveness of digital health interventions in reducing glycated haemoglobin A1c (HbA1c) in adults with type 2 diabetes, published in English from Jan 1, 2009. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint assessed was the change in the mean (and 95% CI) plasma concentration of HbA1c at 3 months or more. Cochrane risk of bias 2 was used to assess risk of bias. Data on reach, uptake, and feasibility were summarised narratively and data on HbA1c reduction were synthesised in a meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation criteria was used to evaluate the level of evidence. The study was registered with PROSPERO, CRD42021247845.

FINDINGS

Of the 3236 records identified, 56 RCTs from 24 regions (n=11 486 participants), were included in the narrative synthesis, and 26 studies (n=4546 participants) in the meta-analysis. 20 studies used SMS as the primary mode of delivery of the digital health intervention, 25 used smartphone applications, and 11 implemented interventions via websites. Smartphone application interventions reported higher reach compared with SMS and website-based interventions, but website-based interventions reported higher uptake compared with SMS and smartphone application interventions. Effective interventions, in general, included people with greater severity of their condition at baseline (ie, higher HbA1c) and administration of a higher dose intensity of the intervention, such as more frequent use of smartphone applications. Overall, digital health intervention group participants had a -0·30 (95% CI -0·42 to -0·19) percentage point greater reduction in HbA1c, compared with control group participants. The difference in HbA1c reduction between groups was statistically significant when interventions were delivered through smartphone applications (-0·42% [-0·63 to -0·20]) and via SMS (-0·37% [-0·57 to -0·17]), but not when delivered via websites (-0·09% [-0·64 to 0·46]). Due to the considerable heterogeneity between included studies, the level of evidence was moderate overall.

INTERPRETATION

Smartphone application and SMS interventions, but not website-based interventions, were associated with better glycaemic control. However, the studies' heterogeneity should be recognised. Considering that both smartphone application and SMS interventions are effective for diabetes management, clinicians should consider factors such as reach, uptake, patient preference, and context of the intervention when deciding on the mode of delivery of the intervention. Nine in ten people worldwide own a feature phone and can receive SMS and four in five people have access to a smartphone, with numerous smartphone applications being available for diabetes management. Clinicians should familiarise themselves with this modality of programme delivery and encourage people with type 2 diabetes to use evidence-based applications for improving their self-management of diabetes. Future research needs to describe in detail the mediators and moderators of the effectiveness and implementation of SMS and smartphone application interventions, such as the optimal dose, frequency, timing, user interface, and communication mode to both further improve their effectiveness and to increase their reach, uptake, and feasibility.

FUNDING

EU's Horizon 2020 Research and Innovation Programme.

The Effect of Health Literacy Intervention on Patients with Diabetes: A Systematic Review and Meta-Analysis

Relevant studies published between January 2010 and June 2021 were identified through relevant databases, including the Science Citation Index Expanded (SCIE) database of Web of Science, PubMed, and Embase, in order to assess the effect of health literacy (HL) intervention on patients with diabetes. A total of 21 articles were eligible. The results showed that: (1) this review involved different HL assessment tools, most of which were self-designed scales and assessment tools focused on measuring functional HL. (2) The differences in glycosylated hemoglobin (HbA1c) (weighted mean difference [WMD] = -0.78, 95% confidence interval [CI]: -0.94, -0.62) and medication adherence (standardized mean difference [SMD] = 1.85, 95% CI: 0.19, 3.52) between the HL intervention group and the usual care group were statistically significant. There was no significant improvement in systolic blood pressure (SMD = -0.05, 95% CI: -0.34, 0.25). Furthermore, this review reported that self-efficacy (SMD = 0.85, 95% CI: 0.65, 1.04) was increased, and the level of HL was improved. In the assessments of risk of bias, 90% of the studies were classified as medium. The quality of the evidence of medication adherence was very low, and the reliability of the conclusions was not enough to confirm the effect of HL.

Subphenotyping of COVID-19 patients at pre-admission towards anticipated severity stratification: an analysis of 778 692 Mexican patients through an age-sex unbiased meta-clustering technique

Background

The COVID-19 pandemic has led to an unprecedented global health care challenge for both medical institutions and researchers. Recognizing different COVID-19 subphenotypes—the division of populations of patients into more meaningful subgroups driven by clinical features—and their severity characterization may assist clinicians during the clinical course, the vaccination process, research efforts, the surveillance system, and the allocation of limited resources.

Objective

We aimed to discover age-sex unbiased COVID-19 patient subphenotypes based on easily available phenotypical data before admission, such as pre-existing comorbidities, lifestyle habits, and demographic features, to study the potential early severity stratification capabilities of the discovered subgroups through characterizing their severity patterns, including prognostic, intensive care unit (ICU), and morbimortality outcomes.

Methods

We used the Mexican Government COVID-19 open data, including 778,692 SARS-CoV-2 population-based patient-level data as of September 2020. We applied a meta-clustering technique that consists of a 2-stage clustering approach combining dimensionality reduction (ie, principal components analysis and multiple correspondence analysis) and hierarchical clustering using the Ward minimum variance method with Euclidean squared distance.

Results

In the independent age-sex clustering analyses, 56 clusters supported 11 clinically distinguishable meta-clusters (MCs). MCs 1-3 showed high recovery rates (90.27%-95.22%), including healthy patients of all ages, children with comorbidities and priority in receiving medical resources (ie, higher rates of hospitalization, intubation, and ICU admission) compared with other adult subgroups that have similar conditions, and young obese smokers. MCs 4-5 showed moderate recovery rates (81.30%-82.81%), including patients with hypertension or diabetes of all ages and obese patients with pneumonia, hypertension, and diabetes. MCs 6-11 showed low recovery rates (53.96%-66.94%), including immunosuppressed patients with high comorbidity rates, patients with chronic kidney disease with a poor survival length and probability of recovery, older smokers with chronic obstructive pulmonary disease, older adults with severe diabetes and hypertension, and the oldest obese smokers with chronic obstructive pulmonary disease and mild cardiovascular disease. Group outcomes conformed to the recent literature on dedicated age-sex groups. Mexican states and several types of clinical institutions showed relevant heterogeneity regarding severity, potentially linked to socioeconomic or health inequalities.

Conclusions

The proposed 2-stage cluster analysis methodology produced a discriminative characterization of the sample and explainability over age and sex. These results can potentially help in understanding the clinical patient and their stratification for automated early triage before further tests and laboratory results are available and even in locations where additional tests are not available or to help decide resource allocation among vulnerable subgroups such as to prioritize vaccination or treatments.

Feasibility of mHealth interventions for depressive symptoms in Latin America: a systematic review

Depression is a prevalent disorder and leading cause of disability in Latin America, where the mental health treatment gap is still above 50%. We sought to synthesise and assess the quality of the evidence on the feasibility of mHealth-based interventions for depression in Latin America. We conducted a literature search of studies published in 2007 and after using four electronic databases. We included peer-reviewed articles, in English, Spanish or Portuguese, that evaluated interventions for depressive symptoms. Two authors independently extracted data using forms developed a priori. We assessed appropriateness of reporting utilising the CONSORT checklist for feasibility trials. Eight manuscripts were included for full data extraction. Appropriate reporting varied greatly. Most (n = 6, 75%) of studies were conducted in primary care settings and sought to deliver psychoeducation or behaviour change interventions for depressive symptoms. We found great heterogeneity in the assessment of feasibility. Two studies used comparator conditions. mHealth research for depression in Latin America is scarce. Included studies showed some feasibility despite methodological inconsistencies. Given the dire need for evidence-based mental health interventions in this region, governments and stakeholders must continue promoting and funding research tailored to cultural and population characteristics with subsequent pragmatic clinical trials.

Efficacy of telemedicine on glycaemic control in patients with type 2 diabetes: A meta-analysis

BACKGROUND

Telemedicine is defined as the delivery of health services via remote communication and technology. It is a convenient and cost-effective method of intervention, which has shown to be successful in improving glyceamic control for type 2 diabetes patients. The utility of a successful diabetes intervention is vital to reduce disease complications, hospital admissions and associated economic costs.

AIM

To evaluate the effects of telemedicine interventions on hemoglobin A1c (HbA1c), systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), post-prandial glucose (PPG), fasting plasma glucose (FPG), weight, cholesterol, mental and physical quality of life (QoL) in patients with type 2 diabetes. The secondary aim of this study is to determine the effect of the following subgroups on HbA1c post-telemedicine intervention; telemedicine characteristics, patient characteristics and self-care outcomes.

METHODS

PubMed Central, Cochrane Library, Embase and Scopus databases were searched from inception until 18^th of June 2020. The quality of the 43 included studies were assessed using the PEDro scale, and the random effects model was used to estimate outcomes and I² for heterogeneity testing. The mean difference and standard deviation data were extracted for analysis.

RESULTS

We found a significant reduction in HbA1c [-0.486%; 95% confidence interval (CI) -0.561 to -0.410, P < 0.001], DBP (-0.875 mmHg; 95%CI -1.429 to -0.321, P < 0.01), PPG (-1.458 mmol/L; 95%CI -2.648 to -0.268, P < 0.01), FPG (-0.577 mmol/L; 95%CI -0.710 to -0.443, P < 0.001), weight (-0.243 kg; 95%CI -0.442 to -0.045, P < 0.05), BMI (-0.304; 95%CI -0.563 to -0.045, P < 0.05), mental QoL (2.210; 95%CI 0.053 to 4.367, P < 0.05) and physical QoL (-1.312; 95%CI 0.545 to 2.080, P < 0.001) for patients following telemedicine interventions in comparison to control groups. The results of the meta-analysis did not show any significant reductions in SBP and cholesterol in the telemedicine interventions compared to the control groups. The telemedicine characteristic subgroup analysis revealed that clinical treatment models of intervention, as well as those involving telemonitoring, and those provided via modes of videoconference or interactive telephone had the greatest effect on HbA1c reduction. In addition, interventions delivered at a less than weekly frequency, as well as those given for a duration of 6 mo, and those lead by allied health resulted in better HbA1c outcomes. Furthermore, interventions with a focus on biomedical parameters, as well as those with an engagement level > 70% and those with a drop-out rate of 10%-19.9% showed greatest HbA1c reduction. The patient characteristics investigation reported that Hispanic patients with T2DM had a greater HbA1c reduction post telemedicine intervention. For self-care outcomes, telemedicine interventions that resulted in higher post-intervention glucose monitoring and self-efficacy were shown to have better HbA1c reduction.

CONCLUSION

The findings indicate that telemedicine is effective for improving HbA1c and thus, glycemic control in patients with type 2 diabetes. In addition, telemedicine interventions were also found to significantly improved other health outcomes as well as QoL scores. The results of the subgroup analysis emphasized that interventions in the form of telemonitoring, via a clinical treatment model and with a focus on biomedical parameters, delivered at a less than weekly frequency and 6 mo duration would have the largest effect on HbA1c reduction. This is in addition to being led by allied health, through modes such as video conference and interactive telephone, with an intervention engagement level > 70% and a drop-out rate between 10%-19.9%. Due to the high heterogeneity of included studies and limitations, further studies with a larger sample size is needed to confirm our findings.

An Umbrella Review of Text Message Programs for Adults With Type 2 Diabetes

Purpose

The purpose of this umbrella review was to synthesize the evidence from published systematic reviews on the effectiveness of text message programs for adults with type 2 diabetes (T2DM) on glycemic management (A1C), self-management, and other clinical outcomes. The effect of directionality of the program was also explored.

Methods

A systematic search was conducted using multiple databases. Inclusion criteria were systematic review of text message programs for adults with T2DM, evaluated A1C, and English language. Quality assessment was completed using AMSTAR-2 guidelines. Data were extracted by multiple coders, and results were synthesized.

Results

The final sample included 9 systematic reviews published between 2011 and 2019, with 72 unique international studies. Text message programs focused on diabetes self-management and reducing health risks through educational and motivational content with some providing personalized feedback. A meta-analysis of program effect on A1C was conducted in 5 reviews with a pooled difference in A1C from −0.38% to −0.8%. Adults with T2DM of shorter duration and lower A1C had better treatment effects. Evidence on unidirectional versus bidirectional programs is conflicting; however, both improve outcomes. Evidence of text message programs targeting medication engagement was inconclusive. Some programs improved blood pressure, lipids, self-management, self-efficacy, and health behaviors. High satisfaction and an average of 9.6% to 18.7% attrition was reported.

Conclusions

Text messaging programs can improve T2DM outcomes, are a highly accessible mode of communication, are relatively inexpensive, and are an underutilized adjunct to clinical care.