Digital Interventions for Recreational Cannabis Use Among Young Adults: Systematic Review, Meta-Analysis, and Behavior Change Technique Analysis of Randomized Controlled Studies

BACKGROUND

The high prevalence of cannabis use among young adults poses substantial global health concerns due to the associated acute and long-term health and psychosocial risks. Digital modalities, including websites, digital platforms, and mobile apps, have emerged as promising tools to enhance the accessibility and availability of evidence-based interventions for young adults for cannabis use. However, existing reviews do not consider young adults specifically, combine cannabis-related outcomes with those of many other substances in their meta-analytical results, and do not solely target interventions for cannabis use.

OBJECTIVE

We aimed to evaluate the effectiveness and active ingredients of digital interventions designed specifically for cannabis use among young adults living in the community.

METHODS

We conducted a systematic search of 7 databases for empirical studies published between database inception and February 13, 2023, assessing the following outcomes: cannabis use (frequency, quantity, or both) and cannabis-related negative consequences. The reference lists of included studies were consulted, and forward citation searching was also conducted. We included randomized studies assessing web- or mobile-based interventions that included a comparator or control group. Studies were excluded if they targeted other substance use (eg, alcohol), did not report cannabis use separately as an outcome, did not include young adults (aged 16-35 y), had unpublished data, were delivered via teleconference through mobile phones and computers or in a hospital-based setting, or involved people with mental health disorders or substance use disorders or dependence. Data were independently extracted by 2 reviewers using a pilot-tested extraction form. Authors were contacted to clarify study details and obtain additional data. The characteristics of the included studies, study participants, digital interventions, and their comparators were summarized. Meta-analysis results were combined using a random-effects model and pooled as standardized mean differences.

RESULTS

Of 6606 unique records, 19 (0.29%) were included (n=6710 participants). Half (9/19, 47%) of these articles reported an intervention effect on cannabis use frequency. The digital interventions included in the review were mostly web-based. A total of 184 behavior change techniques were identified across the interventions (range 5-19), and feedback on behavior was the most frequently used (17/19, 89%). Digital interventions for young adults reduced cannabis use frequency at the 3-month follow-up compared to control conditions (including passive and active controls) by -6.79 days of use in the previous month (95% CI -9.59 to -4.00; P<.001).

CONCLUSIONS

Our results indicate the potential of digital interventions to reduce cannabis use in young adults but raise important questions about what optimal exposure dose could be more effective, both in terms of intervention duration and frequency. Further high-quality research is still needed to investigate the effects of digital interventions on cannabis use among young adults.

TRIAL REGISTRATION

PROSPERO CRD42020196959; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=196959.

Health and Wellness Coaching and Sustained Gains: A Rapid Systematic Review

The Transtheoretical Model of Change identifies key stages in behavior change, including a maintenance stage occurring when a behavior has been upheld for at least 6 months. Health and wellness coaching has demonstrated support for health behavior change, but maintenance of gains has received little attention. Our rapid systematic literature review characterizes both the research exploring sustained gains with health and wellness coaching and what is known about sustained gains after the completion of a health and wellness coaching engagement. Guided by The Cochrane Rapid Reviews Methods Group "Interim Guidance," we drew 231 studies from the 2018 and 2020 Sforzo et al "Compendium of the health and wellness coaching literature," and "Addendum…" appendices. Initial screening and coding for inclusion and exclusion criteria yielded 28 studies for data extraction. We examined studies across outcome categories (physiological, behavioral, psychological, and health risk assessment) to determine whether outcome measures were: not sustained; partially sustained; fully sustained; or improved from immediate post-intervention to a later follow-up period. Twenty-five of the 28 studies reviewed demonstrated partially, or fully, sustained or improved outcomes in one or more variables studied, with sustained gains demonstrated across outcome categories, strengthening confidence in HWC as a facilitator of lasting change.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

3. Prevention or Delay of Diabetes and Associated Comorbidities: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Weight loss and lifestyle change among high-risk individuals enrolled in a digital diabetes prevention program: A longitudinal study of private and public health insurance members in Western New York

Weight loss is critical to reduce diabetes risk. Diabetes Prevention Programs (DPPs) are effective for weight loss, although less is known about digital DPPs. This study explores the association between Brook+, a 52-week digital DPP, and weight loss. This longitudinal observational study uses a sample of 5,516 private, Medicare, and Medicaid health insurance members from Western New York enrolled into Brook+ between December 2020 and December 2022. We used multivariable generalized linear regression models to estimate the association between completion of the Brook+ program, overall and stratified by health insurance type, and 5% weight loss using odds ratios (OR) and 95% confidence intervals (CI), adjusted for age and gender. We also estimated average weight loss from baseline associated with high engagement with the program using adjusted linear regression models. In the pooled sample, those who completed the Brook + program had 21% increased odds of 5% weight loss (OR = 1.21 95% CI: (1.02 - 1.44)). Among users enrolled in private, Medicare, and Medicaid health insurance, program completion was associated with 21%, 33%, and 13% increased odds of 5% weight loss, compared to those who did not complete Brook+. Interacting with health coaches, increased physical activity, and meal logging were all significant predictors of weight loss. Our results suggest that digital DPPs are promising for large-scale diabetes prevention via weight loss and lifestyle change.

Delivering the National Diabetes Prevention Program: Assessment of Outcomes in In-Person and Virtual Organizations

The Centers for Disease Control and Prevention's Diabetes Prevention Recognition Program (DPRP) has helped organizations deliver the National Diabetes Prevention Program (National DPP) lifestyle change program for over 10 years. Four delivery modes are now approved: in person, online (self-paced, asynchronous delivery), distance learning (remote, synchronous delivery), and combination (hybrid delivery using more than one delivery mode). We assessed outcomes using data from 333,715 participants who started the 12-month program between January 1, 2012, and December 31, 2018. The average number of sessions attended was highest for in-person participants (15.0), followed by online (12.9), distance learning (12.2), and combination (10.7). The average number of weeks in the program was highest for in-person participants (28.1), followed by distance learning (20.1), online (18.7), and combination (18.6). The average difference between the first and last reported weekly physical activity minutes reflected an increase for in person (42.0), distance learning (27.1), and combination (15.0), but a decrease for online (-19.8). Among participants retained through session 6 or longer, average weekly physical activity minutes exceeded the program goal of 150 for all delivery modes. Average weight loss (percent of body weight) was greater for in person (4.4%) and distance learning (4.7%) than for online (2.6%) or combination (2.9%). Average participant weight loss increased gradually by session for all delivery modes; among participants who remained in the program for 22 sessions, average weight loss exceeded the program goal of 5% for all delivery modes. In summary, if participants stay in the program, most have positive program outcomes regardless of delivery mode; they have some outcome improvement even if they leave early; and their outcomes improve more the longer they stay. This highlights the benefits of better retention and increased enrollment in the National DPP lifestyle change programs, as well as enhancements to online delivery.

The characteristics and acceptance of Technology-Enabled diabetes prevention programs (t-DPP) amongst individuals with prediabetes: A scoping review

AIM AND OBJECTIVE

As rising global prevalence of diabetes burdens an overstrained healthcare system, it would be prudent to employ primary prevention strategies. This review aims to detail characteristics of technology-enabled diabetes prevention programs (t-DPP) and the technology acceptance amongst prediabetic individuals.

DESIGN

A scoping review.

REVIEW METHODS

Summative and direct content analysis.

DATA SOURCES

Seven electronic databases-PubMed, Cochrane, Embase, CINAHL, Scopus, PsycINFO and Web of Science-were searched from inception till 9 June 2022 for primary studies conducted on t-DPP. Initial search identified 2412 unique articles. Removal of duplicates and irrelevant articles resulted in 58 full text articles screened and 17 articles meeting the eligibility criteria. There was no limitation to study type or year of publication, but language was limited to English.

RESULTS

Common t-DPP characteristics include physical activity (n = 17), diet control (n = 16), coaching (n = 12), social support (n = 9) and skills acquisition (n = 12). Technological acceptance of t-DPPs were generally positive as participants found them useful (n = 5) and easy to use (n = 4), with majority of the participants interested (n = 5) and engaging well with it (n = 13). However, personal-, design- and technological-level factors were found to negatively influence t-DPPs acceptance.

CONCLUSION

This review reported a generally positive technological acceptance. The result encourages remote delivery of diabetes prevention programs, offering researchers a guide to t-DPP development. However, it also highlights the need for integration of behavioural change theories and socio-cultural considerations, with gaps in knowledge amongst men and young adults.

IMPLICATIONS FOR NURSING

The success of t-DPP can reinforce clinical advice and sustain health behaviours advocated by nurses. Involvement of diabetes-trained nurses would enable continual risk assessment, monitoring and timely intervention to prevent diabetes and potential complications.

REPORTING METHOD

PRISMA-ScR checklist.

Cost and cost-effectiveness analysis of a digital diabetes prevention program: results from the PREDICTS trial

Although technology-assisted diabetes prevention programs (DPPs) have been shown to improve glycemic control and weight loss, information are limited regarding relevant costs and their cost-effectiveness. To describe a retrospective within-trial cost and cost-effectiveness analysis (CEA) to compare a digital-based DPP (d-DPP) with small group education (SGE), over a 1-year study period. The costs were summarized into direct medical costs, direct nonmedical costs (i.e., times that participants spent engaging with the interventions), and indirect costs (i.e., lost work productivity costs). The CEA was measured by the incremental cost-effectiveness ratio (ICER). Sensitivity analysis was performed using nonparametric bootstrap analysis. Over 1 year, the direct medical costs, direct nonmedical costs, and indirect costs per participant were $4,556, $1,595, and $6,942 in the d-DPP group versus $4,177, $1,350, and $9,204 in the SGE group. The CEA results showed cost savings from d-DPP relative to SGE based on a societal perspective. Using a private payer perspective for d-DPP, ICERs were $4,739 and $114 to obtain an additional unit reduction in HbA1c (%) and weight (kg), and were $19,955 for an additional unit gain of quality-adjusted life years (QALYs) compared to SGE, respectively. From a societal perspective, bootstrapping results indicated that d-DPP has a 39% and a 69% probability, at a willingness-to-pay of $50,000/QALY and $100,000/QALY, respectively, of being cost-effective. The d-DPP was cost-effective and offers the prospect of high scalability and sustainability due to its program features and delivery modes, which can be easily translated to other settings.

Mental health diagnosis attenuates weight loss among older adults in a digital diabetes prevention program

Objective

Diabetes Prevention Programs (DPP) are effective at reducing diabetes incidence via clinically significant weight loss. Co-morbid mental health condition(s) may reduce the effect of DPP administered in-person and telephonically but this has not been assessed for digital DPP. This report examines the moderating effect of mental health diagnosis on weight change among individuals who enrolled in digital DPP (enrollees) at 12 and 24 months.

Methods

Secondary analysis of prospective, electronic health record data from a study of digital DPP among adults (N = 3904) aged 65-75 with prediabetes (HbA1c 5.7%-6.4%) and obesity (BMI ≥30 kg/m²).

Results

Mental health diagnosis only moderated the effect of digital DPP on weight change during the first 7 months (p = 0.003) and the effect attenuated at 12 and 24 months. Results were unchanged after adjusting for psychotropic medication use. Among those without a mental health diagnosis, digital DPP enrollees lost more weight than non-enrollees: -4.17 kg (95% CI, -5.22 to -3.13) at 12 months and -1.88 kg (95% CI, -3.00 to -0.76) at 24 months, whereas among individuals with a mental health diagnosis, there was no difference in weight loss between enrollees and non-enrollees at 12 and 24 months (-1.25 kg [95% CI, -2.77 to 0.26] and 0.02 kg [95% CI, -1.69-1.73], respectively).

Conclusions

Digital DPP appears less effective for weight loss among individuals with a mental health condition, similar to prior findings for in-person and telephonic modalities. Findings suggest a need for tailoring DPP to address mental health conditions.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change)

BACKGROUND

The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions.

METHODS

In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use.

DISCUSSION

If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.

3. Prevention or Delay of Type 2 Diabetes and Associated Comorbidities: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Social media interventions addressing physical activity among emerging adults who use cannabis: A pilot trial of feasibility and acceptability

PURPOSE

Cannabis use is common among emerging adults (ages 18-25), yet few prevention interventions have targeted this unique developmental period. Physical activity (PA) is an under-utilized intervention target for cannabis use, despite research showing its potential utility. Based on prior promising social media-delivered interventions targeting cannabis and PA separately, we developed and piloted, in a randomized controlled feasibility trial (NCT04901910), interventions for emerging adults who use cannabis that focused on PA.

PROCEDURES

Using social media, we recruited 60 emerging adults (Mean age=21.7 years; 63.3% female sex) who used cannabis (>=3 times/week for the past month) and could engage in PA. We randomized participants into one of 3 conditions (PA-Only; PA+Cannabis, Attention-Control) that each lasted 8 weeks and were delivered in secret Facebook groups by health coaches. We collected follow-up data at 3- and 6-months post-group start. Outcomes are presented descriptively given the pilot nature and limited sample size.

RESULTS

The interventions were rated favorably, with ratings of the content in each condition averaging around 3 on a 5-point scale. Both intervention groups demonstrated larger reductions in cannabis consequences and cannabis-impaired driving over time than the control condition. Findings were mixed regarding patterns of change in cannabis use in the intervention conditions. Proportions of group members reporting increased PA ranged from 38.9% to 80.0% across time.

CONCLUSIONS

Interventions targeting PA and delivered via social media to emerging adults who regularly use cannabis offer a novel intervention target. These interventions warrant future investigation in larger trials over a longer follow-up period.

A Pilot Study to Examine the Feasibility and Acceptability of a Virtual Adaptation of an In-Person Adolescent Diabetes Prevention Program

BACKGROUND

Rates of prediabetes and type 2 diabetes are alarmingly high among racial/ethnic minority youth. The current study examines the virtual adaptation of an in-person peer-led youth diabetes prevention program.

METHODS

The initial phase involved the study team adapting workshop sessions from an in-person to a virtual format (Zoom). We conducted a 2-h feasibility pilot in December 2020 and implemented the full 12 session pilot program from June to September 2021 with 14 prediabetic adolescents recruited from our hospital-based general pediatric clinic. Weekly sessions were led by trained peer educators and focused on promoting healthy eating and physical activity using behavioral techniques (e.g., goal setting, brainstorming, and problem solving).

RESULTS

The virtual adaptation of our program was shown to be feasible and acceptable among our pilot participants. We were able to deliver the same workshop content and behavioral skills development as the in-person workshop using a variety of Zoom features.

CONCLUSIONS

Our peer-led youth diabetes prevention program was successfully adapted and implemented in a virtual format and was well accepted by at-risk youth. Future research is needed to examine the impact of virtual youth lifestyle interventions on behavioral and clinical outcomes such as weight and diabetes risk.

Adaptation of diabetes prevention program for Chinese Americans - a qualitative study

BACKGROUND

Studies have demonstrated that a culturally and linguistically tailored Diabetes Prevention Program (DPP) can be effective in reducing diabetes risk in Chinese Americans. The purpose of this study was to explore the cultural and linguistic acceptability of the Centers for Disease Control and Prevention's Prevent T2 curriculum in an online format in the Chinese American community in New York City (NYC).

METHODS

Three focus groups among a total of 24 Chinese Americans with prediabetes and one community advisory board (CAB) meeting with 10 key stakeholders with expertise in diabetes care and lifestyle interventions were conducted. Each focus group lasted approximately 1 to 1.5 h. All groups were moderated by a bilingual moderator in Chinese. The sessions were audiotaped, transcribed and translated to English for analysis. Using Atlas.ti software and open coding techniques, two researchers analyzed transcripts for thematic analysis.

RESULTS

Five key themes were identified: barriers to behavioral changes, feedback on curriculum content and suggestions, web-based intervention acceptability, web-based intervention feasibility, and web-based intervention implementation and modifications. Participants with prediabetes were found to have high acceptability of web-based DPP interventions. Suggestions for the curriculum included incorporating Chinese American cultural foods and replacing photos of non-Asians with photos of Asians. Barriers included lack of access to the internet, different learning styles and low technology self-efficacy for older adults.

CONCLUSION

Although the acceptability of web-based DPP in the Chinese American community in NYC is high, our focus group findings indicated that the major concern is lack of internet access and technical support. Providing support, such as creating an orientation manual for easy online program access for future participants, is important.

Participants' perspectives on perceived usefulness of digital and in-person diabetes prevention programs: A qualitative study to inform decisions related to program participation

Objective

Given the effectiveness of both in-person and digital diabetes prevention programs (DPPs), participants have an opportunity to select a delivery mode based on their needs and preferences. The objective of this study was to understand and compare participants' experiences with digital and in-person DPPs to identify factors that affected how useful participants perceived these two program delivery modes.

Methods

Semi-structured interviews with participants who were enrolled in DPPs as either a digital (n = 23) or in-person (n = 20) program within one health care system were conducted. Data were analyzed following the template method using the qualitative software NVivo 12.

Results

Findings from the interviews indicated that creating accountability for weight loss was crucial for all program participants. In the digital program, weight and food tracking played a central role in creating accountability, while in the in-person program, group interactions fostered accountability. The digital program was perceived to encourage self-monitoring, oftentimes resulting in participants' reflection on their habits. The in-person program provided a platform for group support and mutual encouragement.

Conclusions

Participants perceived both programs as similarly useful. Yet program characteristics such as the ability to engage with other participants in-person or to seamlessly track weight on a daily basis appealed to different participants. It may be beneficial to align participants' preferences with programs' characteristics and strengths.

Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations

Approximately 1 in 3 American adults has prediabetes, a condition characterized by blood glucose levels that are above normal, not in the type 2 diabetes ranges, and that increases the risk of developing type 2 diabetes. Evidence-based treatments can be used to prevent or delay type 2 diabetes in adults with prediabetes. The American Medical Association (AMA) has collaborated with health care organizations across the country to build sustainable diabetes prevention strategies. In 2017, the AMA formed the Diabetes Prevention Best Practices Workgroup (DPBP) with representatives from 6 health care organizations actively implementing diabetes prevention. Each organization had a unique strategy, but all included the National Diabetes Prevention Program lifestyle change program as a core evidence-based intervention. DPBP established the goal of disseminating best practices to guide other health care organizations in implementing diabetes prevention and identifying and managing patients with prediabetes. Workgroup members recognized similarities in some of their basic steps and considerations and synthesized their practices to develop best practice recommendations for 3 strategy maturity phases. Recommendations for each maturity phase are classified into 6 categories: (1) organizational support; (2) workforce and funding; (3) promotion and dissemination; (4) clinical integration and support; (5) evaluation and outcomes; (6) and program. As the burden of chronic disease grows, prevention must be prioritized and integrated into health care. These maturity phases and best practice recommendations can be used by any health care organization committed to diabetes prevention. Further research is suggested to assess the impact and adoption of diabetes prevention best practices.

Moving Food Assistance into the Digital Age: A Scoping Review

One of the most basic needs globally, food assistance refers to the multitude of programs, both governmental and non-governmental, to improve food access and consumption by food-insecure individuals and families. Despite the importance of digital and mobile Health (mHealth) strategies in food insecurity contexts, little is known about their specific use in food assistance programs. Therefore, the purpose of this study was to address that gap by conducting a scoping review of the literature. Keywords were defined within the concepts of food assistance and digital technology. The search included relevant peer-reviewed and grey literature from 2011 to 2021. Excluded articles related to agriculture and non-digital strategies. PRISMA guidelines were followed to perform a partnered, two-round scoping literature review. The final synthesis included 39 studies of which most (84.6%) were from the last five years and United States-based (93.2%). The top three types of articles or studies included text and opinion, qualitative research, and website, application, or model development (17.9%). The top three types of digital tools were websites (56.4%), smartphone applications (20.5%), and chatbots (5.1%). Nineteen digital features were identified as desirable. Most tools included just one or two features. The most popular feature to include was online shopping (n = 14), followed by inventory management, and client tracking. Digital tools for individual food assistance represent an opportunity for equitable and stable access to programs that can enhance or replace in-person services. While this review identified 39 tools, all are in early development and/or implementation stages. Review findings highlight an overall lack of these tools, an absence of user-centered design in their development, and a critical need for research on their effectiveness globally. Further analysis and testing of current digital tool usage and interventions examining the health and food security impacts of such tools should be explored in future studies, including in the context of pandemics, where digital tools allow for help from a distance.

3. Prevention or Delay of Type 2 Diabetes and Associated Comorbidities: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Evaluating the Implementation of a Digital Diabetes Prevention Program in an Integrated Health Care Delivery System Among Older Adults: Results of a Natural Experiment

The purpose of this natural experiment study was to assess the effectiveness of a 12-month digital Diabetes Prevention Program (DPP) for adults aged 65-75 years with prediabetes and obesity within a large, integrated health care system. Adjusting for propensity scores and covariates, patients who enrolled and participated in the digital DPP had a mean weight loss of 8.6 lb over 12 months and 5.7 lb by 24 months, compared with a steady, minimal weight loss of 1.3 lb over 12 months and 2.8 lb by 24 months among patients not enrolled. There was a significant difference in mean change in A1C between enrolled and nonenrolled patients over 12 months (-0.10%), but not by 24 months (-0.06%). Digital DPP appears to be an effective weight loss option and potential diabetes prevention intervention for older adults at high risk for type 2 diabetes.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Delivering the National Diabetes Prevention Program: Assessment of Enrollment in In-Person and Virtual Organizations

The aim of the US Centers for Disease Control and Prevention's (CDC) National Diabetes Prevention Program (National DPP) is to make an evidence-based lifestyle change program widely available to the more than 88 million American adults at risk for developing type 2 diabetes. The National DPP allows for program delivery using four delivery modes: in person, online, distance learning, and combination. The objective of this study was to analyze cumulative enrollment in the National DPP by delivery mode. We included all participants who enrolled in CDC-recognized organizations delivering the lifestyle change program between January 1, 2012, and December 31, 2019, and whose data were submitted to CDC's Diabetes Prevention Recognition Program. During this time, the number of participants who enrolled was 455,954. Enrollment, by delivery mode, was 166,691 for in-person; 269,004 for online; 4,786 for distance-learning; and 15,473 for combination. In-person organizations enrolled the lowest proportion of men (19.4%) and the highest proportions of non-Hispanic Black/African American (16.1%) and older (65+ years) participants (28.2%). Online organizations enrolled the highest proportions of men (27.1%), younger (18-44 years) participants (41.5%), and non-Hispanic White participants (70.3%). Distance-learning organizations enrolled the lowest proportion of Hispanic/Latino participants (9.0%). Combination organizations enrolled the highest proportions of Hispanic/Latino participants (37.3%) and participants who had obesity (84.1%). Most in-person participants enrolled in organizations classified as community-centered entities (41.4%) or medical providers (31.2%). Online and distance-learning participants were primarily enrolled (93.3% and 70.2%, respectively) in organizations classified as for-profit businesses or insurers. Participants in combination programs were enrolled almost exclusively in organizations classified as medical providers (89%). The National DPP has reached nearly half a million participants since its inception in 2012, but continued expansion is critical to stem the tide of type 2 diabetes among the many Americans at high risk.

Using Community Health Workers to Address Barriers to Participation and Retention in Diabetes Prevention Program: A Concept Paper

Objective:

The PreventionLink of Southern Maryland is a 5-year project to eliminate barriers to participation and retention in the National Diabetes Prevention Program (DPP) lifestyle change program to prevent or delay the onset of type 2 diabetes in adults with prediabetes. This is the study to identify the obstacles to participation and retention in the DPP lifestyle change program among high burden populations and learn how CHWs have reduced the identified barriers to participation and retention for high burden populations.

Methods:

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to conduct this literature review. We have used the Scopus and PubMed, including all types of studies and peer-reviewed documents published in English between 2010 and 2020.

Results:

From 131 identified articles, 18 articles were selected for qualitative synthesis. The reviewed literature documented following as main barriers to participate in a DPP lifestyle change program: time, cost, lack of transportation, cost of transportation, commute distance, technology access, access to facilities and community programs, caregiver responsibilities, lack of health literacy and awareness, and language. CHWs can address these barriers to participation and retention, they were involved in educating and supporting roles; they worked as bridges between healthcare providers and participants and as intervention team members.

Conclusions:

Diabetes prevention program participants with social determinant risk factors who most need CHW services are unlikely to have financial resources to pay for CHW services out-of-pocket. Hence, the public and private health plans that pay for their prediabetes care should consider paying for these CHW services and there is a need to trust more to CHW and have them as a “community health teams” member.

Development of a computer-aided text message platform for user engagement with a digital Diabetes Prevention Program: a case study

Digital Diabetes Prevention Programs (dDPP) are novel mHealth applications that leverage digital features such as tracking and messaging to support behavior change for diabetes prevention. Despite their clinical effectiveness, long-term engagement to these programs remains a challenge, creating barriers to adherence and meaningful health outcomes. We partnered with a dDPP vendor to develop a personalized automatic message system (PAMS) to promote user engagement to the dDPP platform by sending messages on behalf of their primary care provider. PAMS innovates by integrating into clinical workflows. User-centered design (UCD) methodologies in the form of iterative cycles of focus groups, user interviews, design workshops, and other core UCD activities were utilized to defined PAMS requirements. PAMS uses computational tools to deliver theory-based, automated, tailored messages, and content to support patient use of dDPP. In this article, we discuss the design and development of our system, including key requirements and features, the technical architecture and build, and preliminary user testing.

Linking Network Characteristics of Online Social Networks to Individual Health: A Systematic Review of Literature

Social networks have long been viewed as a structural determinant of health. With the proliferation of digital technologies, numerous studies have examined the health implications of online social networks (OSNs). However, the mechanisms through which OSNs may influence individual health are poorly understood. Employing a social network approach, this paper presents a systematic review of the literature examining how network characteristics of OSNs are linked to individuals' health behavior and/or status. Drawing on keyword searches in nine databases, we identified and analyzed 22 relevant articles from 1,705 articles published prior to 2017. The findings show that individual health is associated with a number of network characteristics, including both individual-level attributes (e.g., centrality) and network-level attributes (e.g., density, clustering). All of the included studies (n = 22) have focused on egocentric networks, and nine studies also collected whole network data of online health communities. Based on our review, we highlight three fruitful areas in the application of OSNs in public health: (1) disease and risk detection, (2) disease prevention and intervention, and (3) health behavior change. However, the precise mechanisms and causal pathways through which OSNs affect health remain unclear. More theoretically grounded, longitudinal, and mixed methods research is needed to advance this line of research.

Costing a population health management approach for participant recruitment to a diabetes prevention study

Limited research has reported the economic feasibility-from both a research and practice perspective-of efforts to recruit and enroll an intended audience in evidence-based approaches for disease prevention. We aimed to retrospectively assess and estimate the costs of a population health management (PHM) approach to identify, engage, and enroll patients in a Type 1 Hybrid Effectiveness-Implementation (HEI), diabetes-prevention trial. We used activity-based costing to estimate the recruitment costs of a PHM approach integrated within an HEI trial. We took the perspective of a healthcare system that may adopt, and possibly sustain, the strategy in the typical practice. We also estimated replication costs based on how the strategy could be applied in healthcare systems interested in referring patients to a local diabetes prevention program from a payer perspective. The total recruitment and enrollment costs were $360,424 to accrue 599 participants over approximately 15 months. The average cost per screened and enrolled participant was $263 and $620, respectively. Translating to the typical settings, total recruitment costs for replication were estimated as $193,971 (range: $43,827-$210,721). Sensitivity and scenario analysis results indicated replication costs would be approximately $283-$444 per patient enrolled if glucose testing was necessary, based on the Medicare-covered services. From a private payer perspective, and without glucose testing, per-participant assessed costs were estimated at $31. A PHM approach can be used to accrue a large number of participants in a short period of time for an HEI trial, at a comparable cost per participant.

Prevention of Type 2 Diabetes

The global diabetes burden is staggering, and prevention efforts are needed to reduce the impact on individuals and populations. There is strong evidence from efficacy trials showing that lifestyle interventions promoting increased physical activity, improvements in diet, and/or weight loss significantly reduce diabetes incidence and improve cardiometabolic risk factors. Implementation research assessing the feasibility, effectiveness, and cost-effectiveness of delivering these proven programs at the community level has shown success, but more research is needed to overcome barriers to implementation in different settings globally. New avenues of research should be considered to combat this public health issue.

Web-Based Peer Support Interventions for Adults Living With Chronic Conditions: Scoping Review

Background

Globally, 1 in 3 adults live with multiple chronic conditions. Thus, effective interventions are needed to prevent and manage these chronic conditions and to reduce the associated health care costs. Teaching effective self-management practices to people with chronic diseases is one strategy to address the burden of chronic conditions. With the increasing availability of and access to the internet, the implementation of web-based peer support programs has become increasingly common.

Objective

The purpose of this scoping review is to synthesize existing literature and key characteristics of web-based peer support programs for persons with chronic conditions.

Methods

This scoping review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews guidelines. Studies were identified by searching MEDLINE, CINAHL, Embase, PsycINFO, and the Physiotherapy Evidence Database. Chronic diseases identified by the Public Health Agency of Canada were included. Our review was limited to peer support interventions delivered on the web. Peers providing support had to have the chronic condition that they were providing support for. The information abstracted included the year of publication, country of study, purpose of the study, participant population, key characteristics of the intervention, outcome measures, and results.

Results

After duplicates were removed, 12,641 articles were screened. Data abstraction was completed for 41 articles. There was a lack of participant diversity in the included studies, specifically with respect to the conditions studied. There was a lack of studies with older participants aged ≥70 years. There was inconsistency in how the interventions were described in terms of the duration and frequency of the interventions. Informational, emotional, and appraisal support were implemented in the studied interventions. Few studies used a randomized controlled trial design. A total of 4 of the 6 randomized controlled trials reported positive and significant results, including decreased emotional distress and increased health service navigation, self-efficacy, social participation, and constructive attitudes and approaches. Among the qualitative studies included in this review, there were several positive experiences related to participating in a web-based peer support intervention, including increased compassion and improved attitudes toward the individual’s chronic condition, access to information, and empowerment.

Conclusions

There is limited recent, high-level evidence on web-based peer support interventions. Where evidence exists, significant improvements in social participation, self-efficacy, and health-directed activity were demonstrated. Some studies incorporated a theoretical framework, and all forms of peer support—emotional, informational, and appraisal support—were identified in the studies included in this review. We recommend further research on web-based peer support in more diverse patient groups (eg, for older adults and chronic conditions outside of cancer, cardiovascular disease, and HIV or AIDS). Key gaps in the area of web-based peer support will serve to inform the development and implementation of future programs.

Return on Investment: Medical Savings of an Employer-Sponsored Digital Intensive Lifestyle Intervention, Weight Loss

OBJECTIVE

This study aimed to determine the medical cost impact and return on investment (ROI) of a large, commercial, digital, weight-management intensive lifestyle intervention (ILI) program (Real Appeal).

METHODS

Participants in this program were compared with a control group matched by age, sex, geographic region, health risk, baseline medical costs, and chronic conditions. Medical costs were defined as the total amount paid for all medical expenses, inclusive of both the insurers' and the study participants' responsibility.

RESULTS

In the 3 years following program registration, the intent-to-treat (ITT) cohort had significantly lower medical expenditures than the matched controls, with an average of -$771 or 12% lower costs (P = 0.002). Among 4,790 ITT participants, a total savings of $3,693,090 compared with total program costs of $1,639,961 translated into a 2.3:1 ROI. Program completers (n = 3,990), who attended more sessions than the overall ITT group, had greater mean weight loss (-4.4%), greater cost savings (-$956 or 14%), and an ROI of 2.0:1 over the 3-year time frame compared with matched controls.

CONCLUSIONS

The findings demonstrated that the digital weight-management ILI was associated with a significantly positive ROI. Employers and payers willing to cover the cost of an ILI that produces both weight loss and demonstrated cost benefits can improve health and save money for their population with overweight or obesity.

Effectiveness of an Integrated Engagement Support System to Facilitate Patient Use of Digital Diabetes Prevention Programs: Protocol for a Randomized Controlled Trial

Background

Digital diabetes prevention programs (dDPPs) are effective behavior change tools to prevent disease progression in patients at risk for diabetes. At present, these programs are poorly integrated into existing health information technology infrastructure and clinical workflows, resulting in barriers to provider-level knowledge of, interaction with, and support of patients who use dDPPs. Tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient engagement and adherence to these programs and improved health outcomes.

Objective

This study aims to use a rigorous, user-centered design (UCD) methodology to develop a theory-driven system that supports patient engagement with dDPPs and their primary care providers with their care.

Methods

This study will be conducted in 3 phases. In phase 1, we will use systematic UCD, Agile software development, and qualitative research methods to identify key user (patients, providers, clinical staff, digital health technologists, and content experts) requirements, constraints, and prioritization of high-impact features to design, develop, and refine a viable intervention prototype for the engagement system. In phase 2, we will conduct a single-arm feasibility pilot of the engagement system among patients with prediabetes and their primary care providers. In phase 3, we will conduct a 2-arm randomized controlled trial using the engagement system. Primary outcomes will be weight, BMI, and A_1c at 6 and 12 months. Secondary outcomes will be patient engagement (use and activity) in the dDPP. The mediator variables (self-efficacy, digital health literacy, and patient-provider relationship) will be measured.

Results

The project was initiated in 2018 and funded in September 2019. Enrollment and data collection for phase 1 began in September 2019 under an Institutional Review Board quality improvement waiver granted in July 2019. As of December 2020, 27 patients have been enrolled and first results are expected to be submitted for publication in early 2021. The study received Institutional Review Board approval for phases 2 and 3 in December 2020, and phase 2 enrollment is expected to begin in early 2021.

Conclusions

Our findings will provide guidance for the design and development of technology to integrate dDPP platforms into existing clinical workflows. This will facilitate patient engagement in digital behavior change interventions and provider engagement in patients’ use of dDPPs. Integrated clinical tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient adherence to these programs and improved health outcomes by addressing barriers faced by both patients and providers. Further evaluation with pilot testing and a clinical trial will assess the effectiveness and implementation of these tools.

Trial Registration

ClinicalTrials.gov NCT04049500; https://clinicaltrials.gov/ct2/show/NCT04049500

International Registered Report Identifier (IRRID)

DERR1-10.2196/26750

The Use of Telehealth Technology to Support Health Coaching for Older Adults: Literature Review

BACKGROUND

Health coaching is an intervention process for driving behavior change through goal-setting, education, encouragement, and feedback on health-related behaviors. Telehealth systems that include health coaching and remote monitoring are making inroads in managing chronic conditions and may be especially suited for older populations.

OBJECTIVE

This literature review aimed to investigate the current status of health coaching interventions incorporating telehealth technology and the associated effectiveness of this intervention to deliver health care with an emphasis on older adults (aged 65 and older).

METHODS

A literature review was conducted to identify the research conducted on health coaching combined with remote monitoring for delivering health care to older adults. The Ovid MEDLINE and CINAHL databases were queried using a combination of relevant search terms (including middle aged, aged, older adult, elderly, health coaching, and wellness coaching). The search retrieved 196 papers published from January 2010 to September 2019 in English. Following a systematic review process, the titles and abstracts of the papers retrieved were screened for applicability to health coaching for older adults to define a subset for further review. Papers were excluded if the studied population did not include older adults. The full text of the 42 papers in this subset was then reviewed, and 13 papers related to health coaching combined with remote monitoring for older adults were included in this review.

RESULTS

Of the 13 studies reviewed, 10 found coaching supported by telehealth technology to provide effective outcomes. Effectiveness outcomes assessed in the studies included hospital admissions/re-admissions, mortality, hemoglobin A_1c (HbA_1c) level, body weight, blood pressure, physical activity level, fatigue, quality of life, and user acceptance of the coaching program and technology.

CONCLUSIONS

Telehealth systems that include health coaching have been implemented in older populations as a viable intervention method for managing chronic conditions with mixed results. Health coaching combined with telehealth may be an effective solution for providing health care to older adults. However, health coaching is predominantly performed by human coaches with limited use of technology to augment or replace the human coach. The opportunity exists to expand health coaching to include automated coaching.

3. Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Impact of a Digital Diabetes Prevention Program on Risk Factors for Chronic Disease in a Workforce Cohort

OBJECTIVE

Evaluate the effect of a digital Diabetes Prevention Program (dDPP) on chronic disease risk factors in a workplace population.

METHODS

dDPP participants were employees and spouses with BMI ≥ 24 kg/m and prediabetes or diabetes (n = 84). Annual change in risk factors before and after dDPP were assessed in the dDPP group and in a retrospectively identified matched control group drawn from those who participated in a dDPP after the conclusion of this study (n = 252).

RESULTS

In the dDPP group, body weight, BMI, fasting glucose, triglycerides, total cholesterol and LDL-cholesterol decreased in the post-dDPP period compared with the pre-dDPP period (P < 0.05). In the control group, no difference between the annual change before and after dDPP was observed (P > 0.37).

CONCLUSION

The dDPP was effective in reducing risk factors for chronic disease in a workplace setting.

Drivers of weight loss in a CDC-recognized digital diabetes prevention program

INTRODUCTION

To investigate the impact of the digital Livongo Diabetes Prevention Program (DPP) on weight at 12 months, understand participants' self-monitoring behaviors associated with greater weight loss, and evaluate the impact of coaching interactions on more frequent self-monitoring behaviors.

RESEARCH DESIGN AND METHODS

A retrospective analysis was performed using data from 2037 participants enrolled in the Livongo DPP who completed lesson 1 and recorded a starting weight during 2016-2017. Self-monitoring behaviors, including weigh-ins, food logging, activity, and coach-participant interactions, were analyzed at 6 and 12 months. Subgroup analysis was conducted based on those who were highly engaged versus those minimally engaged. Multiple regression analysis was performed using demographic, self-monitoring, and lesson attendance data to determine predictors of weight loss at 12 months and coaching impact on self-monitoring.

RESULTS

Participants had a mean age of 50 years (SD ±12), with a starting weight of 94 kg (SD ±21), were college-educated (78%), and were female (74%). Overall, participants lost on average 5.1% of their starting weight. Highly engaged participants lost 6.6% of starting body weight, with 25% losing ≥10% at 12 months. Logistic regression analysis showed each submitted food log was associated with 0.23 kg (p<0.05) weight loss, each lesson completed was associated with 0.14 kg (p<0.05) weight loss, and a week of 150 active minutes was associated with 0.1 kg (p<0.01) weight loss. One additional coach-participant message each week was associated with 1.4 more food logs per week, 1.6% increase in weeks with four or more weigh-ins, and a 2.7% increase in weeks with 150 min of activity.

CONCLUSIONS

Food logging had the largest impact on weight loss, followed by lesson engagement and physical activity. Future studies should examine further opportunities to deliver nutrition-based content to increase and sustain weight loss for DPP.

Comparative Effectiveness of 2 Diabetes Prevention Lifestyle Programs in the Workplace: The City and County of San Francisco Diabetes Prevention Trial

Introduction

Data on the comparative effectiveness of Diabetes Prevention Programs (DPPs) in the workplace are limited.

Methods

Between September 2015 and July 2016, employees of the City and County of San Francisco who were at risk for type 2 diabetes (N = 158) were randomly assigned to one of 2 DPP-derived programs recognized by the Centers for Disease Control and Prevention: an in-person YMCA-DPP (n = 78) or an online virtual lifestyle management DPP (VLM-DPP) offered through Canary Health (n = 80). The primary outcome was change in body weight assessed at 6 and 12 months. Follow-up ended in August 2017.

Results

Both the YMCA-DPP and VLM-DPP yielded a significant reduction in percentage body weight at 6 months. For the YMCA-DPP, mean percentage change at 6 months was −2.70% (95% confidence interval [CI], −3.91% to −1.48%) and at 12 months was −2.46% (95% CI, −4.24% to −0.68%). For the VLM-DPP, mean percentage change at 6 months was −2.41% (95% CI, −4.07% to −0.77%) and at 12 months was −1.59% (95% CI, −3.51% to 0.33%). The mean between-condition difference at 6 months was −0.25% (95% CI, −2.04% to 1.55%) and at 12 months was −0.84% (95% CI, −3.03% to 1.34%). No significant differences were observed between conditions.

The YMCA-DPP had a slightly higher reduction in waist circumference than VLM-DDP at 6 months (mean between-condition difference −2.00 cm [95% CI, −4.24 to 0.25 cm]). Participant engagement, expressed as mean number of completed core program sessions, was significantly higher for the YMCA-DPP than the VLM-DPP. Participants of the YMCA-DPP completed an average of 10.2 sessions (95% CI, 9.0 to 11.4), and participants of the VLM-DPP completed an average of 5.9 sessions (95% CI, 4.7 to 7.1). The adjusted mean between-condition difference was 4.2 sessions (95% CI, 2.54 to 5.99).

Conclusion

Both the YMCA-DPP and VLM-DPP yielded weight loss at 6 months, which was maintained at 12 months in the YMCA-DPP. The workplace may be an effective setting to offer DPPs.

A systematic review of the behaviour change techniques and digital features in technology-driven type 2 diabetes prevention interventions

Objectives

Our aim was to conduct a systematic review to determine which technology-driven diabetes prevention interventions were effective in producing clinically significant weight loss, and to identify the behaviour change techniques and digital features frequently used in effective interventions.

Methods

We searched five databases (CINAHL, EMBASE, MEDLINE, PsychINFO, and Pubmed) from inception to September 2018 and reviewed 19 experimental and non-experimental studies of 21 technology-driven diet plus physical activity interventions for adults (≥18 years) at risk of developing type 2 diabetes. Behaviour change techniques were coded using the BCT taxonomy v1, and digital features were identified via thematic analysis of intervention descriptions.

Results

Sixty-three per cent of interventions were effective in the short term (achieving ≥3% weight loss at ≤6 months), using an average of 5.6 more behaviour change techniques than non-effective interventions, and 33% were effective in the long term (achieving ≥5% weight loss at ≥12 months), using 3.7 more behaviour change techniques than non-effective interventions. The techniques of social support (unspecified), goal setting (outcome/behaviour), feedback on behaviour, and self-monitoring of outcome(s) of behaviour were identified in over 90% of effective interventions. Interventions containing digital features that facilitated health and lifestyle education, behaviour/outcome tracking, and/or online health coaching were most effective.

Conclusion

The integration of specific behaviour change techniques and digital features may optimise digital diabetes prevention interventions to achieve clinically significant weight loss. Additional research is needed to identify the mechanisms in which behaviour change techniques and digital features directly influence physical activity, dietary behaviours, and intervention engagement.

Health Care Utilization and Medical Cost Outcomes from a Digital Diabetes Prevention Program in a Medicare Advantage Population

This study examined the effects of a digital diabetes prevention program (DPP) on health care costs and utilization among Medicare Advantage participants. Patients (n = 501) received access to a plan-sponsored, digitally-delivered DPP accessible through computer, tablet, or smartphone. Prior research demonstrated a 7.5% reduction in body weight at 12 months. A comparison group who did not participate in the DPP was constructed by matching on demographic, health plan, health status, and health care costs and utilization. The authors assessed effects on cost and utilization outcomes using difference-in-differences regressions, controlling for propensities to participate and engage in the DPP, in the 12 months prior to DPP enrollment and 24 months after. Though post-enrollment data showed trends in decreased drug spending and emergency department use, increased inpatient utilization, and no change in total nondrug costs or outpatient utilization, the findings did not reach statistical significance, potentially because of sample size. The population had low costs and utilization at baseline, which may be responsible for the lack of observed effects in the short time frame. This study demonstrates the challenges of studying the effectiveness of preventive programs in a population with low baseline costs and the importance of using a large enough sample and follow-up period, but remains an important contribution to exploring the effects of digital DPPs in a real-world sample of individuals who were eligible and willing to participate.

3. Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Engagement With a Digital Platform for Multimodal Cognitive Assessment and Multidomain Intervention in a Japanese Population: Pilot, Quasi-Experimental, Longitudinal Study

Background

As the global prevalence of dementia continues to rise, multidomain lifestyle interventions that address modifiable risk factors associated with pathological cognitive decline are increasing. Although some digital options have been developed to increase the reach and scalability of these programs, because of cultural differences, the efficacy of the programs in one population cannot easily be generalized to populations in other countries.

Objective

This investigation aimed to examine the usability and engagement of a digitally delivered multidomain cognitive lifestyle intervention developed in the United States for a Japanese population.

Methods

This feasibility investigation utilized a quasi-experimental, single-arm, nonrandomized, longitudinal design where participants engaged in the behavioral intervention on a smartphone. Of the 559 participants that initially enrolled (age: mean 51 years, SD 7.5 years; 51.7% female [289/559]), 242 completed the final testing trial. Participants enrolled in a multidomain lifestyle program that consisted of (1) psychoeducational material, (2) physical activity tracker, (3) nutrition tracker, (4) audio-based meditations, and (5) health coaching. Engagement with the program was assessed through the total number of app sessions and the use of the exercise, diet, and meditation tracking features within the app. The total number of minutes exercised was collected through subjective user inputs, and nutrition was quantified by the Mediterranean-DASH Intervention for Neurodegenerative Delay diet adherence score.

Results

Significant relationships existed between overall nutrition score and frequency of nutrition tracking (r=0.18), frequency of physical activity tracking (r=0.19), and the total number of minutes exercised (r=0.22). Total minutes exercised was significantly correlated with total app sessions (r=0.57), frequency of physical activity tracking (r=0.85), frequency of nutrition tracking (r=0.64), number of times participants meditated (r=0.46), and total lessons read (r=0.36). The number of completed lessons was significantly related to frequency of physical activity tracking (r=0.40), frequency of nutrition tracking (r=0.43), the total number of times participants meditated (r=0.35), and total minutes exercised (r=0.33). Dividing the cohort into two groups based on lesson completion (<10 lessons completed vs ≥10 lessons completed), significant differences were observed between the total minutes exercised, frequency of physical activity tracking, frequency of nutrition tracking, and total number of times participants meditated (all P values <.01).

Conclusions

Overall, this cross-cultural feasibility study in Japanese users demonstrated that the various engagement metrics were significantly correlated, and greater engagement was related to improved nutrition scores and increased time exercising. In addition, the relationships between lesson completion and other engagement metrics suggest that there may be value in exploring mechanisms that enhance lesson completion. Future research should examine the program in randomized control trials to more rigorously evaluate program efficacy.

A Digital-First Model of Diabetes Care

If we were to create the diabetes care experience anew, there is little doubt that it would not resemble the current bricks-and-mortar way we do things currently. For however a future model of care is designed, it would assume a digital-first approach, whereby the modern conveniences of digitally-mediated services we have experienced in other industries would be reflected in our diabetes care. To this end, our diabetes data would be liberated, transparent to those that need it, but safe and secure otherwise. We would have access to new tools that create insights that lower the burden, not add to it. And access to care would be just in time, convenient, and from a distance when needed. What is stopping a digital-first model is complex and deeply seated, but not insurmountable with engagement from industry, regulators, and care providers that are all willing to modernize the way care is delivered. Personal human interaction will continue to play an important part in the care for millions of people living with diabetes, no matter the sophistication of these digital services. What these technologies will provide is the human capacity to deal with the higher need, vulnerable people for whom access to timely care is an issue. Moreover, it will provide choice for an increasingly diverse population that seeks options for the form, and the delivery, of their personalized care.

Effectiveness of DVD vs. group-initiated diabetes prevention on information uptake for high & low health literacy participants

OBJECTIVE

This study evaluates the effectiveness of technology versus in-person, group-initiated diabetes prevention to enhance comprehension of learning objectives between patients with differing health literacy (HL).

METHODS

Evidence-based content through either a DVD (n = 217) or in-person, group class (n = 225) to initiate the intervention. A teach-back call was used to assess comprehension of, and reinforce, learning objectives. Chi-squared was used to determine differences between conditions (DVD vs Class) and HL levels (High n = 361 vs. Low n = 81) and regression analyses were used to examine relationships.

RESULTS

DVD participants performed significantly better across teach back questions (15.4 ± 2.5 v. 14.8 ± 2.6, p < 0.01), demonstrated comprehension in fewer teach-back rounds (1.9 ± 0.7 v. 2.1 ± 0.7, p < 0.01), and answered more questions correctly on the first try (4.2 ± 1.6 v. 3.4 ± 1.8, p < 0.01). Models for HL levels and modality by HL level were statistically significant (p < 0.01) favoring the DVD.

CONCLUSION

Initiating a diabetes prevention program with the use of a DVD appears to be a superior option to in-person, class sessions. Teach-back and teach-to-goal strategies enables participants of both high and low health literacy levels to receive and confirm mastery of diabetes prevention objectives.

PRACTICE IMPLICATIONS

A teach-back call may improve information uptake increasing the likelihood of health behavior uptake.

Patient-Driven Diabetes Care of the Future in the Technology Era

The growing burden of diabetes is fueled by obesity-inducing lifestyle behaviors including high-calorie diets and lack of physical activity. Challenges in access to diabetes specialists and educators, low adherence to medications, and inadequate motivational support for proper disease self-management contribute to poor glycemic control in patients with diabetes. Simultaneously, high patient volumes and low reimbursement rates limit physicians' time spent on lifestyle behavior counseling. These barriers to efficient diabetes care lead to high rates of diabetes-related complications, driving healthcare costs up and reducing the quality of patients' lives. Considering recent advancements in healthcare delivery technologies such as smartphone applications, telemedicine, m-health, device connectivity, machine-learning technology, and artificial intelligence, there is significant opportunity to achieve better efficiency in diabetes care and increase patient involvement in diabetes self-management, which ultimately may put an end to soaring diabetes-related healthcare expenditures. This review explores the patient-driven diabetes care of the future in the technology era.

Community Characteristics and Regional Variations in Diabetes Prevalence in Texas Counties

Diabetes has become a critical population health issue in the United States. Although researchers have focused on diabetes prevalence at the individual level, few studies address community contexts of diabetes prevalence at the county level. The objective of this study is to explore the association between community characteristics and diabetes prevalence in 254 counties in Texas. Using 3 countywide data sets in 2012, the authors measured county-level community characteristics, including social, environmental, and health behavior factors, and examined how these county-level factors are associated with diabetes prevalence. Multivariate ordinary least squares models weighted with population of county were used for estimation. Rurality, physical inactivity prevalence, and obesity prevalence were positively associated with diabetes prevalence, while the percentage of nonphysician health care professionals was negatively associated with diabetes prevalence. The findings indicate that environmental and health behaviors are significantly associated with a high prevalence of diabetes, but more nonphysician health care professionals, including nurse practitioners, may mitigate diabetes prevalence. This study highlights the significance of community factors in diabetes prevalence and provides insights for diabetes prevention programs with nonphysician health care professionals.

3. Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Results From a Trial of an Online Diabetes Prevention Program Intervention

INTRODUCTION

Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions.

STUDY DESIGN

A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!).

SETTING/PARTICIPANTS

Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial.

INTERVENTION

Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions.

MAIN OUTCOMES MEASURES

Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017.

RESULTS

From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP.

CONCLUSIONS

An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.