Relatively inexpensive and accessible self-management interventions to help people manage Type 2 diabetes have been found to significantly reduce the blood sugar marker used to diagnose and manage the disease.
The new study led by researchers from the Texas A&M University School of Public Health found that participation in three types of virtual diabetes self-management interventions in both rural and urban locations resulted in better hemoglobin A1c markers over a six-month study period.
"There are many self-management interventions for people living with Type 2 diabetes, but until now little research has been conducted on their effectiveness based on how they are delivered or when they are used in combination," said Marcia Ory , Regents and Distinguished Professor with the Texas A&M School of Public Health and the Center for Community Health and Aging , who led the study.
Other key researchers were Gang Han , Matthew Lee Smith , Samuel Towne, Keri Carpenter and former doctoral student Chinelo Nsobundu, all affiliated with the Center for Community Health and Aging. Their study was conducted under a rural health moonshot initiative supported by Blue Cross and Blue Shield of Texas.
The research team assessed the effectiveness of self-paced, virtual diabetes self-management interventions to reduce the hemoglobin A1c levels of Texans with Type 2 diabetes who live in rural and urban settings. For their study, published in Frontiers in Public Health, they focused on three interventions: a structured virtual education and support program with one-on-one counseling, a less-structured smartphone application and a sequential combination of both.
The study included 189 adults, ages 25 and older, from 46 Texas counties. All had baseline A1c levels of 7.5 or higher, indicating unmanaged Type 2 diabetes. Their median age was 52, with men making up 23 percent of participants and 35 percent residing in rural areas. Most were white (86 percent) and non-Hispanic/Latino (61 percent), and more than half (55 percent) reported having poor or fair health.
The three-arm randomized controlled trial (in which participants were randomly assigned to two treatments along with a control group) ran from November 2020 to March 2022.
The first intervention was a structured virtual education and support program with one-on-one counseling. It provided six to eight hours of virtual asynchronous training and one-on-one interactions between participants and either a registered nurse or registered dietitian. The one-on-one counseling sessions helped participants build on what was learned during the asynchronous training and create tailored strategies to optimize their diabetes management and self-care.
For the second intervention, participants used a smartphone application that had diabetes self-care skills and chat access to a diabetes coach for personalized support. The third intervention was a sequential combination of the two approaches adding app access to the virtual education and support program.
Each intervention was used for three months, with uniform data including A1c levels taken at baseline and follow-up periods at three months and six months. At baseline, participants self-reported characteristics about themselves, their health and their living environments.
An intent-to-treat analysis found that all the interventions reduced participants' A1c values, and no one intervention modality was significantly different.
"These findings support other studies that found similar diabetes self-management interventions to be effective," Ory said. "In contrast to other studies, however, our longitudinal analyses found that A1c levels remained lower over time, suggesting that providing self-paced training and skill development could have a lasting impact, despite the particular virtual delivery mode."
In addition, the study found that older adults tended to have larger reductions in A1c values and better diabetes management than younger participants and that participants with better baseline health tended to have more positive outcomes.
"About 90 percent of our participants stayed in the study for all six months, a much higher rate than found in similar studies," Smith said. "This could be because of our efforts to make the programs adaptable and to foster engagement through interactive learning programs."
Han cautioned that the results cannot be generalized across all populations with Type 2 diabetes given the study's relatively small sample of participants who were English speakers with access to digital technology and who lived in the same state. In addition, the COVID-19 pandemic made participant recruitment more difficult and required new study protocols.
"Still, we expect that many people with unmanaged Type 2 diabetes — including those from underrepresented groups or who have less access to health care — could experience similar benefits," Ory said.
Ory said this is hopeful news given that the number of adults with Type 2 diabetes has doubled in the United States over the last 20 years, increasing the incidence of heart disease, stroke, kidney failure, blindness and other serious conditions.
By Ann Kellett, Texas A&M University School of Public Health
