Welltang – A smart phone-based diabetes management application – Improves blood glucose control in Chinese people with diabetes

doi:10.1016/j.diabres.2016.03.018

Diabetes Research and Clinical Practice

Volume 116, June 2016, Pages 105-110

https://doi.org/10.1016/j.diabres.2016.03.018 Get rights and content

Abstract

Aims

The primary objective was to evaluate the impact of the smart phone-based diabetes management application, Welltang, on glycated hemoglobin (HbA1c). The second objective was to measure whether Welltang improves blood glucose, low-density lipoprotein cholesterol, weight, blood pressure, hypoglycemic events, satisfaction of patients to use Welltang, diabetes knowledge of patients, and self-care behaviors.

Methods

One hundred evenly randomized subjects with diabetes, aged 18–74 years, were recruited from the outpatient Department of Endocrinology for a 3-month study. The Welltang intervention group received training for the use of Welltang, while the control group received their usual standard of care. HbA1c, blood glucose, low-density lipoprotein cholesterol, weight, blood pressure, hypoglycemic events, satisfaction of patients to use Welltang, diabetes knowledge of patients, and self-care behaviors were measured. Patient data were analyzed using independent t test and paired sample test using SPSS version 12.

Results

The average decrease in HbA1c was 1.95% (21 mmol/mol) in the intervention group and 0.79% (8 mmol/mol) in the control group (P < 0.001). Measures of self-monitored blood glucose, diabetes knowledge, and self-care behaviors improved in patients in the intervention group. Eighty four percent of patients in the intervention group were satisfied with the use of Welltang. Differences in hypoglycemic events, low-density lipoprotein cholesterol, weight, and blood pressure were not statistically significant.

Conclusion

Diabetes patients using the Welltang application achieved statistically significant improvements in HbA1c, blood glucose, satisfaction of patients to use of Welltang, diabetes knowledge, and self-care behaviors.

Introduction

In an epidemiological investigation of Chinese adults, the estimated prevalence of diabetes and prediabetes was 11.6% and 50.1%, respectively [1]. Extrapolations based on sample weighting infer that this may indicate up to 113.9 million Chinese adults with diabetes and 493.4 million with prediabetes. These findings suggest the severity of diabetes is a public health problem in China [1]. These data indicate that diabetes may have reached a critical level in the Chinese general population, with the potential for a major epidemic of complications of diabetes including cardiovascular disease, cerebrovascular disease, and chronic nephropathy in China in the near future without an effective national intervention [1].

The Diabetes Control and Complications Trial (DCCT) and UK Prospective Diabetes Study (UKPDS) have provided clear evidence that plasma glucose, lipid, and blood pressure control prolong or prevent micro- and macrovascular complications [2]. With medical development, it is now possible to achieve excellent glucose control and decrease the risk of many of the diabetic complications. However, one Chinese diabetes prevalence study indicated that less than one-third were aware of their condition and only one-quarter received treatment for diabetes. Moreover, just over one-third of patients treated for diabetes have attained their glycemic control goal [1]. The reason for the difference between the best evidence-based medicine and actual practice might depend not only on the heavy workload of the physicians to make changes in clinical practice, but also on the central daily life role of the patients in implementing excellent management plans [3].

Cellular phones are widely used across socioeconomic groups, and their technical capabilities including text messaging, internet access, applications, and the ability to connect to sensing devices are continuously being enhanced, making smart phones a promising means for health care delivery. Many individuals carry smart phones everywhere, allowing smart phone health interventions to be an integral part of an individual’s routine. They have been used to facilitate weight loss [4], increase exercise activity [5], and manage chronic diseases, particularly diabetes [6], [7], [8].

A number of existing internet- and phone-based systems and programs have shown promise [6], [7], [8], [9]. Among these, Welltang, which means “smiling to diabetes” in Chinese, is a smart phone diabetes management application designed in Chinese language and culture. The primary objective of this study was to estimate the impact of Welltang on glycated hemoglobin (HbA1c) for a 3-month period. The second objective was to evaluate the impact of Welltang on blood glucose, low-density lipoprotein cholesterol (LDL-C), weight, blood pressure, hypoglycemic events, satisfaction of patients to use the Welltang application, diabetes knowledge of patients, and self-care behaviors.

Section snippets

Subjects

This study was a 3-month, non-blinded, randomized trial (ClinicalTrials.gov NCT02313090) that initially recruited 100 people diagnosed with diabetes mellitus (18 with type 1 diabetes and 82 with type 2 diabetes), who were referred to the Department of Endocrinology at The First Affiliated Hospital, College of Medicine, Zhejiang University from January 2014 to February 2014. The age range of patients was 18–74 years old. No limitation for HbA1c was defined. In order to be eligible, patients had

Results

Demographic characteristics of the 100 subjects that participated in the study are shown in Table 1. Demographic characteristics, baseline HbA1c, and blood pressure were similar for both study groups. Medication regimens of patients were grouped evenly as oral hypoglycemic, insulin alone, or insulin and oral hypoglycemic. Prior to study enrollment, all subjects used a smart phone.

All patients in the Welltang intervention group continued to use the Welltang application. The mean number of

Discussion

This pilot study found that the smart phone-based application, Welltang, is effective in the diabetes management of lowering HbA1c, and improving clinical, behavioral, and diabetes knowledge outcomes in adults with diabetes during a 3-month period. The decrease in HbA1c level was similar to the results that Quinn and colleagues previously reported with one smart phone-based intervention at the end of a 1-year study [9]. Additionally, patients found this smart phone-based application easy to

Conflicts of interest

The authors have no conflicts of interest to disclose.

Acknowledgments

We would like to thank Shanghai Geping Information and Technique Company Ltd. for the download and use of the Welltang application for free. Zhou W, Chen M, Yuan J, and Sun Y performed the research; Zhou W designed the research study; Chen M analyzed the data; and Zhou W wrote the paper.

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Which behaviour change techniques work best for diabetes self-management mobile apps? Results from a systematic review and meta-analysis of randomised controlled trials
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Self-management is pivotal in addressing noncommunicable diseases, such as diabetes. The increased availability of digital behaviour change interventions (DBCIs) delivered through mobile health apps offers unprecedented opportunities to enhance self-management and improve health outcomes. However, little is known about the characteristics of DBCIs for diabetes that significantly impact glycaemic control. Therefore, our systematic review with meta-analysis aimed to summarize characteristics and behaviour change components in DBCIs for diabetes self-management and explore potential associations with metabolic outcomes.
A systematic search was conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials published until November 2023. The main outcome variable was the change in the mean difference of HbA1c levels between baseline and follow-up across intervention and control groups. Random-effects meta-regression was used to explore variation in glycaemic control as a function of prespecified characteristics of study designs and app interventions.
A total of 57 studies was included in the analysis, showing a statistically significant percentage point reduction in HbA1c for the intervention group compared to the control arm (−0.36, 95% CI = −0.46 to −0.26, p < 0.001). The inclusion of “self-monitoring of behaviour” as a behaviour change technique (β = −0.22, p = 0.04) and “taking medication” as a target behaviour (β = −0.20, p = 0.05) was associated with improved metabolic outcomes.
Our analyses endorse the use of diabetes self-management apps, highlighting characteristics statistically associated with intervention effectiveness and guiding the design of more effective DBCIs.
This project received funding from the European Union’s Horizon 2020 programme.
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
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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.
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 A_1c (HbA_1c) 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 HbA_1c 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 HbA_1c 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.
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 HbA_1c) 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 HbA_1c, compared with control group participants. The difference in HbA_1c 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.
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.
EU's Horizon 2020 Research and Innovation Programme.
New Digital Health Technologies for Insulin Initiation and Optimization for People With Type 2 Diabetes
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Citation Excerpt :
Several existing software tools are being offered to support the management of T2D. Overall, these tools have reported equivalent or improved HbA1C levels and hypoglycemic outcomes compared with standard care (Table 1).22–49 The use of 4 tools (LTHome, Mobile Insulin Titration Intervention [MITI], Health2Sync, and the mobile diabetes management system [MDMS]) was associated with a reduced frequency of contact with HCPs needed by participants.
The health and economic burden of type 2 diabetes is of global significance. Many people with type 2 diabetes eventually need insulin to help reduce their risk of serious associated complications. However, barriers to the initiation and/or optimization of insulin expose people with diabetes to sustained hyperglycemia. In this review, we investigated how new and future technologies may provide opportunities to help overcome these barriers to the initiation and/or optimization of insulin.
A focused literature search of PubMed and key scientific congresses was conducted. Software tools and devices developed to support the initiation and/or optimization of insulin were identified by manually filtering >300 publications and conference abstracts.
Most software tools have been developed for smartphone platforms. At present, published data suggest that the use of these technologies is associated with equivalent or improved glycemic outcomes compared with standard care, with additional benefits such as reduced time burden and improved knowledge of diabetes among health care providers. However, there remains paucity of good-quality evidence. Most new devices to support insulin therapy help track the dose and timing of insulin.
New digital health tools may help to reduce barriers to optimal insulin therapy. An integrated solution that connects glucose monitoring, dose recording, and titration advice as well as records comorbidities and lifestyle factors has the potential to reduce the complexity and burden of treatment and may improve adherence to titration and treatment, resulting in better outcomes for people with diabetes.
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(1) Examine the mobile applications that address lifestyles to improve the metabolic control of adult patients with diabetes mellitus. (2) Describe the characteristics of the used mobile applications, identify the healthy lifestyles they target, and describe any of their adverse effects.
Review systematic reviews. We included studies that used any mobile application to help patients improve diabetes mellitus self-management by focusing on healthy lifestyles. Studies needed to include a control group receiving regular care with no mobile devices. In May 2018, Medline, Embase, Cochrane, LILACS, PsychINFO, Cinahl and Science Direct were searched, updated in June 2021. The methodological quality of the studies was assessed by the Amstar-2 tool.
First 804 articles were analyzed to select 17 systematic reviews, of which the methodological quality of seven was high or moderate. Interventions lasted 1−12 months. Twenty-three different mobile applications were identified that were all related to eating and physical activity. Significant changes were noted in HbA1c values. No clear improvement was observed for weight/BMI, lipid profile, quality of life or blood pressure. No adverse effects were found.
Managing the lifestyle of patients with diabetes using mobile applications improves short-term glycemic control, but the long-term results are not conclusive. The identified mobile applications focus on food and physical activity. Most are free. No adverse effects caused by using them were identified.
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View all citing articles on Scopus

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Welltang – A smart phone-based diabetes management application – Improves blood glucose control in Chinese people with diabetes

Abstract

Aims

Methods

Results

Conclusion

Introduction

Section snippets

Subjects

Results

Discussion

Conflicts of interest

Acknowledgments

Can J Diabetes

Am J Prev Med

Patient Educ Couns

Prevalence and control of diabetes in Chinese adults

JAMA

American diabetes association position statement: standards of medical care in diabetes

Diabetes Care

Twenty-first century behavioral medicine: a context for empowering clinicians and patients with diabetes

Diabetes Care

Weight loss by mobile phone: a 1-year effectiveness study

Public Health Nutr

MobileMums: a randomized controlled trial of an SMS-based physical activity intervention

Ann Behav Med

WellDoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction

Diabetes Technol Ther

Telemedical support to improve glycemic control in adolescents with type 1 diabetes mellitus

Eur J Pediatr

Implementation of telehealth support for patients with type 2 diabetes using insulin treatment: an exploratory study

Inform Prim Care

Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control

Diabetes Care