By Max Bingham, PhD
HbA1c Is Reduced With an Online Gaming Approach Toward Diabetes Education
A team-based gaming approach delivering self-managed diabetes education via a mobile app and e-mail can lead to reductions in HbA1c that are comparable to starting a new diabetes medication, according to Kerfoot et al. (p. 1218). They suggest this may represent a scalable solution to improve outcomes among patients with poorly controlled diabetes across wide geographic areas. The spaced education paradigm involves presenting various health scenarios to participants who are then asked to immediately answer multiple-choice questions on the subjects. Following their answers, the participants receive the correct answers combined with an explanation of the topic and a score based on their performance. The material is then presented again to the participants in the following weeks and months to reinforce learning and generate meaningful behavior change. The approach is not unique to diabetes education and has previously been employed in diverse environments such as commercial sales where learning and behavior change are key objectives. Traditional diabetes self-management education has had some success in achieving meaningful short-term reductions in HbA1c. However, the effects reportedly wear off quickly. By modifying the approach to include spaced education, the authors hypothesized that they might be able to generate more sustained HbA1c reductions. In a randomized trial design, the researchers assigned ∼200 patients who are veterans with poorly controlled diabetes to the diabetes self-management education game and ∼200 others to an active control game. They found that the intervention group had significantly greater reductions in HbA1c over 12 months in comparison to control subjects. Going further with a post-hoc analysis, they showed that additional reductions might be possible when baseline HbA1c is particularly high and out of control. Commenting further, author B. Price Kerfoot stated: “The results are encouraging and suggest that the game, when implemented across health care systems, has the potential to improve the health of many patients with diabetes. To play, patients only need a desire to improve their health, a competitive spirit, and an e-mail account or mobile device.”
Reliability of Glucose Recordings During GDM Called Into Question
The reliability of self-monitoring of blood glucose in patients with gestational diabetes mellitus (GDM) is under the spotlight this month with Cosson et al. (p. 1181) warning that what a patient might write down in a logbook can in some cases be very questionable indeed. And given that treatment changes may be informed by these values, they additionally warn that poorer pregnancy outcomes can be expected if the reporting is less than accurate and timely. The study focused on 91 women with GDM who were given glucose monitoring devices and asked to record in a logbook their blood glucose values immediately prior to meals and then again at 2 h after the meals. They were told that insulin interventions may be needed if their blood glucose values were outside the set glucose cutoff points, but they were not told that the devices were actually recording all values over the 2-week study period. According to the authors, about 60% of the subjects actually measured >80% of the measurements requested. On top of this, the average time between pre- and postprandial measurements was ∼140 min and just under half of the participants managed to make the second measurement with the target range of 100–140 min. Perhaps most telling was that ∼23% of the women had <90% matched values between what the glucose meters recorded and what was recorded in the logbook. And the consequences? Poor adherence was associated with higher rates of preeclampsia and poor timing of the postprandial glucose measurement with higher HbA1c levels at delivery—presumably because excessively late measurements would lead to underestimation of peak glucose levels. According to author Emmanuel Cosson: “We could have had even worse results if we had not included women who had entirely understood how to manage self-monitoring blood glucose. Our results show that using the memory of blood glucose meters or automatically generated diaries from glucose meters should be used to guide clinical management and also for research purposes.”
Diabetes Rates Might Not Be Declining and Remain “Worryingly” High in the U.S.
The vexed question of whether diabetes rates in the U.S. are actually declining or not is picked apart in a Perspective this month by Selvin and Ali (p. 1139). According to the authors, care is needed as diabetes rates likely remain worryingly high and might in fact still be rising. The Perspective starts with a response to the National Health Interview Survey (NHIS), which was published in 2014 and reported substantial and sustained decreases in diabetes incidence between 2008 and 2014. But was it correct? According to Selvin and Ali, the answer might not be so simple. By examining trends that might be influencing the true rates of diabetes in the population, a picture starts to emerge of changes in definitions of what diabetes is, how it is diagnosed, and major shifts in the trends of diabetes risk factors. Chief among these trends are likely the spiking rates of obesity and overweight in the U.S. population. Prediabetes, consistently underdetected according to the authors, will likely be the key factor that will drive rates of diabetes higher in the near future. The other key point they raise is that the diagnostic criteria for diabetes and prediabetes have changed over the years. Through some careful analysis they suggest that despite these changes, it is likely that peak diagnosis might have been reached. Taken together with the surge in underlying risk factors, they warn that concerted efforts are still needed to address both obesity and diabetes. Author Elizabeth Selvin explained: “We think it is premature to declare victory against the epidemic of diabetes in the U.S. We don’t think that true diabetes is decreasing in the population. There has been a major surge in obesity and prediabetes over the past several decades. Diabetes is going to have a serious impact on the population and health system in the years to come.”
Improving Prediction of Heart Failure Risk in Patients With Type 2 Diabetes
A circulating cardiac stress marker may have additional predictive capacity over and above standard risk factors for heart failure in patients with type 2 diabetes. And, according to Ohkuma et al. (p. 1203), if the findings can be replicated, it should mean that the assessment of the marker, NT-proBNP, could help to more accurately identify patients at high risk who might go on to further assessments and earlier interventions, if required. The study, which is a further assessment of the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial cohort, examined the incidence of heart failure in ∼3,000 patients with type 2 diabetes and the levels of a variety of cardiac stress and inflammatory markers. These included the individual and combined effects of NT-proBNP and hs-cTnT as cardiac stress markers and hs-CRP and IL-6 as inflammatory markers. Over a 5-year follow-up of the cohort, 237 patients experienced a heart failure event and, according to the authors, increasing levels of all the markers were individually associated with increased risk of heart failure. This was after adjusting for a range of other factors, including many that are traditionally used to predict heart failure. However, it was only after the addition of NT-proBNP to a model using conventional risk factors that the authors found a meaningful improvement in predictive performance. In contrast, the other three factors did not improve prediction metrics consistently whether added individually or in combination with NT-proBNP. While acknowledging a number of limitations in the study, the authors state that NT-proBNP likely could be used to improve the prediction of heart failure beyond that of widely used clinical risk factors and markers. Commenting more widely on the study, author John Chalmers told Diabetes Care: ”Heart failure is a common presentation of cardiovascular disease in patients with type 2 diabetes. Our findings suggest that the assessment of NT-proBNP will help identify those at high risk of developing heart failure and justify the pursuit of investigation and treatment.”
