August Blog Summary

August Summary

Since aggressive medication therapies have not significantly improved CVD outcomes among type 2 diabetic patients, professionals are trying to identify methods of behavioral interventions that may be more effective. The ENHANCE study was designed to consider how a self-monitoring device could improve the biophysical outcomes of type 2 diabetics compared to traditional behavioral strategies. The study found that both the control and the intervention group improved general lifestyle management with no significant difference in the two behavioral strategies. The researchers of this study suggest that a limitation to this study is that, perhaps a PDA is outdated, and Smartphone application may be more beneficial to test this hypothesis in the future. Another study limitation was the homogonous nature of the study population. Perhaps the study would have yielded different results had a more representative population been involved in the study. The one positive finding from this study is the importance of comparable glycemic control findings between the ACCORD study and the ENHANCE study. These findings suggest that behavioral methods can be just as effective or even more effective in diabetes management as medication therapies.

The questions below were formulated to address study weaknesses, opinions about the role of current technology in behavioral therapies, and other behavioral methods that might be suggested for diabetes management.

Question 1

The researchers in the ENHANCE study suggest that the use of a Smartphone application instead of a PDA may be more effective in diabetes self-management. Overwhelmingly, fellow bloggers tended to agree.  The primary advantage listed is convenience. Clients would be able to track and monitoring BG levels, insulin doses, and carbohydrate intake with the convenience of their personal phone which is typically with them at all times. Another advantage listed is that this data would serve to educate clients, providing continuous feedback (reports, charts, etc.) about how they are managing their diabetes. This feedback can help them to understand the relationships between BG levels, carbohydrate intake, exercise, and insulin as the changes are occurring. This empowerment would provide the client with a sense of self efficacy and a better understanding of diabetes management.

However, some bloggers did see potential for a downside to use of a Smartphone application. Expense is listed as the main con against using them. Not everyone can afford a Smartphone and so, this could not be a recommendation for all clients. It would be necessary to get a feeling for the client’s financial situation before suggesting it as an option. Also, older generations are often not as technologically inclined as younger generations and may prefer to go with a more traditional, “pen and paper” method of tracking and recording. Another interesting issue brought up by Kelsey is that perhaps a Smartphone application would not promote self-efficacy because people would rely on them too heavily. It is worth considering that perhaps an app would be too much of a crutch. What would happen if this person lost their phone or had to go without a phone for a long period of time? They may not have actually learned the skills necessary to care for themselves in this time.

Applications do currently exist for diabetes management and there are a wide variety of features to be found in each one. Before recommending an application to a client, it is important to know how the application works, which ones are the top rated ones, and if the application is approved for use by the rest of the healthcare team (the doctor). Molly points out that there is now the omniPod (cost on web, $660!!), which is an insulin pump that does all of the functions an app would be able to perform.

Questions 2

Researchers suggested that a limitation to the study was the highly homogonous study population. Most participants were white women, highly-educated, employed, and insured. When asked how a future study could be modeled that would be representative of the population, bloggers responded with the following: Most bloggers responded to this question with the opinion that the exclusion criterion was too strict. As a result, the research team ended up with a very homogenized study group. If the researchers would have been less strict about their exclusion criteria, they would have gotten more participants and a more representative sample of the population. These researchers did not advertise to a diverse enough population and could have utilized more social media outlets to gather various participants. Bloggers also suggest that a better incentive, such as a financial incentive could have been offered to increase participation. Other bloggers suggest that more outreach into various types of community organizations (hospitals, universities, government orgs.) would have been more beneficial. Emily makes a great point that the criterion for different populations should be defined ahead of time and incentives planned accordingly.

As the ENHANCE study clearly demonstrates, it is important to consider what populations you want to study and to carefully formulate your study design to match this. If you want to study a representative sample of the U.S., you need to make sure that your exclusion criterion does not exclude certain segments of the population. You also must provide powerful incentives to those who are required to commit a significant amount of their time and effort in order to draw them to participate. These can all significantly affect the outcome interpretation of study outcomes.

Question 3

When asked what types of behavioral interventions worked best, most bloggers responded that journaling is a well recognized tool to develop self-awareness. Not only does it help the dietitian to identify areas for improvement, but often times the client feels it is beneficial in staying on track as well. Alana, Erin, and Angela all cite the importance of recording emotions as well as food intake. Identifying areas of emotional stress can help the client cue into triggers that they didn’t know existed and help them on their path to reaching their goals. My personal feeling is that although journaling is a powerful tool initially, it is hard to sustain long-term. In my rotations, I have seen clients who had much success with journaling but once they felt confident about what they were doing, they quit using the journaling method. As a result, bad habits slowly started returning without them realizing. I see how wonderful the tool can be, but I also see its limitation that it may not be sustainable for long-term use.

Nate and Kelsey also suggest that setting very small and achievable goals is extremely important. Kelsey also makes a great point that including the family on the intervention and achievement of goals can be a huge motivator and encouragement for client. Molly feels that motivational interviewing is the most effective behavioral tool because it identifies areas that the client is interested in achieving.