Effectiveness of Automated Mobile Phone Based Text Messaging on the Improvement of Glycaemic Outcomes

India currently has 65 million people with type 2 diabetes and the number is increasing. In addition to its human costs, diabetes imposes a large economic burden. In those of average income in India, diabetes care consumes 25% of the family budget where one member is affected and proportionately more when there are other affected members (which is not uncommon); much of this expenditure is on medical and nursing costs aimed at achieving good glycaemic control. Diabetes management is important because it leads to better long-term clinical outcomes. The proof of principle trial - United Kingdom Prospective Diabetes Study (UKPDS) in patients with type 2 diabetes demonstrated that glycaemic control from the time of diagnosis produced beneficial effects during the trial and that these persisted for at least ten years afterwards (despite the confluence of HbA1c levels post-trial). There was continued improvement in microvascular complications and emergent significant reductions in myocardial infarction and death - the 'legacy effect'. Similar prolonged benefit has been demonstrated for Type 1 diabetes in the Diabetes Control and Complication Trial (DCCT) and its follow-up (for at least 17 years).

Improving glycaemic control involves lifestyle modification (diet and physical activity), prompt introduction of hypoglycaemic therapy where necessary and then compliance with the treatment and monitoring. Dietary measures early after diagnosis lead to improved glycaemia and reductions in other cardiovascular risk factors. The importance of physical activity is often overlooked, but it contributes to maintenance of weight loss long-term, improves physical fitness and reduces cardiovascular risk factors. At or shortly after diagnosis, diabetes education aiming at lifestyle change is helpful in modifying behaviour and can reduce HbA1c. Although these programmes are effective, the benefits diminished over time e.g. the DESMOND programme resulted in improved HbA1c levels at twelve months but not at three years. There is evidence that the sustained benefit may be more likely if the educational programme is reinforced at a later stage. A major barrier to implementation of all education programmes, and particularly those which include reinforcement, is cost. Because they involve personal contact, the programmes are expensive and in reality, are offered to only small proportion of patients, even in developed countries. Although attempts have been made to utilise trained non-medical, non-nursing staff in education programmes in India, this model, while less expensive, has not been widely adopted. Attendance at educational sessions is also problematic, as it requires taking time off work or away from the family, or the venue is considered inaccessible.

Text messaging (short message service, SMS) has the potential to overcome some of the difficulties. It is relatively cheap and potentially scalable. For example, in people with pre-diabetes in India the investigators have shown a 36% reduction in progression to diabetes over 2 years with text messaging-assisted behavioural modification. This reduction is similar to that achieved in India using personal contact methods. There are relatively few high quality studies on the role of text messaging or mobile phone contact as an aid to management of established Type 2 diabetes. In a pilot study in India, the investigators have demonstrated that text messaging can improve compliance with medications. A recent Cochrane review of IT-assisted methodologies for diabetes care and education suggested a small benefit for glycaemia, greatest where mobile phones (as opposed to home computers) were the delivery medium. The average lowering of HbA1c, as a result of mobile phone input on a range of studies was 5.5 mmol/mol (0.5%). This is clinically significant. Part of the reason for this benefit may reside in the nature of mobile phone contacts, being passive and, if appropriately designed, the message content can be encouraging rather than threatening in nature. The messages can also be sent repeatedly, with their frequency and timing dictated by the recipient.