Study of Diabetes Self-Management Program Finds Parity Between In-Person, Digital Formats


A diverse group of 1242 patients received diabetes self-management education either in-person or online and achieved lowered blood glucose and depression levels, had fewer symptoms of hypoglycemia, and exercised more.

A national study of Stanford University’s diabetes self-management education (DSME) program involving 1242 patients has found that the digital format was just as effective as in-person lessons in lowering blood sugar and reducing depression when given in real-world environment.

The study, published in the Journal of Medical Internet Research, examined the effectiveness of the Better Choice, Better Health diabetes program, which was developed at Stanford and is now offered in both in-person and digital formats to health plans. In this study, the program was offered to patients recruited through Anthem, according to a statement from Canary Health, which provides digital self-management education for several chronic conditions.

DSME is recognized as an effective way to give patients with diabetes the tools to manage their disease, preventing progression and complications. A joint statement from the American Diabetes Association, the American Association of Diabetes Educators (AADE), and the Academy of Nutrition and Dietetics in 2015 found the numbers of patients who get training “disappointingly small,” and the organizations developed an algorithm to extend DSME more patients with type 2 diabetes (T2D), especially those newly diagnosed.

The new study cites similar concerns, and says that less than 7% of those with T2D receive DSME in the year after diagnosis. While the AADE has standards, few Stanford model programs meet the national standards for diabetes self-management education and support, say the authors, led by Kate Lorig, DrPH, a pioneer in self-management education and the director of the Stanford Patient Education Research Center.

At present, the authors write, there is “no means for certifying or recognizing web-based programs,” in DSME. This is not the case in diabetes prevention; the CDC has recognized digital as well as face-to-face programs, and CMS expects to include digital formats when Medicare begins paying for diabetes prevention programs in 2018.

Lorig’s Stanford model, which involves 6 weeks of training and can include a family member, is centered on the personalized “action plan,” a detailed outline of how the person with T2D will achieve desired amounts of exercise or stick with dietary goals. In the Better Choices, Better Health digital format, groups of roughly 25 people form online discussion groups where they are supported by coaches, who are peers with a chronic condition themselves. Community-based programs have reached more than 50,000 people in 39 states, the authors report, and web-based programs have reached 2000.

With 29 million people in the United States living with diabetes—most of them T2D—the potential to reach many more people at a lower cost makes digital formats attractive, assuming they are shown to be effective.

Results in the new study suggest they are.

Through the Stanford study, 1010 people took part in the digital format, and 232 took part in face-to-face formats at 3 sites. Because this was a translation study, researchers wrote, the population was not screened to isolate participants with certain symptoms or clinical factors. Thus, some of the subgroups analyses looked at only those in the population who demonstrated problems in the variable of interest. Researchers found:

  • Among the patients providing blood samples (489), 20% had a glycated hemoglobin (A1C) of 9% or higher at baseline. At the 6-month follow-up, the share fell to 15.3%, and the mean reduction for those with A1C of 9% or higher was —0.93%.
  • To evaluate depression, 877 patients were given the 8-question Patient Health Questionnaire. At baseline, 22% had symptoms indicating clinical depression, and at 6 months that share had fallen to 16.3%.
  • At baseline 38.4% of 865 of the patients had 2 or more symptoms of hypoglycemia; by the 6-month mark, the share was reduced to 32.4%.
  • At baseline, 35% of the patients were nonadherent; by 6 months, 29.4% were.
  • When the study began, 23.2% of 876 patients reported having no aerobic exercise. At 6 months, this was down to 18.4%, with a mean increase in exercise of 43 per week among those who reported limited or no exercise before the intervention.

There was a very slight uptick in A1C (0.05%) among those who started below 9%, and there was some slacking off of exercise for those who were faring well before the intervention. However, the researchers wrote, “the improvements for the less well-off group were much greater than any negative changes for those who had been doing well at baseline.”

Notably, there were no significant differences in outcomes between those who received in-person and digital formats, except for some advantage in sleep for those in the face-to-face groups. While overall the participants were well-educated women, the digital format group was statistically more likely to be male—which is important for health plans, since diabetes programs report that it is harder to get men to take part.

“We clearly achieved our goal in showing that evidence-based diabetes self-management programs are equally effective for a larger, more diverse group of people who would typically enroll through their health plans,” said Lorig.

Also noteworthy for payers: the researchers observe that with an average participation time of 2.5 hours per week, the total time of the in-person workshops exceeds the 10 hours typically covered by insurance. But less time than that is typically ineffective, they write.

“This study confirms previous evidence empowering individuals to self-manage their condition levels to improved health outcomes,” said Neal Kaufman, MD, MPH, chief medical officer of Canary Health. “These results should be a clear call for broader clinical acceptance of digital health self-management as a crucial part of transforming healthcare to a value-based model.”


Lorig K, Ritter PL, Turner RM, English K, Laurent DD, Greenberg J. Benefits of diabetes self-management for health plan members: a 6-month translation study. J Med Internet Res 2016;18(6):e164. DOI: 10.2196/jmir.5568.

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