A national study of more than 21,000 users found NHS England’s Healthy Living Platform was associated with improved diabetes outcomes after one year, but researchers said improving engagement and widening access remained key challenges.
Study: Investigating the uptake, maintenance and effectiveness of a national online type 2 diabetes self-management intervention in the UK (Healthy Living): a retrospective cohort study. Image credit: Pixel-Shot/Shutterstock.com
A recent retrospective cohort study found that the UK National Health Service (NHS) Healthy Living Program for Diabetes Self-Management provided modest health benefits for enrolled patients. The study was published in the journal Pro Swan.
The NHS is building on the success of HeLP and diabetes
Type 2 diabetes (T2D) is a common non-communicable disease (NCD) whose prevalence is rapidly increasing. It is associated with multiple serious complications, including death. Healthcare costs also run into billions of pounds in the UK alone.
A self-management approach leads to better health outcomes. This includes a healthy diet, exercise, stress management, regular monitoring, and appropriate use of prescription medications. In the UK, the National Institute for Health and Care Excellence (NICE) recommends structured diabetes self-management education programs, such as the Diabetes Education and Self-Management (DESMOND) program for ongoing and newly diagnosed patients.
Digital alternatives have the potential to expand the scope of such efforts and reduce health inequalities. For the first time, the NHS introduced HeLP-Diabetes, a web-based program for patients referred by general practitioners and providing a discussion forum. A healthy living program was continued based on its effectiveness in lowering HbA1c after 1 year compared to patients receiving usual care.
The official name is “Healthy Living for Type 2 Diabetics.” This online program focuses on Diabetes Self-Management Education and Support (DSMES). Unlike HeLP-Diabetes, Healthy Living is a packaged program with a website that provides extensive educational materials, including:
- “Learning” section – multiple modules forming a structured curriculum
- “Find the Answers” section – a variety of diabetes-related topics without special arrangements
- Tools Section – Different types of goal and tracker tools derived from the HeLP-Diabetes website.
The current study sought to understand effectiveness in terms of program scope, participant engagement, and association with changes in clinical outcomes 1 year later.
Thousands of people participated, but few modules were completed.
Researchers found that 21,820 T2D patients had activated a Healthy Living account. However, only 5% met the program completion criterion, defined as accessing 60% of the learning journey within 9 months, and most did not get beyond the first part of the first section.
Compared to controls (non-activators), users of this program were more likely to be female. Twice as likely to be from the least deprived region and more than twice as likely to be taking non-insulin medication compared to the least deprived region. 65% less likely to be Asian and 44% less likely to be Black than whites. They are also 50% less likely to be a current smoker than non-smokers.
These differences persisted between those who participated in Healthy Living and those who did not, and between those who completed the program and those who did not. The median time spent on the website was 7 minutes.
Healthy living leads to modest clinical benefit
Results showed that after one year, activators were more likely to have lower glycated hemoglobin (HbA1c), lower body mass index (BMI), lower systolic and diastolic blood pressure (BP), and complete all eight recommended diabetes treatment processes. Its use was not associated with changes in insulin use.
A decrease in HbA1c of 3 to 5 mmol/mol is considered the threshold for clinical significance. The average reduction in HbA1c in this study was 1.3 mmol/mol compared to the matched control set in the National Diabetes Audit (NDA) database. This equates to a 0.1% reduction in Diabetes Control and Complications Trial (DCCT) units.
Similarly, Healthy Living participants had an average decrease in BMI of 0.2 kg/m2, systolic blood pressure by 1.2 mmHg, and diastolic blood pressure by 0.6 mmHg compared to controls. They were 60% more likely to complete the diabetes treatment process than controls.
The reduction in HbA1c with this approach was smaller than the mean reduction of 2.6 mmol/mol reported in HeLP diabetes. The decrease in systolic blood pressure was also small. However, reductions in diastolic blood pressure and BMI, as well as completion of care processes, were higher in healthy living participants.
The greater reductions in HbA1c reported with other DSMES interventions may be due to more intensive or individualized input and support, as well as self-care reminders. The authors suggest that even if this magnitude is small, reductions in HbA1c are clinically meaningful at a population level and may result in fewer vascular complications.
Real-world data reveals program performance
These results are from a real-world population that used the free online DSMES program and evaluated a variety of outcomes. Although we were able to address potential confounding by combining large-scale real-world NDA and healthy living datasets with robust analytical methods, confounding may still exist.
However, this study still has some limitations. The follow-up period was only 1 year, which is shorter than needed to assess long-term effects. The Healthy Living sample for efficacy analysis was only 25% of the total cohort matching the data coverage period to the NDA period. The coronavirus disease 2019 (COVID-19) pandemic limited general practice visits and referrals during the first few months, impeding timely and widespread dissemination of the program.
No mention was made of the effects of drug changes. Diabetic complications were not measured.
Stronger engagement can lead to greater improvements
Overall, the findings suggest that the healthy living program showed modest improvements in certain diabetes-related clinical outcomes at 1 year, especially among highly adherent patients. At a population level, this may contribute to a small but significant reduction in microvascular and macrovascular complications of diabetes. It can also reduce workload at the primary care level by giving patients access to information about their condition and its management.
Increasing long-term participation and equitable access are areas of focus for improving the public health impact of programs.
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