An app that provided cognitive behavioral therapy (CBT) led to improvements in glycemic control, according to a randomized controlled trial (RCT). A total of 669 adults with type 2 diabetes and an HbA1c level of 7% to 11% were randomly assigned to receive access to a digital therapeutic app delivering CBT (called BT-001) or a control app for 90 days, with a primary outcome of mean change in HbA1c level at 90 days.
The industry-funded study was published by Diabetes Care on Oct. 1, 2022. The following commentary by Lawrence H. Greenblatt, MD, FACP, was published in the ACP Journal Club section of Annals of Internal Medicine on Jan. 3.
Diabetes self-management education and support (DSMES) is recommended at diagnosis and at least yearly, although only a minority of patients receive these services. DSMES strives to improve knowledge and optimize self-care behaviors. For patients with diabetes, CBT delivered individually or in groups has been effective for facilitating behavior change and improving glycemic control. Clinicians who have CBT delivery skills are in high demand given the increasing rates of mental health concerns. Apps that use CBT to address common mental health concerns are widely available and are lower-cost alternatives to in-person delivery, and some have been shown to improve clinical outcomes. An app that delivers CBT to patients with diabetes has potential for meaningful clinical effect.
The RCT by Hsia and colleagues found that use of BT-001 resulted in a 0.39% reduction in HBA1c at 90 days compared with a control app. Although this reduction is less than that typically seen for commonly used medications such as metformin or sulfonylureas (1% to 1.5%), the reduction is not far below that expected for dipeptidyl peptidase-4 inhibitors (0.5% to 1.0%).
The relatively short follow-up of the trial (90 d) may have led to an underestimation of the longer-term effect on HbA1c levels, as average fasting glucose values fell during the first 8 weeks of the intervention. However, it is unknown if the behavior changes will be sustained.
I am hopeful that future trials will evaluate attitudes toward exercise and dietary changes that can improve glycemic control and reduce cardiovascular risk. It would be helpful to know if the app improves confidence in diabetes self-management and how it compares with other forms of DSMES.