Personalised care and support planning in Singapore: qualitative interviews with people living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) is a person-centred approach for the care of people living with long-term conditions. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) adapts the Year of Care Partnerships (YOCP) approach to CSP in the UK for people living with diabetes at Singapore polyclinics. Polyclinics are multi-storey primary care hubs that provide affordable, multidisciplinary, comprehensive, and high-throughput public health care for the multi-ethnic, multilingual Singapore population. AIM: To explore the experience of PACE-D-enrolled people living with diabetes with personalised CSP at Singapore polyclinics. DESIGN & SETTING: Qualitative interviews of people living with diabetes who experienced personalised CSP at National University Polyclinics (NUP) in Singapore between July 2020 and November 2021. METHOD: PACE-D-enrolled people living with diabetes who experienced personalised CSP were purposively sampled. In-depth semi-structured interviews were recorded, transcribed, and analysed using Braun and Clarke's reflexive thematic analysis. RESULTS: Fifty-two patients participated in the study. Four main themes were identified. Theme 1 was the importance of the care-planning letter. Patients reported that the CPL prompted reflection and patient preparation for CSP conversations. Theme 2 was the role of the programme coordinator. PACE-D programme coordinators amplified self-management by playing advocate and confidant beyond administrative duties. Theme 3 was the value of the personalised CSP conversation. CSP providers were perceived as partners in care, with more time to listen compared with usual consultations. Patient engagement was affected by language confidence. Theme 4 was agency in self-management. With adequate time and support, patients increased in confidence and agency both in CSP engagement and diabetes self-management. CONCLUSION: While language confidence may affect patient engagement, personalised CSP shows promise for strengthening patient engagement and self-management among people living with diabetes at Singapore polyclinics.

Mindsets and self-efficacy beliefs among individuals with type 2 diabetes.

Growth mindsets and self-efficacy beliefs have been known to predict and promote resilience, challenge seeking, and improved outcomes in areas such as education and intelligence. However, little is known about the role of these two potentially influential beliefs in the context of type 2 diabetes (T2D), specifically in terms of whether and in which domains (i.e., beliefs toward general life, general health, or condition-specific domains) these beliefs-or lack thereof-is prevalent among individuals with T2D. Given the lifelong challenges that individuals with diabetes often encounter with managing their disease, many may slip into a conceding negative belief that their diabetes is "too difficult to control" or simply "out of their hands," inhibiting proactive self-management efforts. Results from our study (n = 893) revealed that individuals with T2D had a significantly lower growth mindset towards their blood glucose level and lower self-efficacy towards their general health, blood glucose, and cholesterol levels compared to those without T2D. Among participants with T2D, further analyses showed a pattern of higher HbA1c among those with lower growth mindsets and self-efficacy toward their general health or blood glucose level. These findings identify the belief-domains that may pose barriers to necessary self-care behaviors, informing future interventions to promote improved diabetes care and management.

Implementing and evaluating care and support planning: a qualitative study of health professionals' experiences in public polyclinics in Singapore.

BACKGROUND: Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments. METHODS: Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them. RESULTS: Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP 'going well' all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals' accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers' person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals' ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP. CONCLUSION: Health professionals' interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Women's Usage Behavior and Perceived Usefulness with Using a Mobile Health Application for Gestational Diabetes Mellitus: Mixed-Methods Study.

The prevalence of gestational diabetes mellitus (GDM) is increasing, and only a few mobile health (mHealth) applications are specifically designed to manage GDM. In this mixed-methods study, a follow-up study of a randomized controlled trial (RCT) analyzed a largely automated mHealth application-based lifestyle coaching program to (a) measure the application's usage behavior and (b) explore users' perceptions of its usefulness in GDM management. Quantitative data were collected from the 170 application users who had participated in the intervention arm of the RCT. Semi-structured interviews (n = 14) captured users' experiences when using the application. Data were collected from June 2019 to January 2020. Quantitative data were analyzed descriptively, and interviews were analyzed thematically. Only 57/170 users (34%) logged at least one meal, and only 35 meals on average were logged for eight weeks because of the incorrectly worded food items and limited food database. On the contrary, an average of 1.85 (SD = 1.60) weight values were logged per week since the weight tracking component was easy to use. Many users (6/14 (43%)) mentioned that the automatic coach messages created an immediate sense of self-awareness in food choices and motivated behavior. The findings suggest that for GDM management, a largely automated mHealth application has the potential to promote self-awareness of healthy lifestyle choices, reducing the need for intensive human resources. Additionally, several gaps in the application's design were identified which need to be addressed in future works.

A Smartphone App to Restore Optimal Weight (SPAROW) in Women With Recent Gestational Diabetes Mellitus: Randomized Controlled Trial.

BACKGROUND: Women with a history of gestational diabetes mellitus (GDM) are at an increased risk of developing type 2 diabetes mellitus (T2DM). Lifestyle interventions aimed at postpartum weight loss to reduce T2DM risk have been reported, but poor compliance remains a barrier. Smartphone-based interventions may improve compliance, but data on its use in women with recent GDM are limited. OBJECTIVE: This trial aimed to investigate the efficacy of a smartphone app in restoring optimal weight following delivery in women with GDM, in the setting of a population with high rates of GDM and type 2 diabetes. METHODS: In this unblinded randomized controlled trial, 200 women with GDM were randomized to receive the intervention or standard care following delivery. The intervention enabled logging of weight, meals, and activity, with web-based interaction with a team comprising dieticians, a physiotherapist, and an occupational therapist. The primary outcome was an achievement of optimal weight (defined as the restoration of first trimester weight if first trimester BMI≤23 kg/m2 or weight loss of at least 5% from first trimester weight if first trimester BMI>23 kg/m2) at 4 months post partum. Secondary outcome measures included absolute weight loss, serum metabolic markers, self-reported nutritional intake, health education, and quality of life via questionnaires and user engagement in the intervention group. RESULTS: In total, 40% (38/96) of women in the intervention group achieved optimal weight at 4 months post delivery compared with 32% (28/93) in the control group (P=.27). Compared with the control group, women in the intervention group reported significantly reduced caloric intake at 4 months after delivery (P<.001) and higher health-directed behavior scores (P=.045). The intervention group also reported increased emotional distress scores (P=.01). At 4 months, participant engagement with the intervention was maintained at 60.8% (SD 33.9%). CONCLUSIONS: Although a statistically significant increase in women achieving healthy weight was not observed, this app remains promising, as women in the intervention group reported improved health behaviors and lower caloric intake. Importantly, the high retention rates suggest that a larger study with a longer follow-up period might confirm the effectiveness of this app for weight management. TRIAL REGISTRATION: ClinicalTrials.gov NCT03324737; https://clinicaltrials.gov/ct2/show/NCT03324737. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-7691-3.

A Randomized Controlled Trial to Evaluate the Effects of a Smartphone Application-Based Lifestyle Coaching Program on Gestational Weight Gain, Glycemic Control, and Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: The SMART-GDM Study.

OBJECTIVE: SMART-GDM examined whether Habits-GDM, a smartphone application (app) coaching program, can prevent excessive gestational weight gain (EGWG) and improve glycemic control and maternal and neonatal outcomes in gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: In this randomized controlled trial, women diagnosed with GDM between 12 and 30 weeks were randomly assigned to usual care (control) or to additional support from Habits-GDM that integrated dietary, physical activity, weight, and glucose monitoring (intervention). The primary outcome was the proportion of participants with EGWG. Secondary outcomes included absolute gestational weight gain (GWG), glycemic control, and maternal, delivery, and neonatal outcomes. RESULTS: In total, 340 women were randomized (170 intervention, 170 control; mean ± SD age 32.0 ± 4.2 years; mean BMI 25.6 ± 5.6 kg/m2). There were no statistically significant differences in the proportions of women with EGWG, absolute GWG, or maternal and delivery outcomes between experimental groups. Average glucose readings were lower in the intervention group (mean difference -0.15 mmol/L [95% CI -0.26; -0.03], P = 0.011) as were the proportions of glucose above targets (premeal: 17.9% vs. 23.3%, odds ratio 0.68 [95% CI 0.53; 0.87], P = 0.003; 2-h postmeal: 19.9% vs. 50%, 0.54 [0.42; 0.70], P < 0.001). When regarded as a composite (although not prespecified), the overall neonatal complications (including birth trauma, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress, neonatal intensive care unit admission, and perinatal death) were significantly lower in the intervention group (38.1% vs. 53.7%, 0.53 [0.34; 0.84], P = 0.006). CONCLUSIONS: When added to usual care, Habits-GDM resulted in better maternal glycemic control and composite neonatal outcomes (nonprespecified) but did not reduce EGWG among women with GDM.

Barriers to Gestational Diabetes Management and Preferred Interventions for Women With Gestational Diabetes in Singapore: Mixed Methods Study.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with risks for both the mother and child. The escalated prevalence of GDM because of obesity and changes in screening criteria demands for greater health care needs than before. OBJECTIVE: This study aimed to understand the perception of patients and health care providers of the barriers to GDM management and preferred interventions to manage GDM in an Asian setting. METHODS: This mixed methods study used a convergent parallel design. Survey data were collected from 216 women with GDM, and semistructured interviews were conducted with 15 women and with 8 health care providers treating patients with GDM. Participants were recruited from 2 specialized GDM clinics at the National University Hospital, Singapore. RESULTS: The patients were predominantly Chinese (102/214, 47.6%), employed (201/272, 73.9%), with higher education (150/216, 69.4%) and prenatal attendance at a private clinic (138/214, 64.2%), already on diet control (210/214, 98.1%), and receiving support and information from the GDM clinic (194/215, 90.2%) and web-based sources (131/215, 60.9%). In particular, working women reported barriers to GDM management, including the lack of reminders for blood glucose monitoring, diet control, and insufficient time for exercise. Most women preferred getting such support directly from health care providers, whether at the GDM clinic (174/215, 80.9%) or elsewhere (116/215, 53.9%). Smartphone apps were the preferred means of additional intervention. Desirable intervention features identified by patients included more information on GDM, diet and exercise options, reminders for blood glucose testing, a platform to record blood glucose readings and illustrate or understand trends, and a means to communicate with care providers. CONCLUSIONS: A GDM-focused smartphone app that is able to integrate testing, education, and communication may be a feasible and acceptable intervention to provide support to women with GDM, particularly for working women.

The Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) protocol: a non-randomised controlled trial of personalised care and support planning for persons living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) has been shown to improve diabetes outcomes, patient experience and provider morale in the care of persons living with diabetes. However, this has not been confirmed in controlled studies. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) is a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore. METHODS: Teamlet-empanelled patients with diabetes at four polyclinics are recruited for this study. Participants who attend either of the two Intervention clinics are sent their investigation results in a care planning letter (CPL) to prepare them for the CSP conversation. This conversation is facilitated by a trained CSP practitioner who engages them in discussion of concerns, goals and action plans, and documents their plans for subsequent review. Participants in the two Control clinics will receive standard diabetes care. Participants will complete two or more CSP conversations (Intervention) or regular consultations (Control) at the annual review visits within the 18 months of the study. The sample size is calculated at 1620 participants, with glycated haemoglobin (HbA1c) as the primary outcome measure. Secondary outcome measures include patient activation (as measured by PAM-13) and changes in healthcare utilisation and cost. DISCUSSION: This study is a pragmatic trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in a real world setting. It promises to provide insights with regard to the implementation of this model of care in Singapore and the region. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04288362. Retrospectively registered on 28 February 2020.

Smart Phone APP to Restore Optimal Weight (SPAROW): protocol for a randomised controlled trial for women with recent gestational diabetes.

BACKGROUND: Gestational diabetes (GDM) is a known risk factor for type 2 diabetes mellitus (T2DM), and women with a history of GDM have a 7-fold increased risk of developing the disease. Achieving a healthy weight post-delivery is key in reducing the risk of future diabetes in these women. The aim of this trial is to investigate the use of an interactive smartphone application (APP) to restore women to optimal weight following delivery. METHODS: This will be an open-label randomized controlled trial. Two hundred women with gestational diabetes will be randomized to receive the intervention or standard care following delivery. Participants will be reviewed at 6 weeks and 4 months post-delivery. The intervention is an APP serving as a platform for weight, diet and physical activity tracking. The APP provides 3-5 min educational videos suggesting suitable lifestyle adjustments relevant to postnatal period such as breast feeding, diet and exercise. Lastly, the APP will allow real-time interaction between users and the team of dietitians, physiotherapists and occupational therapists to encourage restoration of optimal weight. Women in the control arm will be informed about the increased risk of developing T2DM and advised to maintain a healthy weight. Primary outcome measure is the restoration of participants' booking weight if booking BMI ≤ 23, or weight loss of at least 5% from booking weight if booking BMI > 23 over the 4 month period. Secondary outcome measures will assess serum metabolic and inflammatory markers, quality of life via questionnaires and cost-effectiveness of the intervention at each follow-up visit. DISCUSSION: This will be the first randomised controlled trial investigating the use of a smartphone application for postpartum weight loss in women with gestational diabetes. The major ethnic groups in our study population represent the majority of ethnic groups in Asia, amongst which the prevalence of diabetes is high. If shown to be effective, this APP may be used in wider clinical settings to improve postpartum weight loss and reduce the risk of developing T2DM in these women. TRIAL REGISTRATION: This study was registered on clintrials.gov on the 30th of October 2017, under the trial registration number: NCT03324737 .

Health Care Providers' Perceptions of Responsibilities and Resources to Reduce Type 2 Diabetes Risk After Gestational Diabetes Mellitus.

IN BRIEF Gestational diabetes mellitus (GDM) increases the risk for type 2 diabetes. This qualitative study aimed to evaluate health care providers' perceptions of care responsibilities and resources related to reducing type 2 diabetes risk among women with previous GDM in Singapore. Health care providers acknowledged a shared responsibility. They felt that they had less understanding of compliance with long-term maintenance of lifestyle change, exacerbated further by fragmentation of follow-up care. The application of more integrated patient-centered care models, combined with greater health literacy, is urgently required in this area.

Comprehensive assessment of insulin resistance in non-obese Asian Indian and Chinese men.

AIMS/INTRODUCTION: Indian individuals are more insulin resistant (IR) than Chinese individuals, even among those with a non-obese body mass index (BMI). However, BMI often underestimates body fat in Indian individuals, and it remains unclear whether Indians would remain more IR than Chinese individuals when both BMI and body fat are equally matched. MATERIALS AND METHODS: Using the hyperinsulinemic-euglycemic clamp with stable-isotope infusion, we comprehensively assessed IR between 13 non-obese Indian men with 13 Chinese men matched for age, BMI and body fat. We further compared the differences in insulin metabolic clearance rate (MCR) between the two groups and its relationship with various metabolic parameters. The response of lipid and amino acid metabolism to insulin stimulation was also evaluated using metabolomic profiling. RESULTS: The rates of endogenous glucose production during fasting were similar, and endogenous glucose production was completely suppressed during insulin clamp for both ethnic groups. Glucose disappearance during insulin clamp was also similar between the two groups, even after accounting for differences in insulin concentration. Metabolomic profiles of amino acids and various acylcarnitines were similar during both fasting and insulin clamp. However, plasma insulin during clamp was significantly higher in Indian men, indicating that insulin MCR was lower. Insulin MCR correlated significantly with total adiposity and skeletal muscle insulin sensitivity. CONCLUSION: When equally matched for body fat, non-obese Indian men had similar skeletal muscle insulin sensitivity and endogenous glucose production to Chinese men. The effects of insulin on lipid and amino acid metabolism were also similar. Low insulin MCR is associated with greater adiposity and lower skeletal muscle insulin sensitivity.

The Prevalence of Gestational Diabetes Mellitus Among Asian Females is Lower Using the New 2013 World Health Organization Diagnostic Criteria.

OBJECTIVE: To determine the impact of the new 2013 World Health Organization (WHO) criteria for gestational diabetes mellitus (GDM) diagnosis on GDM prevalence and pregnancy outcomes in Asian ethnic groups compared to the 1999 WHO criteria. METHODS: A retrospective cohort study included 855 pregnant females of Chinese, Malay, and Asian Indian ethnicity at high risk of GDM who underwent 75-g oral glucose tolerance tests (OGTTs) between July 2008 and June 2010 in a tertiary center in Singapore. GDM prevalence, reclassification, and pregnancy outcomes were determined using the 2013 and 1999 diagnostic cutoffs for fasting and 2-hour postglucose (PG) values. RESULTS: The prevalence of GDM was reduced from 28.8% to 21.1% when the 2013 criteria were used. Overall, 10.2% subjects were reclassified from GDM to normal using the 2013 criteria, and 2.6% were reclassified from normal to GDM, giving a net reclassification rate of 12.8%. Reclassification from GDM to normal was greatest among Chinese, followed by Asian Indians, but the prevalence rate was unchanged among Malays. Babies of mothers who were reclassified from normal to GDM were more likely to have birth weight >95th centile and shoulder dystocia. CONCLUSION: The prevalence of GDM was reduced when the 2013 criteria were used, with the greatest reduction seen among Chinese, followed by Asian Indians. Lowering the fasting cutoff as per the new criteria identified a select group of patients who might benefit from GDM treatment. However, raising the 2-hour PG cutoff would miss a significant number of patients who might potentially benefit from GDM treatment.