Introduction: A Global Challenge in Prediabetes
Prediabetes affects hundreds of millions worldwide, with rising prevalence driven by urbanization, lifestyle changes, and aging populations. While lifestyle modification programs have shown strong efficacy at reducing diabetes risk, real-world uptake remains a hurdle. PREDIABETEXT (Prediabetes Text Message Digital Intervention for the Prevention of Type 2 Diabetes Mellitus) represents an innovative attempt to scale prevention through a low-intensity, digitally delivered approach integrated into primary care.
What was PREDIABETEXT?
PREDIABETEXT is a theory-driven, multifaceted intervention designed for the primary care setting in Mallorca, Spain. It combines patient-facing SMS text messages with an online training program for health care professionals. The trial employed a pragmatic, 6-month, three-arm cluster randomized design to evaluate the impact on HbA1c and other clinical, behavioral, and psychological outcomes.
Three arms at a glance
- Intervention A: Patients receive SMS text messages only.
- Intervention B: Patients receive SMS messages plus online training for their health care professionals.
- Control: Usual primary care without structured digital intervention.
Study Design and Real-World Setting
The trial clustered at health care professionals to minimize contamination, with 58 professionals across 16 centers. Patients aged 18–75 at risk for T2DM were invited from professional rosters, prioritizing those with recent prediabetes indicators (HbA1c 6.0–6.4% or fasting glucose 110–125 mg/dL). The intervention used the Balearic Islands Health Service SMS system to deliver up to 74 messages over six months, integrating behavior change techniques (BCTs) to support diet, physical activity, and overall lifestyle changes.
Interventions in Detail
Patients in both SMS groups received knowledge-based, behaviorally informed messages three times per week, including nutrition guidance, portion sizes, and strategies to reduce ultraprocessed foods, alcohol, and added sugars. Physical activity guidance focused on frequency, intensity, duration, and reducing sedentary behavior, with motivational content tailored to weight loss or smoking cessation when applicable.
Intervention Group B added an online, 16-hour accredited training for health care professionals, designed to improve predisease management through updated guidelines, communication techniques, and monitoring strategies. Access to training was password-protected to prevent cross-contamination.
All participants and professionals had to provide informed consent, with ethical oversight from regional committees.
Outcomes and Key Findings
The primary outcome was HbA1c at six months. Across groups, HbA1c remained relatively stable, with mean values around 6.07% in Intervention A, 6.12% in Intervention B, and 6.18% in control. Intention-to-treat analyses found no statistically significant differences between either intervention group and control for HbA1c.
Secondary outcomes encompassed fasting glucose, lipid profiles, liver enzymes, inflammatory markers, and cardiovascular risk via the REGICOR-Framingham score. Notably, LDL cholesterol rose significantly in Intervention A compared with control, while most other cardiometabolic measures showed no meaningful between-group differences in the ITT framework.
Behavioral and lifestyle metrics—adherence to the Mediterranean diet, total energy expenditure from physical activity, sedentary time, and alcohol intake—also showed no significant group differences. Although the risk of progression to diabetes favored both intervention arms (lower odds ratios), these reductions were not statistically significant.
Process Insights: Qualitative Feedback
Embedded interviews with patients and professionals highlighted perceived benefits and challenges. Patients valued dietary messages and frequency, with some requesting more personalization or periodic in-person follow-ups. Health care professionals found the training helpful for raising awareness of prediabetes management but cited time constraints and a preference for blended learning formats. The mixed-methods evidence underscored the importance of tailoring digital health interventions to real-world workflows and patient heterogeneity.
Implications for Future Diabetes Prevention
The PREDIABETEXT study demonstrates the feasibility and scalability of a low-intensity, digitally delivered prevention program in a European primary care context. While the primary glycemic outcome did not reach statistical significance, the trial provides valuable lessons for optimizing digital prevention: higher intensity, longer duration, more personalized content, integration with wearable devices, and targeted recruitment of underserved populations may enhance effectiveness. Future work should also examine cost-effectiveness, implementation strategies, and cross-country generalizability to inform policy and routine practice.
Conclusion
PREDIABETEXT contributes to the evolving evidence base on digital health in diabetes prevention. It shows that information delivery via SMS, even when paired with clinician training, may require higher design fidelity, personalization, or multimodal engagement to meaningfully reduce diabetes risk in primary care settings.
