Overview: A Digital Approach to Prediabetes Prevention
Prediabetes affects millions worldwide and poses a clear risk for progression to type 2 diabetes mellitus (T2DM). In Mallorca, Spain, researchers tested a multifaceted digital intervention called PREDIABETEXT in a real-world primary care setting. The trial explored whether a low-to-moderate intensity program, delivered mainly through SMS messages and supported by online clinician training, could improve long-term glycemic control and related health outcomes versus usual care.
What Was Studied and How It Was Designed
The study used a pragmatic, three-arm cluster randomized design across primary care centers. Clusters were defined by health care professionals to minimize contamination across groups. Participants were adults aged 18–75 with at least one prediabetes criterion (eg, HbA1c 6.0–6.4% or fasting glucose 110–125 mg/dL) and access to a mobile phone for SMS messages. The three arms included:
- Group A: Patients received a structured SMS program focused on diet and physical activity over six months.
- Group B: Patients received the same SMS program plus a 16-hour online professional training course for their health care providers.
- Control: Usual care with no added digital interventions.
The trial enrolled 58 health care professionals representing 16 centers and 365 patients, with randomization occurring at the professional level. The primary outcome was HbA1c at six months, complemented by a wide array of secondary outcomes including fasting glucose, lipid profiles, anthropometrics, cardiovascular risk, and lifestyle behaviors. A mixed-methods approach incorporated a qualitative process evaluation to capture participant and clinician experiences.
Key Components of the Intervention
The patient-facing arm delivered up to 74 SMS messages per participant across six months, drawing on behavior change techniques to promote healthier eating, reduced ultraprocessed foods, weight management, and increased physical activity. Messages were designed to be actionable, concise, and culturally tailored for Spanish-speaking participants. For health care professionals, the B arm included an accredited online program on prediabetes management covering diagnosis, treatment, communication strategies, and monitoring practices. This combination aimed to synchronize patient education with provider skills for better preventive care.
Results in Real-World Practice
At six months, HbA1c levels were 6.07% for the SMS-only group, 6.12% for the SMS-plus-training group, and 6.18% for controls. Analyses using intention-to-treat principles showed no statistically significant differences between the intervention arms and usual care for HbA1c or most secondary outcomes, including fasting glucose, insulin resistance markers, lipids (with a notable LDL increase in one group), and anthropometric measures.
Some promising signals emerged: both intervention groups showed a trend toward reduced risk of progression to diabetes, though these did not reach statistical significance. The training component substantially increased health care professional knowledge immediately after completion, but gains were not consistently sustained across six months. Adherence to SMS messages was high, with the majority of participants receiving at least 95% of the planned messages.
Interpretation and Implications for Practice
The PREDIABETEXT trial demonstrates that a low-intensity digital approach, implemented in authentic primary care settings, can be integrated into routine practice at a relatively low cost. However, the lack of significant improvements in HbA1c and other key biomarkers highlights the challenge of achieving durable physiological changes with SMS-based strategies alone, especially over a short six-month horizon. The authors note that higher-intensity, personalized, or hybrid models—potentially incorporating wearables, real-time feedback, and longer follow-up—might yield more substantial benefits. The study also emphasizes the importance of implementation science to understand how to optimize uptake, adherence, and scalability in diverse populations.
Takeaways for Researchers, Clinicians, and Policy Makers
- Digital health interventions in prediabetes are feasible in public health systems but may require greater intensity or personalization to affect glycemic outcomes meaningfully.
- Clinician training can enhance knowledge, yet sustained impact may demand ongoing reinforcement and multidisciplinary engagement.
- Real-world trials with integrated electronic health records and CMS-like platforms provide valuable guidance for scalable diabetes prevention strategies.
- Future research should explore longer follow-up periods, hybrid models (digital plus periodic in-person contact), and inclusion of underserved groups to improve generalizability.
Conclusion
While PREDIABETEXT did not significantly reduce HbA1c or other biomarkers at six months, it offers critical lessons about designing scalable, low-cost digital interventions for diabetes prevention. The findings underscore the potential of combining patient-facing digital tools with clinician education, while also pointing to the need for higher-intensity, longer-term strategies to achieve meaningful reductions in diabetes risk at the population level.
