Question

What would be the limitations and delimitations of the use of the digital tools for diabetes management?

Answer 1

Diabetes self-management education (DSME) and training is a collaborative process through which people with, or at risk for, diabetes gain the knowledge and skills needed to modify their behavior and successfully self-manage the disease to improve health outcomes.
The components of DSME are healthy eating, self-monitoring of blood sugar (SMBG), medication adherence, and diabetes complications risk reduction behavior.

Online diabetes education

The conventional education for diabetes self-management has been supplemented with several web portals, blogs, and structured online educational materials. The online portals and apps may be cost-effective, convenient, easy to use and learn anywhere at anytime to understand diabetes, its complications, and how to individualize and self-manage.

Healthy Eating

There are apps that help patients improve their nutritional choices and monitor their food and caloric intake. Many apps include a feature that allows users to search food databases by typing or scanning bar codes. For example, GoMeal, My Fitness pal, Calorie Counter by MyNetDiary, and Glucose Buddy offer extensive databases, allowing users to quickly look up nutritional information including carbohydrate content and calories. In addition, these apps offer target planning and goal setting to help users manage their weight and caloric intake.

Insulin dose calculators

Accurate bolus insulin doses require calculations based on factors such as current and target blood glucose, carbohydrate-to-insulin ratios, total grams of carbohydrate in meals, insulin sensitivity factors, and insulin on board.
It is difficult for insulin requiring patients to account for all these factors for their insulin dosing. Introduction of automatic bolus calculators integrated in the insulin pump (bolus wizard) have shown to help patients to more accurately meet prandial insulin dosage requirements, improve postprandial glycemic excursions, and achieve optimal glycemic control.
The majority of people with diabetes do not use insulin pumps due to cost, lack of insurance coverage, or other unrelated issues. Apps such as Insulin Calculator, Bolus Calc, Insulin Dose Calculator Pro, and Diabetes Personal Calculator for non-pump users are available to help patients in insulin dosing. The Food and Drug Administration (FDA) has not approved most of the available apps.

Physical activity

Many developers have created digital tools for physical activity monitoring such as pedometers, wristband sensors, and personal digital assistants. Examples of few mobile apps for monitoring steps and physical activities are; pacer, Steps pedometer and step counter activity tracker, Map My Walk, Stepz, Walker-Pedometer Lite, Footsteps, iRunner and Runtastic Pedometer.
These apps allow users to track their activity, count calories, and provide ways for weight management. In addition, many apps help people change their physical activity by providing instruction to perform such activities, modeling/demonstrating, feedback on performance, planning social support/change, prompting review of goals, facilitating social comparison, setting graded tasks, and goal setting for a behavioral outcome.

Self-monitoring of blood glucose

Self-monitoring of blood glucose (SMBG) is recognized as an important tool for decision-making for both patients and health care providers.
With the advances in blood glucose meters and mobile technology, it has become possible to address several of these issues. For example, iBGStar is an external device that fits easily to an iPhone and functions as a glucose meter that helps patients carry their glucose meter along with a smartphone.

A number of apps such as GoMeal, Diabetes Net Diary, and Glooko provide an e-Log book where blood glucose data can be saved and printed later or can be emailed to health care providers. In addition, these apps have graphical displays to see and interpret blood glucose entries and thus motivate patients to improve blood glucose testing frequency resulting in better glucose control.
Recently, FDA approved Accu-Check Aviva Expert glucose meter with built-in insulin advisor as it has shown to improve glycemic control and treatment satisfaction without increasing severe hypoglycemia in insulin requiring patients with diabetes.

Medication adherence

Medication non-adherence is very common in people with diabetes resulting in poor glycemic control.

The advantages of using the adherence apps are simple to use and navigate, data storage, medication instruction, and features to download and print a medication chart. Most of the medication adherence apps like MyMedSchedule, My Meds, MedSimple, Medagenda, Pillmanager, Pill reminder, and RxmindMe Prescription cost little.

Outcomes with the use of digital tools for diabetes self-management:

Despite an increase in the use of health-related apps, data is lacking on its benefits and cost-effectiveness, however, there is better glucose control, improved SMBG frequencies, better patient satisfaction, moderate weight loss, and medication adherence with the use of digital tools.

Barriers to use digital tools for diabetes management

1) Cost: A potential barrier to any new medical technology is the cost. In addition, the use of apps requires the person to use an expensive smartphone and an internet data plan. Most payers do not cover the cost of having these devices or apps due to lack of conclusive data. Though diabetes is a major problem in developing countries, these technologies have not been used due to the higher cost of smartphone devices and Internet services.

2) Not useful in certain populations: Most available apps may not be useful for the elderly, non-English speakers, physically challenged, and subjects from a lower socio-economical status.

3) Regulatory barriers: Although the use of digital tools is helpful in the self-management of diabetes, improper use of digital tools or technical issues with the algorithms or software can lead to undesirable side effects. For example, insulin dose calculator software is helpful for patients with diabetes to determine bolus insulin doses. The technical problem can result in higher insulin dose calculation and can result in severe hypoglycemia.