10 Technologies/tools Changing Diabetes Care

Healthcare

 organizations turn to technology to reduce the far-reaching, costly impact of diabetes.

Healthcare providers, payers, and patients expect new technologies and shifts to patient engagement and population health will help the nation's 29.1 million diabetics manage their condition and reduce the costs associated with this dangerous and expensive disease.

In 2012, diagnosed diabetes cost the US $176 billion, and reduced productivity cost another $69 billion, according to the Centers for DiseaseControl. After adjusting for age and gender differences, average medical expenses for people with diabetes were 2.3 times higher than they would have been without diabetes, the American Diabetes Association reported.

More than 1.5 million Americans have Type 1 diabetes; the vast majority of cases are Type 2 diabetes, which typically is linked to obesity. In Type 2 cases, patients still produce insulin and may improve with lifestyle and diet changes. Unchecked, diabetes can lead to more medical complications and even death.

Without attention, US diabetes cases will increase, fueled by Americans' diet of sugar and processed food, Dr. Brett Osborn, author of Get Serious: A Neurosurgeon's Guide to Optimal Health and Fitness, told InformationWeek.

"More than 30% of Medicare dollars are spent on diabetics and/or related complications. Likely diabetes, or more specifically 'insulin resistance,' will be linked to many more disease processes -- i.e., Alzheimer's disease is also referred to as 'Type III diabetes,' as one of its underpinnings is insulin resistance," he says.

In an effort to improve health, reduce costs, and slow down future cases, healthcare providers are educating non-diabetics about how to avoid the condition and using new and long-established tools to help diabetics live healthier lives.

They're influenced by healthcare's transition to patient engagement -- with its growing reliance on patient portals, mobile apps, and the creation of health-focused communities -- plus population health, which considers the multiple factors that make up the population's individual and overall health.

In Cities for Life, a diabetes management program supported by Sanofi US and conducted by the American Academy of Family Physicians Foundation, patients were connected with community resources to help manage their condition. Partners at the University of Alabama researched resources at local churches, YMCAs, gyms, and other sites, then created a database and website -- MyDiabetesConnect.com -- where residents could locate farmers' markets, exercise programs, and other items conducive to health living.

"Obviously what happens in their doctors' offices is very important, but they need to carry out what they plan in their doctors' offices throughout the year," Dr. Edwin Fisher, global director of Peers for Progress at the American Academy of Family Physicians Foundation, tells us. "We really need comprehensive approaches that bring together clinical care, community care,social support, friends, and neighbors, to help people with diabetes live their lives well and take care of their diabetes well."

Increasingly, that care involves technology.

The information pouring in from glucose meters provides developers, researchers, payers, and other members of the healthcare world with a plethora of data for analysis that could provide insight into new treatments or devices. Tens of thousands of diabetics also use the more than 1,000 apps now available to monitor and manage the condition, further fueling both improved health and big-data solutions.

"Ultimately, more aggressive monitoring -- implantable, continuous -- will lead to tighter glucose control. This equates to reduced formation of advanced glycation products and lower bodily inflammation (the damaging, diabetes-associated epiphenomena)," says Osborn. "Google will likely be introducing acontact lens-based glucose monitor in the next several years. This will allow for real-time monitoring of blood glucose, essentially providing a number upon which people can rapidly act. Aggressive treatment early on is the key -- although prevention obviously is ideal."

Tech companies are venturing into the diagnostics and treatment market. Patients can use smartphones to monitor their condition. In addition to Google's under-development smart contact lens, other companies are creating a bionic pancreas and exploring genomes to control diabetes.

Take a look at some of the technologies currently in use, and let us know what your organization is doing to help diabetic patients control costs and improve their health.

Healthcare organizations turn to technology to reduce the far-reaching, costly impact of diabetes.

Smart Lenses

Earlier this year, Google took the wraps off its smart contact lens project, "built to measure glucose levels in tears via a tiny wireless chip and miniaturized glucose sensor embedded between two layers of soft contact lens material." The developer also is investigating whether integrated LED lights could show when glucose levels have passed above or below particular thresholds.

"We're in discussions with the FDA, but there's still a lot more work to do to turn this technology into a system that people can use. We're not going to do this alone: we plan to look for partners who are experts in bringing products like this to market," wrote project co-founders Brian Otis and Babak Parviz on Google's blog. "These partners will use our technology for a smart contact lens and develop apps that would make the measurements available to the wearer and their doctor."

Bionic Pancreas

Engineers from 

Boston University

 created a closed-loop bionic pancreas system that uses continuous glucose monitoring and subcutaneous delivery of rapid-acting insulin and glucagen as directed by an algorithm. The system, currently being tested on people with Type 1 diabetes at Massachusetts General Hospital, could one day make automated blood glucose control a reality, according to the developers' blog.

The manmade pancreas makes a new decision about insulin and glucagen doses every five minutes. Previous bionic pancreases could not administer glucagen, which raises blood glucose in response to hypoglycemia.

"Achieving and maintaining near-normal blood glucose concentrations are critical for the long-term health of people with diabetes. Unfortunately, the therapy required to achieve this goal is extremely demanding, requiring frequent blood glucose checks and either multiple daily insulin injections or the use of an insulin pump," the researchers wrote. "Even with current state-of-the-art insulin replacement, it is almost impossible to completely avoid hyperglycemia and hypoglycemia."

Improving Medication Adherence

The Accountable Care Organization of Greater New York (ACCGNY) and AllazoHealth are partnering on a pilot aimed at improving medication adherence among ACCGNY's Medicare-eligible beneficiaries. Many people in this group are elderly and/or have intellectual and developmental disabilities, and many have multiple conditions, including diabetes, hypertension, epilepsy, and/or hyperlipidemia. The pilot, sponsored by a grant of $91,914 from 2014 Pilot Health Tech NYC, will use AllazoHealth's AllazoEngine to determine which patients are most at risk of not taking their prescribed medications and to predict which interventions are most likely to promote adherence.

Clinical staff will use the results from AllazoEngine to deliver patients' interventions via calls or in-person counseling. The analytics engine bases its results on ACCGNY's historical claims data. In addition to reducing medical costs, the pilot should improve care for IDD patients.

"Our goal is to provide affordable, high quality care to our Medicare beneficiaries. Partnering with AllazoHealth will give us the tools to improve our population's medication adherence and reduce medical costs," said Gabriel Luft, executive director of ACCGNY, in a statement.

s

Former American Idol judge Randy Jackson teamed up with digital health and wellness company Everyday Health to create consumer-facing resources about diabetes on a platform dubbed "Diabetes Step by Step." Jackson will provide blogs, videos, and a diabetes awareness-screening program, slated to run live in a number of cities through November --American Diabetes Month.

Jackson, who was diagnosed with Type 2 diabetes in 1999, wrote about his experiences in Body With Soul: Slash Sugar, Cut Cholesterol, and Get a Jump on Your Best Health Ever. He also has served as the spokesman for the American Heart Association's "Heart of Diabetes" campaign. "Diabetes is an issue that is near and dear to my heart, and this is a tremendous 

opportunity

 to educate people on diabetes prevention and control," Jackson said in a statement.

Smart Monitors

Once big, bulky machines, glucose monitors are now as sleek as an iPhone. Vendors like Gmate integrate an app and smart meter that connects to the iPhone headphone jack, then measures a patient's blood glucose reading.

The Gmate Smart is compatible with Apple's iPhone 3GS, 4, 4S, and 5; the iPod Touch 4th generation; plus iPad and iPad 2. Users download the app from iTunes, insert Gmate's smart device and test strip, apply the sample, and see their results on the Apple device screen

Big Data

Researchers, payers, and providers are exploring the connections between a host of potential causes and effects on diabetics thanks to powerful, lower-cost, and user-friendly big-data and analytics tools. The move to collapse silos and combine multiple research studies to seek trends from greater pools of subjects is generating pilot programs, reallocation of resources, and additional benefits.

Startup Databetes, founded by a person with Type 1 diabetes, uses a data-driven approach to diabetes management that combines apps and smartphones, as well as food and lifestyle data, to help patients manage the condition. Explorys and Accenture are collaborating on an initiative to improve population health approaches for diabetes care.

anagement Apps

There are more than 1,100 iOS and Android apps designed expressly to help people manage diabetes. They include cookbooks and a wide array of management apps that help diabetics track their insulin, exercise, and sugar intake.

Glooko, for example, allows patients to download blood glucose readings to their smartphones, integrate food and lifestyle data, then share that information with health providers. Glooko also makes available diabetes-related data and analytics to healthcare providers and payers to support research into the condition. Diabetes Pilot records glucose, insulin, and other measurements; tracks food nutrients; includes a food database; and allows patients to share data with healthcare providers. And GlucoseBuddy, for iOS, lets users record meals, exercise, insulin levels, and share records with physicians.

Automated Logging

As part of the 2013 Data Design Diabetes Sanofi US Innovation Challenge, Common Sensing developed GoCap, a pen cap that tracks insulin and wirelessly connects with a smartphone. A replacement cap forinsulin pens, the GoCap reads insulin amounts and times, then communicates via Bluetooth with a phone or connected glucometer, HIT 

iver Apps

Developers offer several tools for people who look after individuals with diabetes, as well as patients themselves. Developers such as Dexcom,Medtronic, Glucose Buddy, and American Association of Diabetes Educators offer apps filled with training, education, and other items of use for caregivers.

Triabetes does diabetes better

Fits your day – food, exercise, medicine and more.

Triabetes is an all-in-one app and online service for controlling your diabetes, your way.

The key is a uniquely personal view on how food, exercise and medicine – the three essentials of diabetes – interact over days, weeks and months.

• All in one

See your big picture and know more. Compare food, blood sugar, insulin, medicine, exercise and weight over time.

• Uniquely personal

Shows what is important to you. At work, in the gym or on holiday – wherever you are.

• Feel secure

with the respected CE mark signaling compliance with medical device regulations.

Standalone or connected

As someone with diabetes, Triabetes can be a standalone smartphone app and online companion available from app stores and the Triabetes website

But what makes Triabetes different is that your doctor can also invite you to use the app. This means you and your doctor share information for an added dimension to your diabetes care. For your doctor or nurse., this connected service is called Triabetes Clinic.

Ramadan fasts and Diabetes

Ramadan and Diabetes

Fasting during the holy month of Ramadan is an important spiritual practice.  When you have diabetes, you may be wondering how fasting will affect your diabetes.  There is a lot of misinformation about diabetes and Ramadan.  This handout is written to answer some of the most common questions. 

Does everyone have to fast?

No.  This is based on the Holy Quran as well as the teachings of Islamic religious scholars over centuries. The Quran states that there are groups of people who do not have to fast, especially if it puts their health at risk.  This includes children, pregnant or breastfeeding women, the elderly and anyone who might make themselves ill by fasting.  This also includes people with poorly controlled diabetes, people with type 1 diabetes who take insulin or type 2 on a mixed insulin regimen or those who often have very high or very low blood glucose levels.  

I know many people with diabetes who fast and don’t have a problem.  Is it okay for me?

It is true, many people with diabetes can fast safely, but each person is different.   Part of the decision you will make with your doctor has to do with the kind of diabetes medicine you take.   It is important to schedule an appointment 2-3 months before Ramadan to discuss how fasting might affect your diabetes.  Your doctor or healthcare provider may suggest a change in your medication plan. 

What risks should I be aware of?

These are the key risks:
• Low blood glucose (or hypoglycemia) – The risk of blood glucose levels going too low is highest in people taking insulin or certain diabetes pills. Limit physical activity during fasting hours and be more active after sunset.  Talk with your healthcare provider to find out if your medicine puts you at risk for low blood glucose and discuss how to prevent it.
• High blood glucose (or hyperglycemia) – While low blood glucose levels may happen during the day, after the fast is broken, there is a greater risk to overeat.  Watch out for eating too many sweets and keep the portion sizes moderate.   Even though Ramadan is known as a time of fasting – it is not uncommon for people to gain weight during this month, as in some families, every evening meal is a celebration.
• Dehydration – This is especially a problem during the longer and hotter summer days.  Aim to drink sugar free and caffeine free drinks frequently throughout the evening and before dawn. 

I was told to not check my blood glucose during the day as it will break the fast. Is that true?

Checking blood glucose will not break a fast!    It is important to monitor blood glucose levels especially to identify a low glucose level.  A fast will have to be ended if glucose levels fall too low (below 70 mg/dl)

How is low blood glucose treated?

If glucose levels do fall below 70, take 15 grams of carbohydrate in the form of one of these:  4 glucose tablets, 6 oz regular soda, 4 oz fruit juice or 1 tube glucose gel.  Wait 15 minutes and recheck again.  Follow with a snack if the evening meal is not for more than an hour.  

Do I stop taking medicine during Ramadan?

No.  You continue taking your diabetes medicine, but you will take it at different times.  Your dose may also change.    This is one reason why it is very important to talk with your healthcare provider several months before Ramadan so you can plan ahead for how your diabetes medicines may need to change.

How do I plan my meals since I’m only eating twice a day?

The dawn meal (Suhoor) should contain a balance of whole grain sources of starchy carbohydrates as well as some protein and fat to help slow the digestion and help the feeling of fullness last as long as possible into the day.   Healthy breakfast options good for the hot summer month of Ramadan include:
• Whole grain cereal, low-fat milk, cottage cheese with sliced peaches topped with toasted almonds
• Plain Greek Yogurt flavored with blueberries and cinnamon, whole wheat toast with nut butter.
• Foul (a hearty middle eastern breakfast dish made of lentils or fava beans), small serving of sliced fruit
• Whole wheat roti (unleavened bread) and egg khagina (a southeast Asian dish)

Traditionally the fast is broken (Iftar) after sunset and begins with the eating of dates and drinking water.  Limit dates to 1-2 each evening.  Drink plenty of water and sugar free beverages though out the evening, but avoid caffeine beverages as they can be dehydrating. 

While the iftar meal is a celebration time, aim to not overeat.  Discuss a plan with your dietitian.  Keep sensible portions in mind and follow the same guidelines for healthy eating that you do the rest of the year with an emphasis on whole grains, lean sources of meat, fish and poultry, small amounts of heart healthy fats and limit added sugars.

Ramadan fast can put Muslims with diabetes at risk

Tears ran down the cheeks of an elderly Asian man sitting in his hospital bed during Ramadan last year as he sought reassurance from Muslim chaplain Siddiq Diwan because he could not participate in the annual religious month-long fast.

"I know I am ill and do not have to fast, Imam," the old man said to Diwan at Manchester Royal Infirmary. "But I have never missed one in seven decades, and I really feel bad about it."

While this patient had reluctantly accepted that fasting was not an option for him, thousands of Muslims with diabetes in the UK go ahead regardless. Many will put themselves at risk of serious illness and dangerous complications by taking part in the Ramadan fast (beginning on 28 June) when they go without food, water and even medication between sunrise and sunset – despite the fact that the Qur'an makes exceptions for the sick, pregnant women, children and anyone for whom it would cause physical harm.

As an Imam working at the hospital, Diwan sees the Ramadan dilemma from both sides, and works to resolve issues both in local mosques and among the city's health professionals.

His experiences are echoed in the UK's first study on the beliefs and experiences of Muslims with diabetes during Ramadan, being carried out by Manchester University-based 

psychologist

 Dr Neesha Patel. The results, published in the journal Health Expectations, highlight the intense pressures felt by individuals with diabetes during the period, from family,culture, religion and their own conscience.

More than half the diabetics in Patel's study still fasted; many continued to do so through a sense of obligation, the need to conform or a belief that the Qur'an demanded it. Some altered their own medication during the period of Ramadan – mostly without the advice of their GP orpractice nurse. Some were put under family pressure to follow the fast, while others felt the need to conceal their decision not to fast by snacking in secret.

This problem will not go away on its own. Patel says: "Ramadan is anannual event – it is going to be with us forever. There is a large Muslim population in the UK and the level of diabetes in some of the communities is many times higher than in the UK generally. This is a big issue. For change to happen there needs to be government support."

The UK has a population of 2.7 million Muslims, of whom 325,000 have diabetes. The South Asian population has six times the general rate of the condition. This year the holy month of Ramadan falls in the summer, and fasters in parts of the northern hemisphere will face periods without food or water that last up to 21 hours. These long periods of abstinence will feature for the next 10 years.

Fasting in itself can sometimes be beneficial to health and for many people Ramadan is an intensely spiritual time. But many health professionals are worried about a lack of formal guidance from Islamic as well as health leaders.

Vascular surgeon Dr Noreen Khan is a practising Muslim from northLondon, interested in fasting, who sees people with end-stage diabetes. She believes that diabetics with good glycaemic control can fast safely if GPs revise their medication at least a month before Ramadan, in some cases temporarily substituting longer-acting drugs.

But she says: "In the UK our scholars and theologians have not been prepared to make any rulings. Muslim scholars should give a consensus and provide all GPs with this information, so that they can give patients both medical and religious guidelines."

GP Dr Faizan Ahmed from Moss Side Family Medical Practice in Manchester agrees there is a need for clarity. He says: "At the moment there is a social stigma in some community groups about not fasting, and the onus is very much on the individual to make a decision."

Since 2010, his practice has invited all patients known to be Muslim for a pre-Ramadan review of their health and medication. This he described as a "watershed", with fewer patients ending up in A&E since, and some taking the decision for the first time not to fast because of their health problems.

In the absence of national health guidelines, Diabetes UK, in collaboration with the Muslim Council of Britain, has produced culturally-sensitive material for people who want to fast, and scripts for Imams. This year the charity is sending volunteers into five largely Islamic areas during Ramadan, with the aim of reducing diabetic complications.

Maslaha – an organisation which aims to help Muslims with the dilemmas of living in a western society – has produced award-winning medical and Islamic information in partnership with Tower Hamlets primary care trust about safe fasting.

Medical training does not cover Ramadan. Trainee GP Dr Iyegbe Iredia admits that as a Catholic she was taken aback by her first patient queries about Ramadan: "I would encourage people to fast if they want to, but the advice is all a bit ad hoc at the moment. GPs need clear guidelines, and it would be good to have somewhere to send complex Muslim patients for expert advice."

What does the act of fasting during Ramadan represent in Islam?
Ramadan is important for practicing Muslims, as it is one of the five pillars of Islam and the month in which the holy Quran was revealed. During Ramadan, Muslim people only eat two meals per day, once before sunrise (sehar) and one after sunset (iftar).

Should all Muslims fast during Ramadan?

The Islamic law states that the ‘sick’ can be exempt from fasting for one or all 30 days and give money to the poor, but some Muslims with diabetes may not perceive themselves as being ‘sick’ and will choose to fast. A tension will often exist among Muslims with diabetes who wish to observe Ramadan in accordance with their faith and the competing need to manage their health. This was evident in my recent research, which was the UK's first study on the beliefs and experiences of Muslims with diabetes during Ramadan.

Are there health benefits to fasting?

Fasting during Ramadan is a spiritual time that is believed to teach morals, self-discipline and a time for reflecting on one’s relationship with Allah and fellow people. Currently there are no national guidelines on the benefits of fasting for people with diabetes but there is some evidence to suggest that fasting may be beneficial to health in the general population.

Are there any health risks?

As Ramadan currently falls in the summer and spring months, and will do for the next eight years, daylight lasts between 17 and 19 hours, thus increasing the number of fasting hours. This poses extreme difficulty for Muslims with diabetes that need to eat and take medication regularly to maintain glyceamic control.

Short-term risks of fasting include poor diabetes control (high or lowblood sugars levels) and dehydration.

Long-term risks include mortality, morbidity and reduced quality oflife, but this needs further research to assess the size of the problem in the UK.

Some guidelines have been developed by clinicians working in diabetes to help identify patients at high, moderate and low risk with recommendations for education and pre-Ramadan medical assessments for all Muslim patients wishing to fast, in order the reduce the above risks.

What advice would you give to diabetic Muslims?

To contact Diabetes UK as they have produced culturally-sensitive material, in collaboration with the Muslim Council of Britain on managing diabetes safely for people who wish to fast. Diabetes UK also recommend that people discuss fasting with their General 

Practitioner

 for practical advice on altering their diet and medications, and to speak to their Imam, as Imams often provide support and guidance in accordance with the Quran.