Health IT Conference. Scribe (www.scribeofegypt.com)

1. The Application of Mobile Health to Diabetes
Management: Opportunities and Challenges.
William E. Winter, MD
Departments of Pathology & Pediatrics
University of Florida
Gainesville, FL 32610-0275
winter@pathology.ufl.edu

2. What disease is becoming epidemic in developed and
developing countries?
Diabetes mellitus - A family of disorders characterized by
chronic hyperglycemia and the development of chronic
complications
Pathophysiology
Decr. insulin action -- > hyperglycemia
Insulin action = [Insulin] x Ins. sensitivity
Type 1 DM 10% Absolute decr.
Type 2 DM 90% Relative decr. Decr.
William E. Winter, MD winter@pathology.ufl.edu

3. How common is diabetes mellitus throughout the world?
World Health Organization (WHO) - Key facts (August 2011)
- Worldwide cases: 346 million
- Deaths from incr. glu. ~3.4 million (2004)
- Diabetes deaths. >80% in low- and
middle-income countries
-WHO projection. By 2030, deaths will incr.
2 fold c/w 2005
http://www.who.int/mediacentre/factsheets/fs312/en/index.html

4. How common is diabetes mellitus in Egypt?
International Diabetes Federation (IDF, for 2010)
- 11.4% of Egyptians have diabetes.
Diabetes frequency in MENA (Middle East and North Africa):
Algeria: 8.5%
Iran: 8.0%
Iraq: 10.2%
Jordan: 10.1%
Lebanon: 7.8%
Morocco: 8.3%
Saudi Arabia: 16.8%
Tunisia: 9.3%
United Arab Emirates: 18.7%
http://www.novonordisk.com/images/about_us/changing-diabetes/PDF/Leadership%20forum%20pdfs/MENA%20Forum/Diabetes%20in%20the%20Middle%20East%20and%20Northern%20Africa%20+%20DAS.pdf

5. How common is type 1 diabetes in Egypt?
Incidence is intermediate: 8-16 cases/106
William E. Winter, MD winter@pathology.ufl.edu

6. Why is T1DM so difficult to treat?
Plasma glucose is highly regulated:
Excess --- > Diabetes/complications
Deficiency --- > CNS impairment/death
Plasma glucose pool turns over 4 x/hr (~100 fold per day)
Glucose intake is episodic (meals)
Glucose utilization can be highly variable (acticity)
Balance: maintained by insulin (2ndly by glucagon)
Islets: 1-2 grams!
William E. Winter, MD winter@pathology.ufl.edu

7. Glucose input
- Gut
- Liver
Incretins
[Glucose]
Glu/protein
Beta cells Glucose clearance
ANS - Brain
- Skeletal muscle
- Hormonal control
Insulin - Activity
- Adipose tissue
- Liver
William E. Winter, MD winter@pathology.ufl.edu

8. What are the goals in treating T1DM?
- Avoid hospitalization
- Maintain daily health and activities
avoid symptoms & hypoglycemia
children: normal growth & development
women: normal pregnancy
- Maintain ideal or near ideal glucose
target A1c: <7%
- Delay/prevent long term complications
- “Cure” diabetes
William E. Winter, MD winter@pathology.ufl.edu

9. How can mhealth be applied to improving diabetes care?
Information collection
Disease education
Disease-related alerts and reminders
Integration of social media functions
Disease-related data export
Synchronization w/ PHR (personal health record)
William E. Winter, MD winter@pathology.ufl.edu

10. How can mhealth be applied to information collection?
Self-monitoring data collection
Information w/ immediate effects – recent & historic data
Blood glucose
Ketones (urine, blood)
Medications
Diet
Activity
Hypoglycemic events
Information w/ longer term effects – recent & historic data
Weight
Blood pressure
William E. Winter, MD winter@pathology.ufl.edu

11. How can the data be acquired?
Patient acquires data and inputs data
- SMBG
- Diet recording – touch screen; +/- labor intensive
- Activity recording – touch screen – accuracy (?)
Device acquires data and inputs data
- Glucose
- Device interfaces w/ mobile device
- CGMS: continuous glucose monitoring
- Diet – photo recognition?
- bar-code scanning?
- Activity - Accelerometer
- compensation for transportation (?)
William E. Winter, MD winter@pathology.ufl.edu

12. What can be done with the data?
Patient decides on management
- Variable ability of patients to
- to make the right decisions
Patient & medical team or computer decide on
management Monitor progress between visits
William E. Winter, MD winter@pathology.ufl.edu

13. How can mhealth be applied to disease education?
Disease education
Generic
Blood glucose
Diet
Activity
Medications
Hypoglycemic events
Weight
Blood pressure
Complications
Pregnancy
Personalized
Specific to the patient
William E. Winter, MD winter@pathology.ufl.edu

14. How can mhealth be applied to alerts and reminders [e.g.,
SMS (short message service)]?
Disease-related alerts and reminders
Generic
Blood glucose goals
A1c goals
BP goals
When to screen for retinopathy
When to screen for nephropathy
When to screen for diabetes in pregnancy
Personalized
Specific to the patient
William E. Winter, MD winter@pathology.ufl.edu

15. How can mhealth be used to integrate social media
functions?
Facebook, Twitter
Finding individuals or groups w/ similar challenges
- Advice on treatment
- Support group
William E. Winter, MD winter@pathology.ufl.edu

16. How can mhealth be applied to data export?
Disease-related data export
Data sent to --- > central locale for storage / retrieval
Data sent to --- > physician, nurse, physician
assistant, diabetes educator,
dietician, psychologist, etc.
Interface w/ patient
William E. Winter, MD winter@pathology.ufl.edu

17. How can mhealth be applied to improving diabetes care?
Synchronization w/ PHR (personal health record)
Patient takes a role in their PHR and directly
contributes to their PHR
William E. Winter, MD winter@pathology.ufl.edu

18. Concerning diabetes, what software (apps) for mobile
devices are available?
Chomutare et al.
Features of mobile diabetes applications: review of the
literature and analysis of current applications
compared against evidence-based guidelines.
Journal of Medical Internet Research. 2011, 13(3).
University of North Norway, Tromso, Norway; University of
Tromso; Northern Research Institute, Tromso, Norway
William E. Winter, MD winter@pathology.ufl.edu

19. iTunes diabetes apps
Numbers of apps:
N
2009 60
2011 260 (>400% incr.)
William E. Winter, MD winter@pathology.ufl.edu

20. iTunes diabetes apps
Studied 137 apps: Features
Insulin or medication tracking 65%
Diet tracking 50%
Activity tracking 40%
Weight tracking 39%
Synchronization 29%
Education module 20%* Low
Social media integration 15%
Disease-related reminders 12%
* Only 7/27 (26%) - personalized Low
William E. Winter, MD winter@pathology.ufl.edu

21. Examples of diabetes apps ------ >
Cost
Glucose Buddy Free
Carb Counting with Lenny Free
Diabetes Companion $0.99
Blood Sugar Diabetes Control $0.99
Vree for Diabetes $1.99
BGluMon $1.99
Track 3 $5.99
Diabetes Buddy $2.99
Diabetes Sugar Level Tracker $1.99
Glucose Tracker $0.99
William E. Winter, MD winter@pathology.ufl.edu

22. Can a glucose meter be attached to the mobile device?
William E. Winter, MD winter@pathology.ufl.edu

23. Can a glucose meter be attached to the mobile device?
William E. Winter, MD winter@pathology.ufl.edu

24. What are the challenges in achieving improved glycemic
control in people w/ T1DM diabetes?
Treatment -- > complex
- Insulin
- Diet (total calories, composition, timing of meals)
- Activity
Balance must be achieved between hypo & hyperglycemia
Possible “cure” artifical closed loop pancreas
William E. Winter, MD winter@pathology.ufl.edu

25. Closed loop system “artificial pancreas”
- Description: continuous glucose sensor linked
to insulin-delivery device
Glu.
meter
Insulin
infusion
pump
William E. Winter, MD winter@pathology.ufl.edu

26. What are the knowledge deficits regarding the use of
mobile devices in the treatment of diabetes?
Little data that mobile devices improve outcome (EBM)
~Almost all apps -- > no outcome data
Professional organizations (e.g., ADA) are just beginning
to provide apps
Unclear: Qualifications of the app author
Review of app by scientific body
Other issues:
- Privacy
- Security
William E. Winter, MD winter@pathology.ufl.edu

27. THANK YOU
William E. Winter, MD winter@pathology.ufl.edu