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Robin Goland M.D. and Ruth S. Weinstock M.D. Ph.D.
Introduction
Diabetes mellitus is increasing in prevalence, and now considered an epidemic. It is estimated that 17 million Americans have diabetes, and at least 16 million have pre-diabetes. There are 1 million new patients diagnosed every year. This is a potentially devastating disease, and remains a leading cause of adult blindness, nontraumatic amputations and end stage renal disease. People with diabetes are at increased risk of developing coronary artery disease, congestive heart failure, stroke and peripheral vascular disease. An estimated 65% of individuals with diabetes die of cardiovascular disease.
Self-management training and appropriate therapy can reduce cardiovascular morbidity and mortality, amputation rates, progression of renal disease and blindness. This requires adherence to standards of care and practice guidelines, and includes attention to blood pressure control, glycemic control, lipid levels, and appropriate foot and eye care. These guidelines as well as timely updates are now available to providers electronically. Telemedicine can provide home tele-visits to patients, delivering educational and monitoring services as they are needed, and providing rapid feedback and intervention, which is especially important for individuals with poor access to care. Diabetes is therefore a model chronic disease for the use of telemedicine.
The Use of Telemedicine to Provide Patient Education
Optimal care of patients with diabetes includes education about diabetes and nutritional principles and education about self-management skills, including home blood glucose monitoring and insulin injection techniques. Telemedicine can be used to provide education to patients with diabetes in all of these areas. The American Diabetes Association offers a recognition program for diabetes education programs that provide a curriculum that meets the published national standards. This diabetes education curriculum, including education about causes of diabetes, indications, mechanisms of action and side-effects of medications, how to recognize and treat high and low blood sugars, how to screen for, prevent, and treat diabetic complications, and rationale for diabetes self-care techniques, can be delivered via telemedicine. Similarly, general nutritional principles and meal planning can be communicated via telemedicine. Individual visits can be provided so that patients can learn to optimally match their diet with exercise and medication and optimally control blood glucose, lipid and blood pressure levels.
Education about diabetes self-management techniques can be provided via home tele-visits. Instruction in home blood glucose monitoring, including use of the glucose meter, techniques for obtaining the capillary blood sample, and use of the results can all be delivered via telemedicine. In addition, proper techniques for drawing up insulin and insulin injection with either syringes or insulin pens can be offered at a tele-visit.
Diabetes-Related Web Sites for Patients
There are many diabetes-related sites on the Internet for individuals with diabetes. Listed below are examples of sites found to be informative and reliable.
www.diabetes.org
The American Diabetes Association maintains this site. It provides basic diabetes information, community resources, news items related to diabetes, recipe of the day, information about healthy living, and online shopping for their publications. Information in Spanish is available.
www.cdc.gov/diabetes
The Centers for Disease Control and Prevention maintains this site. This site contains general information about diabetes, national fact sheet and diabetes-related statistics.
www.niddk.nih.gov/health/diabetes
The National Institute of Diabetes & Digestive & Kidney Diseases maintains this site. Information is available on >35 topics, and include a Diabetes Dictionary, information about the different types of diabetes, alternative therapies, and diabetes-related complications. Some of these materials are also available in Spanish. Easy to read publications, statistics, fact sheets, a diabetes newsletter (Diabetes Dateline) and information about clinical trials and financial help for diabetes care are available.
www.niddk.nih.gov/health/nutrit/win.htm
The Weight-control Information Network (WIN) maintains this site, and provides information about weight control, obesity and related nutrition issues.
www.va.gov/diabetes
The Veterans Health Administration provides information for veterans with diabetes at the web site. General information, as well as information of special interest to veterans (such as Agent Orange and Diabetes) are available.
www.nei.nih.gov
The National Eye Institute maintains this site, and provides information related to diabetic eye disease.
www.ndep.nih.gov
The National Diabetes Education Program maintains this site. It provides diabetes information including Spanish- and Asian–language materials. Partners include the National Institute of Diabetes and Digestive and Kidney Disease, The Centers for Disease Control and Prevention, and numerous other organizations.
www.fda.gov/diabetes
The Food and Drug Administration maintains this site. It lists information on new diabetes-related products including medications, glucose meters, lancing devices and sharps disposal, and discusses food and meal planning, diabetes complications and other resources.
www.eatright.org
The American Dietetic Association maintains this site, which includes nutrition and lifestyle tips and fact sheets and guide.
www.jdrf.org
The Juvenile Diabetes Research Foundation maintains this site, and includes general information and news releases about diabetes.
www.diabetes-exercise.org
The Diabetes Exercise and Sports Association maintains this site, which discusses issues related to exercise and nutrition.
www.joslin.org
The Joslin Diabetes Center maintains this site. It provides free online classes, as well as diabetes news, research information, and an online store.
www.endo-society.org
The Endocrine Society maintains this site, which provides patient fact sheets on common endocrine diseases and disorders including diabetes.
www.aace.com
The American Association of Clinical Endocrinologists maintains this site, which provides information and webcasts about common endocrine diseases including diabetes.
The Use of Telemedicine for Diabetes Case Management
In addition to providing diabetes education, telemedicine can be used to provide diabetes case management to patients with diabetes. A diabetes nurse educator often serves as a case manager for patients with diabetes, and helps to coordinate the care as well as to help the patient with self-management procedures and strategies. In some care models, the case manager alone or in collaboration with a physician, directs the titration of diet, exercise and medications to optimize control of blood sugar, blood lipids, blood pressure and weight. The use of telemedicine allows for diabetes case management at a distance in cases where in-person case management visits are not available or not feasible.
For example, a patient with type 2 diabetes may be referred for tele-visits with a nurse case manager. The case manager will work with this patient to modify diet and increase level of activity as individually indicated. Techniques for smoking cessation may be offered as well as continued follow-up and support for the patient who quit smoking. Instruction may be provided in proper foot care, in home glucose monitoring, and in home blood pressure monitoring. The patient may communicate blood glucose and blood pressure results to the case manager and in turn receive advice about changes in medication either from the case manager or the physician. The case manager will provide on-going support and follow-up to help the patient maintain adherence with their regimen, so important in management of a chronic disease.
Diabetes-Related Web Sites for Providers
Diabetes-related resources are available on the internet for health care providers. Sites that have been helpful and reliable include the following:
www.diabetes.org
The American Diabetes Association maintains this site. Updated Clinical Practice Recommendations, from the January supplement of Diabetes Care, can be found on-line. News about diabetes, an on-line store with books for health care professionals, and on-line versions of Diabetes, Diabetes Care, Clinical Diabetes, and Diabetes Spectrum are available.
www.va.gov/diabetes
The Veterans Health Administration clinical practice guidelines for the management of diabetes in the primary care setting, which are algorithmic and evidence-based, are available at this site.
www.cdc.gov/diabetes
The Centers for Disease Control and Prevention maintains this site. This site contains statistics about diabetes including national fact sheet, information about state-based programs, and special research and public awareness projects.
www.niddk.nih.gov/health/diabetes
The National Institute of Diabetes & Digestive & Kidney Diseases maintains this site. General diabetes information, statistics and a newsletter (Diabetes Dateline)
are available, as well as information about clinical trials, research funding opportunities, and special reports and testimony to Congress.
www.niddk.nih.gov/health/nutrit/win.htm
The Weight-control Information Network (WIN) maintains this site, and provides information about weight control, obesity and related nutrition issues.
www.nei.nih.gov
The National Eye Institute maintains this site, and provides information related to diabetic eye disease.
www.ndep.nih.gov
The National Diabetes Education Program maintains this site. It provides diabetes materials in English, Spanish- and Asian–language, and provides reference tools for providers. Information concerning awareness campaigns and programs are available. Partners include the National Institute of Diabetes and Digestive and Kidney Disease, The Centers for Disease Control and Prevention, and numerous other organizations.
www.fda.gov/diabetes
The Food and Drug Administration maintains this site. It lists information on new product approvals and upcoming panel meetings, as well as information on diabetes-related products including medications, glucose meters, lancing devices and sharps disposal.
www.ncbi.nlm.nih.gov
The National Library of Medicine research service, PubMed, resides at this site. PubMed allows the user to search and retrieve millions of MEDLINE citations.
www.jdrf.org
The Juvenile Diabetes Research Foundation maintains this site, and includes general information, legislative activities and news releases about diabetes.
www.diabetes-exercise.org
The Diabetes Exercise and Sports Association maintains this site, which discusses issues related to exercise and nutrition.
www.joslin.org
The Joslin Diabetes Center maintains this site. It provides online courses for health professionals, as well as diabetes news, research information, and an online store.
www.idf.org
www.who.int/ncd/dia
The International Diabetes Federation and the World Health Organization maintain these sites, which include information and statistics about diabetes in countries throughout the world.
www.aadenet.org
The American Association of Diabetes Educators maintains this site, which includes a product catalog and information about continuing education opportunities.
www.endo-society.org
The Endocrine Society maintains this site, which provides information about continuing medical education services, Endocrine Journals online, and news releases.
www.aace.com
The American Association of Clinical Endocrinologists maintains this site, which provides access to AACE publications, continuing education opportunities and other services.
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