Transforming the treatment of diabetes

Technology may help to provide more supportive, efficient, and effective care for diabetes, a leading contributor to heart disease.

About one of every 11 adults in this country has diabetes — a chronic, costly condition that's closely connected to heart disease. Lifestyle changes that encourage eating healthy foods, exercising, and losing weight are the cornerstone of managing both problems. But making those changes can often feel overwhelming and frustrating, especially for people with diabetes. They also need to keep tabs on their blood sugar levels, which are influenced by what and when they eat and exercise.

And getting effective support for managing diabetes with lifestyle changes isn't easy. "The current system for managing diabetes is broken," says Dr. Osama Hamdy, medical director of the Obesity Clinical Program at Harvard-affiliated Joslin Diabetes Center. For starters, there aren't nearly enough endocrinologists for the millions of people with diabetes in this country. Appointments with these specialists are often too short and too infrequent for people to make meaningful progress, he explains.

In addition, the diabetes treatment guidelines focus mostly on medications, which are very expensive. People with diabetes often take three to five oral medications, and some also require insulin to control their blood sugar. "But if we give people the support they need to lose weight through lifestyle changes, we can manage their disease very effectively with fewer medications," says Dr. Hamdy.

A high-tech fix?

The key is using state-of-the-art technology, which can make life easier for both patients and their physicians. This model relies on telemedicine to create a "virtual diabetes clinic," Dr. Hamdy explains. A pilot program he pioneered at Joslin, called Joslin Home, is centered around short, frequent visits with a health care provider — all delivered live but through a smartphone, tablet, or computer. The great thing about virtual visits is that you can do them anywhere — at home or anywhere else you happen to be. There's no need block off half of your day to drive through traffic, park, wait to see the doctor, and drive home.

The appointments are scheduled every one to two weeks and can be with anyone on the diabetes care team: a physician, nurse practitioner, diabetes educator, exercise physiologist, or behavioral therapist. They last just five to 10 minutes and focus on five questions:

1. What's your blood sugar?
2. Are you following your diet plan?
3. Are you following your exercise plan?
4. Are you taking your medications?
5. What do you need from this visit?

The tools you need

"We send people a blood glucose meter to test their blood sugar, and they send the result to a cloud-based server so the doctor can see it. If the result isn't added, that triggers an automated reminder to do a blood sugar check," says Dr. Hamdy. A smartphone app provides this feature, along with a detailed lifestyle intervention plan. For example, there's an animated figure that demonstrates exercises and shows you what a healthy meal looks like. You can also use the app to communicate directly with your pharmacy to schedule medication refills.

The app is based on the Why WAIT (Weight Achievement and Intensive Treatment) program developed at Joslin, which draws from 12 years of published evidence and has helped hundreds of people lose weight and manage their diabetes. The interface was developed by designers from two major entertainment companies, Warner Brothers and Pixar.

Advice and accountability

To lose weight and keep it off, people need uncomplicated advice and lots of encouragement, says Dr. Hamdy. Extreme versions of any diet — low-carb, low-fat, or low-calorie — are simply too restrictive; people just can't stick to those eating patterns over the long haul. "We provide menus that include common foods that people eat every day but decrease the carbohydrate and increase the protein and control the portions," he explains.

The exercise program is tailored to a person's individual needs, but a sample regimen features 10 minutes of stretching in the morning, a brisk 10-minute walk after lunch, and 10 minutes of strength exercises using a resistance band in the evening.

The frequent check-ins with providers help to make people accountable. Just as you brush your teeth before seeing your dentist, you're more likely to stick with your healthy habits if you know someone's going to be seeing your blood sugar results. In fact, people with diabetes tend to be more motivated than people who are only overweight, because they can immediately see changes in their blood sugar related to their lifestyle changes, Dr. Hamdy says.

However, if your progress is slow at first, there's no blame or guilt. "We just keep encouraging them and trust that they'll see results. When they do, they stick with the program," he says.

In four months, people following the Why WAIT program lose an average of 7.7 pounds, and their HbA1c level drops by 0.7 points on average, says Dr. Hamdy (see "What is HbA1c?"). If you can lose 7% of your body weight and maintain that loss for a year, the cost of treating your diabetes drops by 44%.

Right now, the WhyWAIT app (see www.healthimation.com) offers a free one-week trial. After that, it costs $49.99 per month for the first three months, then $10 monthly after that. Unlike generic weight-loss apps, the meal and exercise plans are individualized and based on a comprehensive evaluation of the user. But it doesn't include access to a health care professional.

The payment model for the entire Joslin Home program — including the real-time virtual visits with health care providers and blood sugar monitoring — is still a work in progress. But Dr. Hamdy is currently in discussions with one of the nation's largest health insurance companies to explore ways to provide the plan for its members.

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