A real-time, mobile phone-based telemedicine system to support young adults with type 1 diabetes.

Telemedicine systems have been proposed as a means of supporting people with diabetes in the self-management of their condition. Requirements for monitoring parameters of care, including glycaemic control, extent of analysis and interpretation of data, patient-clinician contacts, and involvement of a multidisciplinary care team with effective communication, can be addressed by telemedicine systems. We describe the development and implementation of an innovative real-time telemedicine system based around transmission and feedback of data to and from a mobile phone. Proprietary Java-based programs were used to link a blood glucose meter to a mobile phone. In addition to immediate transmission of blood glucose data, information about insulin dose, eating patterns and physical exercise were collected. Immediate feedback to the phone included a colour histogram to draw attention to levels of control over glycaemia over the previous two weeks. Clinicians supporting patients had access to summary screens identifying users not testing, and those with levels of blood glucose outside pre-defined limits. More detailed graphical displays of data were used to provide data about control of insulin dose and the degree to which it was modified in response to diet and exercise. The system has been evaluated in a clinical trial conducted in secondary care and is now being adapted for use in a trial in primary care, which is designed to assess its effectiveness in providing integrated management for the patient, general practitioner and pharmacist.

A randomized controlled trial of the effect of real-time telemedicine support on glycemic control in young adults with type 1 diabetes (ISRCTN 46889446).

OBJECTIVE: To determine whether a system of telemedicine support can improve glycemic control in type 1 diabetes. RESEARCH DESIGN AND METHODS: A 9-month randomized trial compared glucose self-monitoring real-time result transmission and feedback of results for the previous 24 h in the control group with real-time graphical phone-based feedback for the previous 2 weeks together with nurse-initiated support using a web-based graphical analysis of glucose self-monitoring results in the intervention group. All patients aged 18-30 years with HbA(1c) (A1C) levels of 8-11% were eligible for inclusion. RESULTS: A total of 93 patients (55 men) with mean diabetes duration (means +/- SD) 12.1 +/- 6.7 years were recruited from a young adult clinic. In total, the intervention and control groups transmitted 29,765 and 21,400 results, respectively. The corresponding median blood glucose levels were 8.9 mmol/l (interquartile range 5.4-13.5) and 10.3 mmol/l (6.5-14.4) (P < 0.0001). There was a reduction in A1C in the intervention group after 9 months from 9.2 +/- 1.1 to 8.6 +/- 1.4% (difference 0.6% [95% CI 0.3-1.0]) and a reduction in A1C in the control group from 9.3 +/- 1.5 to 8.9 +/- 1.4% (difference 0.4% [0.03-0.7]). This difference in change in A1C between groups was not statistically significant (0.2% [-0.2 to 0.7, P = 0.3). CONCLUSIONS: Real-time telemedicine transmission and feedback of information about blood glucose results with nurse support is feasible and acceptable to patients, but to significantly improve glycemic control, access to real-time decision support for medication dosing and changes in diet and exercise may be required.

The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes.

OBJECTIVE: To describe the clinical outcomes of adolescent and young adult female subjects with type 1 diabetes in relation to the disturbance of eating habits and attitudes over 8-12 years. RESEARCH DESIGN AND METHODS: Patients were recruited from the registers of pediatric and young adult diabetes clinics (including nonattenders) and interviewed in the community. A total of 87 patients were assessed at baseline (aged 11-25 years), and 63 (72%) were reinterviewed after 8-12 years (aged 20-38 years). Eating habits and attitudes were assessed by a semistructured research diagnostic interview (Eating Disorder Examination). RESULTS: Clinical eating disorders ascertained from the interview and/or case note review at baseline or follow-up were found in 13 subjects (14.9% [95% CI 8.2-24.2]), and an additional 7 subjects had evidence of binging or purging, bringing the total affected to 26%. Insulin misuse for weight control was reported by 31 (35.6% [25.7-46.6]) subjects. Overall outcome was poor; serious microvascular complications were common and mortality was high. There were significant relationships between disordered eating habits, insulin misuse, and microvascular complications. CONCLUSIONS: Although the cross-sectional prevalence of clinical eating disorders in young women with diabetes is modest, the cumulative incidence of eating problems continues to increase after young adulthood, and this is strongly associated with poor physical health outcomes. The combination of an eating disorder and diabetes puts patients at high risk of mortality and morbidity. Better methods of detection and management are needed.

Poor prognosis of young adults with type 1 diabetes: a longitudinal study.

OBJECTIVE: To determine the role of early behavioral and psychological factors on later outcomes in young adults with childhood- or adolescent-onset type 1 diabetes. RESEARCH DESIGN AND METHODS: We conducted a longitudinal cohort study of patients recruited from the register of the young adult outpatient diabetes clinic, Oxford, U.K. A total of 113 individuals (51 male subjects) aged 17-25 years completed assessments, and 87 (77%) were reinterviewed as older adults (aged 28-37 years). Longitudinal assessments were made of glycemic control (HbA(1c)) and complications. Psychological state at baseline was assessed using the Present State Examination and self-report Symptom Checklist, with corresponding interview schedules administered at follow-up. RESULTS: There was no significant improvement between baseline and follow-up in mean HbA(1c) levels (8.5 vs. 8.6% in men, 9.3 vs. 8.7% in women). The proportion of individuals with serious complications (preproliferative or laser-treated retinopathy, proteinuria or more severe renal disease, peripheral neuropathy, and autonomic neuropathy) increased from 3-37% during the 11-year period. Women were more likely than men to have multiple complications (23 vs. 6%, difference 17%, 95% CI 4-29%, P = 0.02). Psychiatric disorders increased from 16 to 28% (20% in men, 36% in women at follow-up, difference NS), and 8% had psychiatric disorders at both assessments. Baseline psychiatric symptom scores predicted follow-up scores (beta = 0.32, SE [beta] 0.12, P = 0.008, 95% CI 0.09-0.56) and recurrent admissions with diabetic ketoacidosis (odds ratio 9.1, 95% CI 2.9-28.6, P < 0.0001). CONCLUSIONS: The clinical and psychiatric outcome in this cohort was poor. Psychiatric symptoms in later adolescence and young adulthood appeared to predict later psychiatric problems.