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Apps and Diabetic Management

By: Matt Byrd

BHIS 528

University of Illinois at Chicago

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Abstract

This paper is going to examine the opportunities, possible benefits and limitations of using apps

in mobile health (mHealth) to help manage diabetes. It will also offer a framework of what to

look for in a diabetic app to ensure the app is helping to empower the patient to better adhere

to all of their self-management guidelines.

Keywords: Diabetes, Diabetic Management, Applications, Apps, Healthcare Apps, Mobile

Health, mHealth, comprehensive diabetic management, disease management, chronic disease,

self-management, adherence

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Background

Both the Center of Disease Control (CDC) and the World Health Organization (WHO) list

diabetes as a top 10 cause of death in the United States and the World. According to the

American Diabetes Association (ADA) 29.1 million Americans, roughly 9% of the population,

suffer from diabetes and another 86 million people 20 and older are considered prediabetic

(2014). In looking at the top ten causes of death worldwide it is concerning to see that six

continue to grow in the number of lives they take each year; and diabetes is one of those

growing (WHO, 2014).

In addition to the problems diabetes cause for patients, and the number of deaths it is

responsible for each year, it is not just diabetes patients who suffer from its effects. Wodajo

says “The cost of managing chronic diseases is the largest portion of health care expenditures in

developed countries” (2011). In the United States, the ADA says total cost to manage diabetes

is $245 billion with $176 billion being direct medical costs and $69 billion coming from reduced

productivity of patients (2014).

What the prevalence and costs of diabetes shows is an opportunity and need to “develop cost

effective support tools and interventions for diabetes self-management” (Arsand, 2012).

Patients provide the majority of their care themselves and self-management apps can empower

the patient to take control of their chronic disease while providing the tools to do that. In

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addition, decisions that used to be made with a health care provider (HCP) every three months

can now be made quicker and in real time to help ensure better outcomes.

Patient Responsibilities

Diabetic patients are responsible for an extensive list of activities in managing their diabetes.

According to the Joslin Diabetes Center the comprehensive diabetes checklist patients should

follow includes: meal planning, self-monitoring blood glucose (BG) levels, medications, exercise,

knowledge of high and low BG levels and what to do in each case, foot care, sick day

management and urine testing for ketones (2014). In addition, there are nine tests they should

get at least once a year: A1C, kidney function, cholesterol (LDL, HDL and lipids), foot exam, eye

exam, blood pressure, physical, micro albuminuria and GFR.

Because of this, it is necessary to provide tools that will ensure that not only do patients record

information as they receive it, but, also, that the tools can serve as a reminder for the extensive

list of activities that ensure that patients stay compliant with their therapy. Sarasohn-Kahn says

“Studies on patient adherence to prescribed drug regimens have demonstrated that

compliance among patients with chronic illness may be as low as 20 percent” (2010). This can

be due to many factors, but by providing cost effective solutions that can help to improve

adherence patients may see a benefit in their health and society as a whole may see a

reduction in the amount of money spent on care.

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Opportunities/Benefits

In researching this topic, there are key opportunities that are leading to patients being able to

realize three important benefits. These opportunities are: cost, mobile broadband use and

access to information. In a study by Klonoff he said the average cost of apps looked at was

$2.86 with a range in price of $0.99-$6.99 (2013). While adherence to therapy is due to many

factors, by making it cheaper to find ways to help with adherence allows more people to

participate; breaking down socioeconomic barriers. For cost to matter patients must have the

device the app will run on and mobile broadband devices are rapidly growing with the

estimated number of devices in use currently around 1.5 billion. This number is expected to

quadruple in the next five years with every corner of the globe participating (Appendix 1). With

more people using mobile devices and the cost of the apps being cheap enough for anyone to

participate, more patients will have access to information and resources that will make a

difference in their care.

Because of the rise of mobile opportunities and access to information at a low cost three key

benefits are being realized by diabetic app users: tracking key categories of care, personalized

self-management and patient decision support. As mentioned in the Patient Data section,

diabetic patients are responsible for numerous areas in managing their care. The ability for an

app to help in managing this is big. Of the 71 apps Klonoff researched 100% tracked blood

glucose, 76% tracked medication, 68% tracked diet, 41% tracked exercise, 25% tracked weight

and 23% tracked blood pressure (2013). While not all of the areas important to care are

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included in the apps, the areas deemed most important appear in almost half of all apps

studied.

With the ability to track these care areas, it opens to the door for more personalized care in

managing a patient’s diabetes. If patients are able to show their health care provider (HCP)

specific numbers they have tracked between visits , more personalized goals can be set for each

patient instead of generic numbers all diabetics should try to adhere to. If a HCP would like a

patient under 100 on their LDL it does not make much sense to try for that as a goal if the

patient currently is around 200. By knowing their actual, up-to-date, number, it gives patients

and HCPs the opportunity to break the goals down into realistic pieces to aim for which can be

reevaluated at each visit. The point of the apps is not to cut the HCP out of the discussion, but,

rather to provide better data when discussing care and deciding on treatment.

While the diabetic app is not trying to cut the HCP out of the care process, it can offer decision

support in-the-moment for patients when needed. The majority of care a diabetic patient will

receive is self-managed throughout the year and sometimes there is not an ability to get in

touch with the HCP when it is necessary. “Without access to immediate data analysis or actual

treatment recommendations a patient must wait to see their HCP. By then, the patient might

be in a different metabolic state…” (Klonoff, 2013). Some apps do offer decision support based

on the information that is inputted, giving the patient evidenced based options in dealing with

different situations. Even if the app does not offer patient decision support, it does give an

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ability to see past numbers to help the patient determine a best course of action for them

based on preset plans they and their HCP have set up.

With the opportunities of low cost, growing mobile broadband markets and instant access to

information benefits in diabetic care are able to be realized. These benefits include tracking

key areas in diabetic care management, more personalized self-management and patient

decision support. As seen in 20 studies where apps were used without HCP feedback, patients

saw improvements in their HbA1c when using diabetic apps (Klonoff, 2013). Again this is not to

suggest that HCP involvement is not needed in the management of diabetes, but helps to show

the improvements in care that are possible when patients have tools available to them to

become more involved in their care.

Limitations/Concerns

As discussed above there are many benefits to using diabetic apps in helping to manage

patients’ diabetic care. While the benefits are promising, there are limitations and concerns to

the growing diabetic app market. One concern is the apps tend to focus on a part of care such

as diet, exercise or medication, but rarely combine all of these together in a way that would

better help in disease management. By forcing patients to use too many different apps to track

different behaviors and activities it may cause tool overload in the same way too much data

causes patients to freeze and lock up when they have information overload.

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A more serious concern is apps are ignoring evidenced based practices in the management of

diabetic care. Brandell says “As with mobile health apps in general, they too often ignore

evidence-based best practices. In a survey of over 973 diabetes self-management apps...there

are obvious gaps between the evidence-based recommendations and the functionality used”

(2013). One of these evidence-based best practices not being used enough is personalized

education. Klonoff, in a smaller sample of apps showed only 18% of apps offering education for

patients (2013). By increasing education available to patients through easy and accessible

means, such as an app on a mobile device, it may help patients in realizing the improvements

seen in data measurable from past studies.

While the improvements seen in studies of diabetic self-management apps is promising the lack

of apps involved in the studies is concerning. “…only 334 mobile health apps underwent clinical

trials between 1990 and 2010. Surprisingly, only 75 included a control group” (Brandell, 2013).

This may be due to the fact that mobile health apps are not considered devices, and, therefore,

do not need FDA approval to be used. However, in an industry that includes 97,000 health apps

growing at an annual rate near 40%, it would be nice to see more data on how these apps can

affect a patient’s health care.

The last concern at this time is very similar to the concerns with electronic medical records,

patient privacy. Not all apps fall under the Health Insurance Portability and Accountability Act

of 1996 (HIPAA). Apps where patients are entering their own information and using the app as

a log are not subject to HIPAA regulation. However, HIPAA does cover “mHealth applications

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where personal data are uploaded into a device or the Internet” (Klonoff, 2013). This means if

the app has the ability to interact with an EMR privacy of data should be more secure.

Best Apps Available

Healthline created a list of the top apps for diabetic management in 2014. This list of 11 apps

was chosen by Tracy Rosecrans and then medically reviewed by Kenneth R. Hirsch, MD. To help

figure out which apps were truly the best of the best I used the criteria from the Klonoff study

(Appendix B). In addition to this information, I added two categories, price and multiple

platforms. Price is important in making sure the tool is made available to all, and being

available on multiple platforms is important because with the increase in mobile devices

around the world the ability to adjust to multiple platforms is important in reaching the largest

amount of patients possible. In each category the app participated in, the app received 1 point

for having a capability deemed important to managing diabetes. While I thought it was

important to include price it was not a category that received a point value. The total for each

app on the list by Healthline was calculated so as to provide a ranking of the apps offered

(Appendix C). Based on my analysis and the information in this paper, it is my opinion that

Diabetes App is the best app available; with Diabetes Pilot and dbees being a very close second.

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Discussion

While my analysis has limitations in determining the best app, such as not including user

interface, there are some key takeaways in looking at the top apps. As discussed above, many

apps available today take pieces of diabetic management instead of looking comprehensively at

the disease state and what is required of the patient. One of the reasons Diabetes App came

out on top was because in all of the data areas Klonoff discussed as important the app was able

to provide all of those to patients. In addition, it offered functionality in communication with

providers, creating a record, and, most importantly, the educational ability so many diabetic

apps lack.

Of the apps that were chosen as the top apps in 2014 by Healthline, I thought it was interesting

that only one offered social networking capabilities and none offered patient decision support.

It was also noticed when looking at medication tracking that this usually did not include all

medications a diabetic patient would take, but, instead, only tracked their insulin levels. While I

think insulin levels are important to track, diabetic patients can take upwards of seven

medications and it would be helpful to track all of them to help with HCP interactions.

It was also interesting to note that only 5 of the 11 apps listed were offered on multiple

platforms. The only platforms listed as options were Android and iPhone; however, these are

two big names in apps. Hopefully as specific apps become more popular and are noticed as

being the best options they will be offered on more platforms. As discussed in the

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opportunities/benefits section, mobile broadband subscriptions are growing around the world,

and to meet the needs of different patients in different areas of the globe multiple platforms

will be needed.

Conclusion

The market for healthcare apps, and diabetic management apps in particular, is growing at a

rapid rate. While there are possible benefits to patients such as tracking key categories of care,

personalized self-management and patient decision support; the biggest benefit would be

helping to reduce key measurable such as A1C levels.

Although some studies do show that these patient benefits can lead to better numbers for

patients, there are concerns with the diabetic app market. Key concerns at this time are apps

that fail to look comprehensively at diabetes management, ignoring evidenced based practices,

a lack of studies in the industry and patient privacy.

The concerns listed are real, but there are apps out there that rise above these issues. Brandell

says “All diabetes management apps should conform to clinical best practices. This means we

must move beyond mere data logging and being building upon the tenets of today’s diabetes

self-management” (2013). By taking the categories offered by Klonoff and checking to see that

as many as possible are used in the chosen app, it can help to ensure the patient is using a tool

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that will truly empower them to take their self-management of diabetes to a new level. In

doing this, hopefully, over the next decade we will see a reduction in the amount of deaths

caused by diabetes, as well as, see the cost of this chronic disease begin to drop.

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References

American Diabetes Association. (2014). Statistics About Diabetes. National Diabetes Statistics

Report. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/.

Arsand, E., Froisland, D.H., Skrovseth, S.O., Chomutare, T., Tatara, N., Hartvigsen, G., and

Tufano, J.T. (2012). Mobile Health Applications to Assist Patients with Diabetes: Lessons

Learned and Design Implications. Journal of Diabetes Science and Technology, 6(5), pp.

1197-1206.

Brandell, B. and Ford, C. (2013). Diabetes Professionals Must Seize the Opportunity in Mobile

Health. Journal of Diabetes Science and Technology, 7(6), pp. 1616-1620.

Klonoff, D. C. (2013). The Current Status of mHealth for Diabetes: Will It Be the Next Big Thing?

Journal of Diabetes Science and Technology, 7(3), pp. 749-758.

Sarasohn-Kahn, J. (2010). How Smartphones Are Chaning Healthcare for Consumers and

Providers. California HealthCare Foundation. Retrieved from

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HowSmartphon

esChangingHealthCare.pdf.

Wodajo, F. (2011, February 2). Apps for management of diabetes could be vehicles for reducing

health care expenses in future [mHealth]. iMedicalApps. Retrieved from

www.imedicalapps.com/2011/02/apps-for-management-of-chronic-diseases-could-be-

future-vehicles-for-reducing-health-care-expenses/.

World Health Organization. (2014). The top 10 causes of death. Fact Sheets. Retrieved from

http://www.who.int/mediacentre/factsheets/fs310/en/.

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Appendix A

Active Mobile-Broadband Subscriptions by Region

Region

Number of

active mobile-broadband

subscriptions (millions)

2010 2011

Africa 14 27

Arab States 26 42

Asia and Pacific 281 422

Commonwealth of Independent States 63 87

Europe 174 226

The Americas 206 279

(Klonoff, 2013)

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Appendix B

Percentage of Applications Incorporating Data from Monitoring Tasks

Percentage of Applications Incorporating Support Tasks

Function Apple App

Store Literature

Function Apple App

Store Literature

Blood glucose 100 88

Education 100 88

Medication 76 38

Communication 76 38

Diet 68 75

Patient health record 68 75

Physical exercise 41 50

Decision support 41 50

Weight 25 6

Data entry automation 25 6

Blood pressure 23 16

Social networking 23 16

(Klonoff, 2013)

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Appendix C

App Educ Comm PHR Dec Sup DEA Soc Net

Fooducate X

Glooko X X X

Diabetic Audio Recipes Lite X

Diabetic Connect X

Glucose Buddy X

Diabetes App X X X

OnTrack Diabetes X

dbees.com X X

Glucool Diabetes X

Diabetes Pilot X X

WaveSense Diabetes Manager X

App BG Med Diet Exercise Weight BP Cost Mult Platforms Point Value

Fooducate x Free Yes 3

Glooko X X X Free Yes 7

Diabetic Audio Recipes Lite X Free No 2

Diabetic Connect X Free Yes 3

Glucose Buddy X X X X Free Yes 6

Diabetes App X X X X X X Free No 9

OnTrack Diabetes X X X Free No 4

dbees.com X X X X X Free Yes 8

Glucool Diabetes X X X X X X $4.99 No 7

Diabetes Pilot X X X X X X $11.99 No 8

WaveSense Diabetes Manager X X X Free No 4