NUTRITION411: THE PODCAST, EP. 24

The Patient-Centered Approach to Diabetes Technology

Lisa Jones, MA, RDN, LDN, FAND

This podcast series aims to highlight the science, psychology, and strategies behind the practice of dietetics. Moderator, Lisa Jones, MA, RDN, LDN, FAND, interviews prominent dietitians and health professionals to help our community think differently about food and nutrition.

In this episode, Lisa Jones interviews Jennifer Smith, RD, LD, CDCES, and Susan Weiner, MS, RDN, CDN, CDCES, FADCES, about diabetes technology, including smartphone applications, and making recommendations to clients and patients to fit their individual needs. This is episode 1 of a 4-part series. 

Additional Resources:

Listen to part 2 of this 4-part podcast series here. 

 

TRANSCRIPTION:

Narrator:

Hello and welcome to Nutrition 411, the podcast, a special podcast series led by registered dietician and nutritionist Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant 360.

Lisa Jones:

Hello and welcome to Nutrition 411, the podcast where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's podcast is part of a series of short episodes on diabetes technology featuring a Q and A with Jennifer Smith and Susan Weiner. I want to introduce Jennifer first. Jennifer holds a bachelor's degree in human nutrition and biology from the University of Wisconsin Green Bay. She's a registered and licensed dietician, certified diabetes educator, and certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems.

She's an active member of the American Diabetes Association, and American Association of Diabetes Educators, and was an active member and educator for Team WILD, which means we inspire life with diabetes. She's also a contributing author for the Diabetes Sister's website. For the past 10 years, Jennifer has been the Director of Lifestyle and Nutrition with Integrated Diabetes Services. Jennifer has also lived with type one diabetes since she was a child, so she has firsthand knowledge of the day-to-day events that affect diabetes management. Welcome, Jennifer.

Jennifer Smith:

Thank you. It's wonderful to be here.

Lisa Jones:

Yeah, thank you for being here.

Jennifer Smith:

Of course.

Lisa Jones:

And now I want to introduce Susan. Susan is an award-winning nutrition, health, and diabetes expert, and the owner of Susan Weiner Nutrition. Susan served as the 2015 ADCES Diabetes Educator of the Year and is an ADCES fellow. Susan is diabetes and real-life columnist for Endocrine Today and is the on-air host for video interviews and content for healio.com. She's the co-author of the Complete Diabetes Organizer: Your Guide To a Less Stressful and More Manageable Diabetes Life and Diabetes: 365 Tips for Living Well. She has extensive TV, radio, podcast, and video experience and is well-versed in media communications. Welcome, Susan.

Susan Weiner:

Thank you so much, Lisa. It's great to be here.

Lisa Jones:

I'll start out with the first segment and the first segment, what we're going to do is we're going to dive into covering the trends in dietetics. And this is not a trend, I think this is here to stay with the apps, but I want to hear from both of you. My first question is, of course, all about apps, but is how do you initially discuss the possibility of using an app with a person with diabetes? So Susan, I'll go to you first.

Susan Weiner:

Oh, thanks so much, Lisa. That's a great question and I have to take a step back and remind everybody listening today that on average a person living with type one diabetes makes roughly 180 health-related decisions every day. So they're spending 8,700 hours a year managing diabetes, but only 28 minutes a year with a healthcare professional, with so much to think about, what should I eat, when should I eat it, when should I take my insulin and my medications, how will this affect my blood glucose levels? So, we're looking at a lot of data, which can be overwhelming.

So when we're first talking about any kind of technology, we want to assess where a person is on their diabetes journey with app selection and putting that person in the center of care, individualizing recommendations. Just as when we individualize technology, recommending the apps, requires it to be individualized and not a one step fits all philosophy. So consider the health literacy and the numeracy of the person that you're working with. And when you are onboarding them, either live or remotely, you have to do it yourself. If you're a dietician, a diabetes care and education specialist, no matter what type of clinician you are, you need to try the app yourself.

So generally, there are two ways that people come to an app. One is that as a clinician you might be using it in your organization so you're familiar with it. Or a person with diabetes who has the lived experience may come to you and say, "Hey, I've heard on this peer support group or online that I'd like to try this app." So that's the initial issue that I have when suggesting an app or really suggesting any type of technology, finding where the person is on their diabetes journey and starting with that individualization of care.

Lisa Jones:

Yes, I love that. And the other thing that you said that really hit home was to try the app yourself, because a lot of times as dieticians, we're making these recommendations, but I do believe it goes back to the recommendations we should have tried ourselves if we're recommending it to somebody. So a great point. I appreciate you bringing that up, and it does sound overwhelming for the patient. And I want to hear what Jennifer has to say about the apps and the person with diabetes.

Jennifer Smith:

Of course. And Susan, you gave a great... Overall, that's a perfect perspective to bring in in terms of clinical and also the person with diabetes, of course. I think from the perspective of somebody with diabetes, myself, and also working with people who have diabetes, knowing how to bring up an app includes understanding the person that you're working with. So knowing them on a very personal level, because overall the apps have to serve a purpose and they have to serve a purpose to this person's life. So apps have to be useful. They have to have some type of convenience to use them. They may need to improve the person with diabetes organizational skills around their diabetes management. The app should be cost-effective. They should eliminate maybe some parts, log books that they're hand keeping. Great, maybe an app is actually a better step because their phone or their smart device is always with them.

Apps also have to be... In terms of diabetes benefits, they have to be accurate. They have to give some decision support to ensure that the person with diabetes has some safety included along with the use of the app. Much like many of our CGMs now, they are used with an app and they provide alerts and alarms, also some data analysis assistance, which makes it much easier for somebody to make real-time decisions. Again, from a safety perspective, we want these apps to also be able to improve communication between the person with diabetes and their healthcare providers.

Many of the apps connect to a clinical link. As long as the care provider has that access to some type of database the app connects from the person with diabetes' smart device. This overall can help to improve clinical outcomes for the person with diabetes, rather than just coming in every three to six months to check up with their clinician. They can actually access communication in between and get feedback, which again, overall, helps to sometimes decrease the burnout in between visits can occur, because, for people with diabetes, this does not turn off at 10:00 PM when they go to bed. This is a 24/7, all times of day you have to be on with paying attention to your management. So we want these apps to be useful, accurate, and safe overall to reduce the burden to the person living with diabetes.

Lisa Jones:

Well, thank you, Jennifer. That was a great little checklist. I was writing down a bunch of notes when you were saying that for dieticians that are listening because it sounds like you're also kind of being a detective and finding out about your patient. From what Susan was saying, it has to be individualized, but also you have to then match it to the best possible app because there's more than one. So it's not like you're just matching it with the same app all the time. And then that kind of begs the question, what happens when you have somebody that you suggest an app, and then I'm sure there are cases where they come back to you and they say, "No, this didn't work." Then how do you proceed from there?

Jennifer Smith:

Sure. I think the thing that we have to ask is, well, what didn't work? There might've been aspects of the app that actually were beneficial, but overall, was it too much data collection that was necessary? Did the person have to interact with the app too much and that just doesn't fit their lifestyle and it's making it more of a burden to actually use it? There are some levels of apps, I guess, is how you would describe them, some easier to use versus those that you have to interact with more as the user. There are some apps that connect seamlessly with the technology that's on the market, the insulin pumps and smart insulin pens, and blood glucose monitors, to upload the data right from that device to an app via Bluetooth. So it talks, it syncs right with it, so there's less data entry. That might be where in this case or this example that you gave might be where you have to step back and say, "Well, let's try this one. This one we don't have to interact with as much, but it'll still collect the data. It'll still send it over to me. It'll make it beneficial so that I can give you more feedback."

So again, it all boils down to knowing the person and listening. I think that's a piece that's when you're trying to achieve education in a visit with somebody, sometimes education, you have to sit back in your chair and you have to say, "Okay, I need to listen to what the person can receive right now. What do they most need? What are they coming in with in terms of their problem areas?" Because then you may be able to fit an app that does work. It may not give you everything that you think you need, but it's a stepping stone to help the person see that with the use of this, we can see more. I can give you more information for adjustment and it makes a difference. And then they may be able to use a more, I guess, in-depth type of app.

Lisa Jones:

Yes. And with that being said, I can't imagine a world without the apps. You have so much more information at your fingertips than ever before.

Jennifer Smith:

Which is great. Yes.

Lisa Jones:

Yes. I want to ask Susan, and then of course you too, Jennifer, what is your favorite app currently? And I know this probably changes as new ones come on the market, but what is your favorite app is my first question. And the second follow-up is, what do you think is the most usable app right now with all the patients that you work with? Which ones do you think are most popular?

Susan Weiner:

Oh, so let's take a step back from that. Let's take a step back, but I want to say why in the diabetes world, at last count, there were 1200 different diabetes-related apps and over 350,000, I believe, health and lifestyle apps. And unlike other medical devices that Jenny was just talking about, like CGMs, continuous glucose monitors, which as registered dieticians and nutrition professionals, we really should be familiar with, or insulin pumps, the majority of the apps are not necessarily regulated by the FDA, and so they can be produced without significant oversight and regulation, which can come with more risk.

So we are more than happy to suggest and recommend different apps, but they're used for a variety of different things. So I just wanted to give that little bit of background because it totally depends on what you're using it for. If you are on a CGM, a continuous glucose monitor, if you are on a specific insulin pump, some of the apps that you might be using are related to those specific technologies and devices. If you have diabetes, type one diabetes, or type two diabetes, you can be on different insulin pumps, for example.

So for example, if someone was on an agnostic pump or changed from one type of pump to another, they may be on a data collection app like Tidepool or Glooko, which has a lot of features that a provider can use to upload the information from the person that you are working with to get all kinds of data so that you can go through it with them in their next appointment. And that includes a lot of different food apps within it, and it can link to your Apple Watch, for example, or a fitness tracker or another one of the health apps. So specifically, I'm looking at those data collection apps as being very useful and something that I think Jenny and I both use in our practices.

There are different apps and different early adopters of technology depending on the type of diabetes that you have and your age. For example, parents of children with type one diabetes are early adopters of apps and technology because that is the situation that they're in. Somebody with type two diabetes might be a later adopter of an app, especially if they're not on an insulin pump, for example, and may choose to use a food app like Undermyfork or Figwee, or even a free version like MyFitnessPal or Lose It.

So there are different reasons for individualizing different apps. And the fact is, I read one study recently that showed that over 75% of apps are used once after being downloaded and then never used again. So where a person is, not only on their diabetes journey but on their journey with technology, has to constantly be reviewed. And who better to do that than the dietician who has usually the best rapport and the most ongoing rapport with people living with diabetes, whether it's on one-on-one sessions in diabetes education classes, or during medical nutrition therapy? But become really familiar with it and comfortable with it before suggesting it.

Lisa Jones:

Yes. And you just blew my mind, wow, with all that information you provided. Thank you, Susan. And I want to say for the dietician that specializes in the area that both you and Jennifer work in, it sounds like you have to spend most of your time keeping up with all the latest research and all these new things that are being added just to make sure that you're navigating your way through. So that's amazing. Kudos to both of you for that. And I do want to hear from Jennifer about your thoughts. It sounds like you can't just pick one because there are so many, and there's probably not one that's mostly used because it's so individualized and there's a bunch of different categories, if you will.

Jennifer Smith:

That's a great way to condense. Absolutely. And Susan did a great job in terms of why we don't... Do I have some personal favorites? Sure, I do. But in terms of an individualized nature of recommendation, each and every person that I get the opportunity to work with and help, there is going to be an app that may be specific, as Susan said, to the device that they're using. And it may cross over into then an online database that I can use from a clinical standpoint. There may be some apps that I can also use, but become more beneficial from that personalized level. As Susan mentioned, a couple of them, things like Tidepool, which is a great app, can keep notes, and the data syncs with the online database. Many clinicians are actually using Tidepool within their organizations.

One that a lot of parents love is Sugarmate. It actually gives alerts and alarms to the caregiver, especially for the child with diabetes, that they may hear better, especially overnight, than the alarms that actually come from the app that's a follow type of app. So again, I don't have any in particular that are 100% my favorite. From a dietician standpoint, I love, as Susan already mentioned, the Undermyfork, the Figwee. I love Undermyfork because it's really instructional for the person with diabetes to see the impact of some of their choices. You can take pictures of your food and then along with tracking insulin use and those types of things, carb entries, you can make notes and tags. The data shows up right up in the app along with the picture of the food. And so from a historical perspective, you always eat at Frank's Pizza on Friday night, you can see what happened last Friday night, and you can make better decisions because you can see what happened.

So there are many, many, many. These are just not even the tip of the iceberg, like the hair on the tip of the iceberg in terms of recommendations. But as Susan said early on, explore, go into the app stores or the Android-based app area, and take a look at what is available to be able to see what to recommend. Try it out. Try it out from the perspective maybe of what you think it's like to live with diabetes and to make all of these decisions on a day-to-day basis, see how they work, see what you think makes the most effect in terms of your life and whether or not you might recommend something like this. So, yeah.

Lisa Jones:

Yes. Excellent. That's excellent advice. That is great. Especially if you don't know where to start. Explore, look into it, and make sure you're doing your research. So thank you. Thank you both for your comments and our discussion on all about apps.

Jennifer Smith:

Of course.

Narrator:

For more diabetes technology content, visit consultant360.com.