May 2014

Dear (Editor):

In the clinical world, registered dietitians (RDs) are regarded as nutrition
experts. Assessment, counseling and education services provided by RDs are an
important part of modern integrated healthcare. As obesity rates continue to rise,
more Americans are developing type 2 diabetes. Type 2 diabetes can come with
an array of related diseases such as heart disease, and contributes billions of
dollars in expenses.
Diagnosis of or preexisting diabetes in inpatients presents an opportunity to
implement nutrition counseling from RDs, and to observe success of the patients
self-monitoring prior to admission. The use of smartphone apps to help health
monitoring is an emerging trend that has had limited studies performed regarding
its efficacy due to the recent rise in the technology. I focus on type 2 diabetes
because the majority of inpatients present with type 2 related complications. The
study does include type 1 diabetics.
This survey study will help to establish the value of using health monitoring
apps to improve glucose control in diabetic patients. The results of this study
show positive relationship between patients glycosylated hemoglobin levels
being more desirable (lower) and the use of either a glucose monitoring app,
carbohydrate intake monitoring app, or exercise tracking app. However, the study
is inconclusive and more evidence is needed due to limitations of the study,
discussed within.
This study was conducted in fulfillment of requirements of the ARAMARK
Distance Learning Dietetic Internship. The study was conducted under the
supervision of a registered dietitian at NorthShore Evanston Hospital as well as
an ARAMARK Dietetic Internship Director. The study was conducted with the IRB
approval from the hospital site. The conclusion of this study suggests that more
structured studies be performed regarding the efficacy of app use in lowering
glycosylated hemoglobin levels in diabetic patients. Thank you for your
consideration of this manuscript.

Sincerely,

Elizabeth A. Lancione, BS, Human Nutrition - Dietetics (Corresponding Author)
Dietetic Intern
ARAMARK Healthcare Distance Learning Dietetic Internship








Research and Practice Innovation
Smartphone app, glucose control, A1C
Word Count: 3306
















Smartphone Apps and Glucose Control Survey
















Liz Lancione, BS, Human Nutrition - Dietetics
Dietetic Intern
ARAMARK Healthcare Distance Learning Dietetic Internship
Evanston, IL






Smartphone Apps and Glucose Control Survey

ABSTRACT
Nutrition counseling is an essential part of healthcare. A registered
dietitian provides nutrition counseling to patients with a wide variety of diseases
spanning the life cycle. Technology is becoming a more and more integrated
part of nutrition counseling. Mobile phone applications, known as smartphone
apps, are becoming popular tools to help patients track their own health
maintenance. The question that sparked the hypothesis for this study was: Do
smartphone apps really help patients maintain better health? This survey was
conducted to determine whether patients use versus non-use of apps caused a
lower (more desirable) HbA1C level. To perform this survey, data was collected
from medical records of current inpatients in one hospital, which included only
their age, gender, HbA1C, and the date of their last test to determine A1C. The
patients who had their A1C test performed in the past 90 days were then
surveyed with three yes or no questions, asking if they used smartphone apps to
either track carbohydrate intake, blood glucose, or exercise (or a combination of
any). The results of the survey were then analyzed to see if the average A1C of
the patients who did use apps was lower (more ideal) than those who did not use
the apps. The results showed that those who used the apps had, on average, a
glycosylated hemoglobin that was 0.11% lower than those who did not take
advantage of the apps. This could indicate that app instruction could be a
beneficial part of nutrition counseling in the future.
Smartphone Apps and Glucose Control Survey

INTRODUCTION
As obesity and related diseases rise in the United States, more and more
patients are presenting to the hospital with diabetes and diabetes-related
complications. Type 2 diabetes is closely associated with obesity and
cardiovascular diseases. Patients often develop acute complications related to
these diseases if their diabetes is not properly managed, and many require a
hospital stay. The standard measure of how well controlled a persons blood
glucose is can be reflected in their glycosylated hemoglobin percentage, or %
HbA1C.
In the United States, type 2 diabetes is diagnosed in about 2 million adults
above the age of 20 per year. Diabetes mellitus costs billions of dollars each
year to the nation in expenses, including medical costs and productivity losses.
Diabetes that is not well managed can lead to more severe health issues, such
as kidney disease, blindness, damage to the nervous system, and even
amputation
1
. These complications are also very costly to the hospital systems,
patients, insurance companies, and the nation as a whole.
Glycosylated hemoglobin is a measurement of how saturated the
hemoglobin molecules in red blood cells are with glucose. Glucose molecules in
the blood normally become stuck to hemoglobin molecules - this means the
hemoglobin has become glycosylated. As a person's blood sugar becomes
higher, more of the hemoglobin becomes glycosylated. The glucose remains
attached to the hemoglobin for the life of the red blood cell, or about three
months
2
.
Not all patients who enter the hospital are required to have their current
glycosylated hemoglobin (often abbreviated as HbA1C or A1C) measured;
usually only patients who have been diagnosed with diabetes or who show risk
factors for diabetes, such as obesity, are given this simple laboratory test. The
request for a current blood test to determine the A1C of a patient is usually
initiated by a physician order at NorthShores Evanston Hospital. If A1C
measurement has not been taken within the past three months or 90 days, which
is the amount of time it takes for A1C change to occur, reflecting long-term
overall glucose control, a new test is needed. Although this laboratory value is
used to monitor glucose levels over a period of time, the use of the hemoglobin
A1C for the diagnosis of diabetes is not recommended at this time
3
.
By reducing a patients long-term blood glucose concentration, which is
measured by A1C, health risks of high blood glucose can be reduced. Due to
changing healthcare laws, reimbursement conditions are changing. If a patient is
seen and treated in the inpatient setting and later readmitted within a certain
period of time, the hospital will not be reimbursed for the treatment given. In
order to prevent diabetes-related complications causing symptoms that promote
readmission, basic diabetes management education is given to inpatients.
Patients at NorthShore Evanston Hospital who have a HbA1C of 8.0% or greater,
warrant an education session with the inpatient Certified Diabetes Educator
(CDE). Since a great part of diabetes-related symptom and co-morbidity
prevention is related to monitoring and management of blood sugar levels, it is
important for a patient to be equipped with the survival skills to manage their
blood sugar when they are discharged. Properly preparing a patient who has
diabetes to be able to manage their blood sugar on their own can help to prevent
readmissions, and this will help the hospital receive more reimbursement. By
assessing if the use of smartphone or computer apps and health monitoring
technology is related to better glucose control, diabetes educators can determine
if outcomes will improve by suggesting or coaching patients on how to use these
helpful tools. The need for this research at the hospital is due to the need to
prevent readmissions. If the data collected shows evidence of apps increasing
adherence to diabetes management strategies and overall lowering blood sugar
levels, it may change the practice of educating patients with diabetes or at high
risk for diabetes at this hospital.
A literature review done prior to the initiation of this survey revealed that
there has been much talk about the potential of mobile health monitoring, but
little conclusive evidence of significant effects. Most research conducted thus far
on glucose monitoring apps has been aimed at connecting patient and provider
over real-time connections. This may help patients overcome certain barriers to
provider access, such as waiting for appointment time or inability to contact
providers with questions at any given time
4
. According to a review by S Goyal
and JA Cafazzo, there are opportunities for mobile health apps to supplement
traditional care, especially between healthcare provider visits. Mobile health apps
may improve glycemic control by being less likely to allow user error in data entry
than traditional methods. They may also help by providing detailed and accurate
information to healthcare providers to aid in clinical decision-making. A very
helpful monitoring tool that is emerging is a blood glucose monitor that wirelessly
connects blood glucose measurements to mobile apps. These are still in the
works due to privacy concerns. Only online versions of self-monitoring tools
(such as paper glucose logs turning into online glucose logs) are widely available
thus far
4
.
Some trial studies have been attempted that use glucose monitoring apps
in-hospital to help increase efficiency and accuracy of healthcare, specifically
glucose monitoring. These apps and devices, if found to be in compliance with
the Medical Device Directive (a set of regulatory standards for medical device
safety)
5
, could potentially be used for the treatment of acutely ill patients with
type 2 diabetes. To be used in the hospital, these apps must comply with the
same standards that medical devices do
6
. This use of mobile app technology will
be useful in the future, but the focus of the survey conducted at NorthShore was
to focus on patient-focused information tracking apps that allow users to better
track progress of health management habits.
A randomized control trial performed by Kirwan et al focused on the use of
self-management apps for adults with specifically type 1 diabetes. The study
combined the use of a freely available smartphone app combined with weekly
text message feedback from a certified diabetes educator (CDE) to improve
glycemic control. The control group received usual care and the intervention
group used the smartphone app called GlucoseBuddy along with weekly text
message feedback from a CDE. The intervention group significantly improved
their glycemic control as measured by HbA1C percentages, and there was no
significant change in the A1C of the control group. Although this study focused
only on type 1 diabetes patients, the use of apps and feedback from CDEs
should be further studied in all diabetic patients who self-monitor their blood
glucose
7
.
On the other hand, Frazetta, Willet, and Fairchild conducted a systematic
review that takes a look at smartphone application use for type 2 diabetic
patients, instead of type 1 as in the above study mentioned. This review aimed to
evaluate the efficacy of smartphone applications in reducing type 2 diabetic
patients glycosylated hemoglobin. This review focused on randomized control
trials (RCTs) much like the one related to type 1 diabetes described above. The
intervention in these RCTs included a cell phone used to help type 2 diabetics
manage their diabetes. The cell phone apps varied from uploading capillary
blood glucose and medications for review by researchers at regular intervals,
while some included a teaching intervention or immediate feedback. No matter
what the approach was, interventions that included smartphone use to help
manage diabetes significantly lowered HbA1C of participants in the intervention
group
8
. Results depended on ease of use of the apps chosen in each study.
These studies were only used on iPhone apps, which excludes all patients who
do not own an iPhone.
Despite the potential usefulness of these apps, getting patients to use
them may be a large barrier. According to Frazetta, Willet and Fairchild,
smartphone usage by individuals age 65 and older has only increased by 13%
since 2008, while overall smartphone use has increased to 46% of all
Americans
8
.
The populations surveyed at Evanston NorthShore Hospital are inpatients,
a majority of who are over the age of 40. One study by Arnhold and Kirch
focused on diabetes patients aged 50 years or older. The report aimed to
determine what would make a user-friendly app for patients who may not be as
used to mobile smartphone technology. The question addressed in this study
was: How should a mobile application be designed to support an effective self-
management for diabetes patients 50+?
9
. A systematic market analysis was
conducted that analyzed the currently available app areas of focus, user groups
and popularity of the app. The results showed that the reason for low percentage
of older mobile health app users is due to the lack of user-friendly apps and
features of apps. The apps tend to not be needs oriented towards an older
population who has diabetes
9
. Since the current largest age group affected by
diabetes is aged 40-59 years
8
, apps should be aimed at this age group. Greater
involvement of patients and physicians in app design would help this take place
9
.
Promising new apps combine existing modes of communication with
evidence-based methods of patient monitoring and evaluation. It connects these
evidence-based practices that were previously only performed in the hospital to
the home setting
10
. Studies regularly focus on the achievement of the distal goal,
which is usually measurement of glycosylated hemoglobin, instead of proximal
goals such as weight reduction, increases in physical activity and medication
adherence. Monitoring progress toward these proximal goals could help reach
the overall goal of lowering glycosylated hemoglobin.
According to a review by Tran, Tran, and White, the average patient often
lacks the skills for finding and using the most optimal healthcare information. It
can be determined through the proposed study at NorthShore whether its
patients fall into this category, by seeing how many of them actually use phone
apps to track glucose, carbohydrate intake, or exercise
11
. There are many
different types of apps that can be used to improve health by many different
methods, as this overview reveals. Simpler apps may be better suited for older
adults who are not as familiar with technology, and more complex apps may be
preferred by the younger diabetic crowd, such as type 1 diabetics who are
diagnosed at an early age.
The survey that will be conducted at NorthShore Evanston Hospital will be
a survey of inpatients with current A1C levels on file. The purpose of this study is
to find out if they have used glucose monitoring apps, carbohydrate-counting
apps, or health apps (specifically exercise tracking apps). Patients who have
used these apps will be compared to those who have not as the control group, in
order to assess if there are differences in HbA1C between the two groups.
This related to a trend in dietetics regarding the epidemic of diabetes, and
technology transforming nutrition counseling
12
. This trend predicts that
smartphone technology will make tracking nutrition and physical activity data so
easy that it will greatly increase. What cannot be predicted is whether people will
embrace and adopt these technologies. By assessing what type of patient
already uses these apps, we could assess the factors that may influence people
to try the applications.

METHODOLOGY
The location of this study was NorthShore Evanston Hospital. The design
that was used was an anonymous survey design. The resources needed for the
survey were minimal. Online resources and medical journal articles were used to
perform a literature review of prior studies involving diabetics using medical apps,
discussed in the Introduction section above. EPIC medical charts and paper to
print the Excel charts were used to keep track of which patients had already been
surveyed. The only information seen by the surveyor was the patients room
number, age, gender, HbA1C, and the date that the A1C test was performed.
Name and birthday were omitted in the analysis of raw data to prevent HIPPA
violations.
The impact phase of this experiment was the survey being given to the
patient while the patient was in the inpatient setting. It was a single point in
time type of evaluation. The data that was collected is qualitative, instead of
quantitative. The amount of patients who answered yes or no to three questions:
o Have you ever used smartphone or computer apps to track your
blood glucose?
o Have you ever used smartphone or computer apps to track your
carbohydrate intake?
o Have you ever used smartphone or computer apps to track your
exercise?
along with their gender, age and A1C, provided numbers that were analyzed
statistically (percentage who used the apps, percentage of females and males
who used the apps, average age of those who used apps, average A1C of those
who did and did not use apps). This is appropriate to answer the question of
study because these statistics would reveal a relationship, if any, between app
use and % A1C in this hospitals patients. The data collection tool was paper
with a printed Excel spreadsheet, which was then entered into the computerized
Excel spreadsheets to analyze statistically.
Subjects recruiting process was simply obtaining verbal agreement from
patients to answer three quick, anonymous questions before they were asked the
three yes or no questions. Inclusion/exclusion criteria was that any patient with a
relevant A1C on file (taken in the past 90 days prior to being surveyed) was to be
included, and those without a relevant A1C on file was to be excluded.
The statistical evaluation established mean in A1C levels based on
answers to the survey questions, used Excel, and analyzed specifically if there is
a lower average A1C in patients who have used healthcare monitoring apps.

RESULTS
A total of 195 patients replied to the survey questions. 98 respondents
were female and 97 were male. The average age of all respondents was 64.64
years of age. Since some of the patients surveyed were patients of the womens
labor and delivery unit of NorthShore Evanston Hospital, more of the women
surveyed were of childbearing age. While the majority of inpatients in the
hospital who were surveyed were older due to age-associated health problems,
the women had a larger percentage of people under the age of 40. Nineteen
women surveyed were younger than 40, while only 4 men surveyed were under
the age of 40. Of all females surveyed, the average age was 62.63 years of age.
The average age of the males surveyed was 66.67 years old. The average
Hemoglobin A1C of the females surveyed was 6.33%, while average A1C of the
males surveyed was 6.19%. Of those patients who used apps, 27% were males,
and 73% were females.
The average age of those inpatients that use at least one type of app,
whether it is carbohydrate counting, exercise tracking, or glucose monitoring,
was 48.77 years of age. Of these people surveyed who used at least one app,
the average A1C was 6.22%. In contrast, the average age of those who did not
use an app was 67.09 years of age, and their average A1C was 6.33%, slightly
higher than the average of those who used apps. The average of all patients
surveyed, whether they used apps or not, was 6.26%. This shows a slightly
lower and therefore more desirable average HbA1C in those patients who used
smartphone apps to track either their blood glucose readings, carbohydrate
intake, exercise, or a combination of any of these health parameters.

DISCUSSION
A clinical registered dietitian provides education regarding diabetes
management to patients in the inpatient setting when their HbA1C is greater than
8.0% at NorthShore Evanston Hospital. The American Diabetes Association
suggests that diabetic patients maintain an A1C of less than 7%, which is an
estimated average glucose of 154 mg/dl. The purpose of this study was to
determine whether or not the clinical dietitians should provide teaching or
recommendations to diabetic patients for smartphone app use to help manage
their diabetes. While there have been many studies reviewed above that
suggest that smartphone app use helps to improve glucose control, this study
had too many limitations to add to that evidence.
The statistical evaluation should take into consideration the limitations
caused by the demographics of the population surveyed, such as age and
inpatient status. The majority of inpatient diabetic patients are type 2 diabetics.
This is significant because type 1 diabetics are commonly diagnosed at an early
age, and they receive continuous education on how to manage their diabetes,
often including suggested app use. The average age of all inpatients surveyed
was 64.64 years of age, which is considered to be elderly. This average age was
established without exclusion of the outliers of two seven year old males
surveyed on the pediatrics unit, and without exclusion of the women surveyed on
the maternal unit, some of whom were as young as 22 years old.
Another limitation of this study was the lack of education regarding
diabetes that most of the inpatients had previously received. Many inpatients are
hospitalized with complications related to their diabetes, proving that their
diabetes is poorly managed. Others find out that they have diabetes while being
hospitalized for something else and having their A1C tested due to risk factors
such as obesity. This would suggest that inpatients A1C could be higher overall
than outpatient diabetes patients.

CONCLUSION
Improvements of the study would be including outpatient diabetes
patients, who come to dietitians to help improve their disease condition and often
monitor their carbohydrate intake, glucose or exercise. It would also help to
perform a double-blind survey with anonymous responses if possible. The
majority of inpatients being elderly definitely has an effect on their ability to use
smartphone apps. Older patients are commonly uncomfortable with new
technology, and are unwilling to learn it on their own.
Due to the limited ability to reach a wide demographic outside of
inpatients, the evidence has proved inconclusive. Though the group who used
apps averaged an A1C further below the recommended 7% or lower for
diabetics, the limitations of the study show need for more research to provide a
conclusive result. More evidence with fewer limitations is needed. However, due
to the lower average A1C of those who use apps, it would possibly be useful for
RDs in the inpatient setting to suggest that inpatients make an appointment with
the outpatient registered dietitians to learn how to use the new helpful
technology.

DATA
Chart 1: Age, gender and A1C of the patients who had used any apps
64 F 5.2
60 F 5
22 F 5.1
64 F 5.2
54 F 5.7
22 F 4.1
22 F 5.1
48 M 4.6
59 F 5.5
54 F 5.7
60 M 6.3
63 M 5.4
34 F 12.2
53 F 8.2
58 F 6.1
22 M 10.3
60 M 7.1
48.17647059 7M 6.282352941

Chart 2: A1C of all males and females surveyed
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