Diabetes Spectrum
21:91-99,
2008
DOI: 10.2337/diaspect.21.2.91
© 2008 by the American Diabetes Association
Use of Internet Technology to Support Nutrition and Diabetes Self-Management Care
Margaret A. Powers, PhD, RD, CDE,
Susan Burke March, MS, RD, LD/N, CDE and
Alison Evert, MS, RD, CDE
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Abstract
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In Brief
The Internet can be a powerful support for diabetes nutrition and
self-management care. It is prudent for health care professionals to learn how
to maximize its use with their patient population. This article provides an
overview of on how Internet websites can be used in diabetes care, provides
evaluation criteria, and offers a review of selected sites.
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Introduction
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Medical nutrition therapy (MNT) includes determining individuals' specific
nutritional needs based on their medical status and disseminating this
information to them in a manner that enables understanding and adherence to
the goals they set with their health care providers. The great challenge to
this is that MNT requires patients to make behavioral decisions in
environments that may or may not support the planning and execution of these
recommendations. Thus, MNT needs to take into consideration the variety of
situations in which food decisions are made and determine whether patients are
confident and comfortable implementing the nutrition recommendations. As
health professionals, it is important to anticipate and provide support and
resources to each individual to maximally implement the MNT
recommendations.
For some patients, the Internet can be a valuable resource to provide
ongoing information and support outside of the health care organization
(Table 1). A variety of
websites are available that can enhance and reinforce nutrition information,
provide behavioral and motivational support, and track events. The use of
websites can be a thoughtful, planned component of the health care
intervention. The purpose of this article is to describe and categorize
currently available options and provide guidelines that are useful for
evaluating websites.
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Access to Websites
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Although many people have ready access to the Internet in their home or
place of employment, some patients may not have access, may have limited
computer skills, or may not be able to use their work computer for personal
tasks. To facilitate the use of the websites presented in this article and
other recommendations, it may be helpful to provide a list of resources
available to patients for accessing the Internet. Some common helpful
resources are the local public library, community centers, community colleges,
and technical schools. Also, friends and family who own computers may be
willing to help patients gain Internet access.
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Categories of Nutrition Websites
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There are three basic categories of nutrition/health websites that can be
used to support diabetes MNT. These include those providing 1)
content information, 2) behavioral and motivational support, and
3) a means of tracking data.
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Content information sites
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The vast array of websites makes it challenging for health professionals to
know to which content and concepts patients have been exposed. Many patients
access the Internet to gather facts to better understand what diabetes is, how
it is treated, and what they can or should eat. With this information,
patients may come armed to their first medical or education visit with the
information they have gathered and appear ready to prescribe their own
treatment. Other patients need help deciphering the information they have
gleaned or may feel overwhelmed with the amount of information available or
what they have discovered. Providing patients with a few key, high-quality
websites can facilitate "content management," as will discussing
the content they obtained so clarifications can be provided as needed.
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Behavioral and motivational support sites
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As patients explore the content of various websites, they may feel
motivated to take steps to follow therapy recommendations. The content
information may list behaviors that could be followed to achieve desired
outcomes. The presentation of these behaviors may stimulate a positive
behavior change in a way that could not be achieved in a health office or
clinic visit. Additionally, there are websites that specifically focus on the
support aspect of diabetes self-management and guide patients in making and
maintaining choices that promote positive outcomes. These sites may provide
daily or weekly newsletters or short reminders that can be personally
motivating. Some websites offer online support groups specifically targeting
behavioral goals, including weight loss, fitness, and improving clinical
indicators, such as blood glucose and blood pressure.
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Data tracking sites
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Diabetes decisions are driven by data, and the Internet has much to offer
in supporting data collection. There are websites that allow patients to enter
their food intake and physical activity to assess their carbohydrate and/or
caloric balance. Other websites allow patients to download data from their
blood glucose meters. There is also the personal side of diabetes data, which
includes feelings, quality of life, and willingness and ability to carry out
recommendations. Some websites touch on this type of data through assessing
readiness to change and then personalize recommendations and provide a means
of tracking progress.
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Evaluating Websites
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There are literally millions of websites that address the topics of health,
nutrition, or diabetes. A Google search offers > 3 million websites on the
topic of nutrition and diabetes and > 200 million on the topic of nutrition
alone. Such sites are sponsored by health care facilities, health
organizations, food companies, pharmaceutical companies, health device
companies, specialty companies, and individuals with diabetes, and there are
also bulletin boards, e-communities, and blogs on the topic. This great array
of choices offers both opportunities and challenges.
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Decision-point: how can a given website help patients?
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To help patients sort through this maze, health professionals may want to
become familiar with a handful of websites they can offer as specific examples
of what might be valuable and what might be detrimental to advancing therapy
adherence. A Pew Internet Project found that, of patients who seek health
information online, 81% seek information because of a family member's or
friend's illness, 58% seek information for themselves, 46% use online
information to influence their treatment decisions, and 34% say their overall
approach to health care changed as a result of online information.
The first decision point in recommending a website is to determine the goal
the website resource will address. For example, a dietitian might refer a
patient to a specific recipe website that offers tips and recipes to help the
patient become more comfortable preparing low-fat meals. Other specific
reasons for referring a patient to a website might be to help the patient
1) learn more about a specific aspect of diabetes; 2) obtain
recipes that meet taste preferences, the food budget, and health needs;
3) track activity levels; or 4) receive daily tips on being
more successful meeting personal goals. Topics for web searches are listed in
Table 2.
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Decision-point: how can you judge a website's quality?
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A variety of evaluation tools have been developed for evaluating health
websites and can be found by doing an Internet search using the terms
"evaluate health websites" or other similar words of your choice.
The evaluation criteria typically include credibility of the author/sponsor,
purpose, objectivity, quality of information, graphics and design, and ease of
use. One evaluation tool can be found in
Table 3.
An easy cue to identify a reputable site is to look for those with URLs
that end in ".gov." These are government-sponsored sites, such as
those maintained by the National Institutes of Health
(www.niddk.nih.gov/http://medlineplus.gov),
the U.S. Department of Health and Human Services
(www.healthfinder.gov),
and the Centers for Disease Control and Prevention
(www.cdc.gov/diabetes).
Another easy cue is to go to sites sponsored by national health organizations,
such as the American Diabetes Association
(www.diabetes.org)
or educational sites with URLs that end in ".edu," which means
they are maintained by educational institutions. Reasons to be skeptical about
a particular website are included in Table
3.
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Review of Websites
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We reviewed a number of websites, databases, and online diabetes handouts
and have provided a summary of their content in Tables
4 and
5. These sites were selected
because they were created with expert supervision, do not advocate quick
weight loss, and have tracking capabilities. There are many other sites that
meet these basic criteria; these were selected to provide a glimpse of what
you can expect from a website. We suggest that you review what we have done
and then browse the web to check out sites your patients mention to you and
explore others that may have potential to meet the goals of your patients.
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Looking to the Future
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Reliance on technology is one of the things that young people, Baby
Boomers, and even many senior citizens in the United States have in common.
Innovative diabetes self-management education and diabetes MNT strategies are
key to engaging today's technology-savvy population. The interactive format of
the Internet and its availability 24 hours a day make it an appealing mode of
communication for many people. As health professionals trying to facilitate
behavior change among consumers of online health care advice, we must become
knowledgeable and skilled in the use of technology in diabetes care. An
important aspect of that is keeping abreast of the services available on the
Internet.
Lifestyle behaviors and choices of both young people and adults in the
United States have resulted in the twin epidemics of obesity and diabetes,
sometimes called "diabesity." Weight concerns are not limited to
only those with type 2 diabetes; many individuals with type 1 diabetes also
are struggling with the consequences of inactivity and poor food choices. Many
are turning to the Internet to find help in their weight loss efforts.
Although many of the websites evaluated in this article are not exclusively
designed for people with diabetes who are trying to lose weight, some can be
used successfully to increase physical activity or initiate or monitor other
health care behavior changes. The small sampling of websites shared here
reveals the variety of information available to patients. It includes sites
devoted specifically to nutrition information; those offering personalized
meal plans and fitness regimens; online shopping lists; recipe sites; online
record-keeping tools; secure platforms to share personal health information
with health professionals; and convenient access to online support.
However, technology must be used with caution, especially for individuals
with a chronic condition, such as diabetes. It is well known that not all
websites provide safe and reliable health information. Health professionals
should try to stay informed about their patients' use of Internet technology
because it may affect their care. For example, if patients are able to
successfully initiate health behavior changes that result in weight loss or
increased levels of physical activity, their diabetes medications may need to
be adjusted. Information provided in this article can serve as a template for
health professionals to use to evaluate available nutrition and lifestyle
behavior websites.
What is the future of diabetes and nutrition technology? Be assured,
technology will continue to move forward at a rapid rate. The future might
well include devices that can be worn by individuals to electronically record
actual food intake, medications, physical activity, blood glucose levels, and
other health information that can be uploaded in a secure platform and shared
in real time with health professionals. Unfortunately, as technology evolves,
health professionals will surely continue to struggle with the challenge of
integrating new resources into clinical practice. Many health professionals
are enhancing their practices with web-based nutrition and fitness platforms
and are saving time and improving communication with their patients. Among the
unanswered questions remaining is the issue of how health professionals will
be compensated for evaluating increasing amounts of electronically gathered
and disseminated health data (especially if their evaluations occur outside of
traditional medical offices) and how various state laws may affect health
professionals who try to incorporate telemedicine.
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Footnotes
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Margaret A. Powers, PhD, RD, CDE, is a research scientist at the
International Diabetes Center in Minneapolis, Minn. Susan Burke March, MS, RD,
LD/N, CDE, is a registered dietitian, certified diabetes educator, and author
in private practice in Flagler Beach, Fla. Alison Evert, MS, RD, CDE, is a
diabetes nutrition educator at the University of Washington Medical Center
Diabetes Care Center in Seattle, Wash.
Note of disclosure: Dr. Powers has served on an advisory panel
for Eli Lilly and Co. and has received research support from Abbott Diabetes
Care. Ms. Evert has served as a consultant to Eli Lilly and Co. Both companies
have Internet websites mentioned in this article.
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Abstract
Introduction