Abstract Body

During the Covid pandemic, telemedicine(TM) has been more and more accepted by doctors and patients all over the world. Evidence-based research has found telemedicine-based management of type 1 diabetes efficient in delivering equivalent or better care and outcomes when compared to only face to face visits. A year before the covid, Kerala, the most literate state in India, with 96.2% literacy rate, had a community consisting of parents and children with type 1 diabetes. Almost all these parents had access to WhatsApp and were part of the type 1 diabetes community in Whatsapp. This of course doesn't include all of those with type 1 diabetes in the state but included most of those who were economically compromised and didn't have access to the premier hospitals and doctors.

There were total of 4 WhatsApp groups, each consisting of 250 parents and children from all over the state of Kerala, receiving treatment from government hospitals or other private hospitals. The groups also included volunteering doctors, nurses, educators and dietitians where we were also part. Our duty was to give them directions and advices rather than to treat them. We in addition, provided the economically disadvantaged families with free supplies including insulin, glucometers, strips and injection needles based on their needs. All the communications in the group were based on updated telemedicine guidelines in India.

As a team, we have been providing 24/7 advices and services free of cost to the entire community together with multiple online educational programs via the zoom. Some of these programs were with parents and children together and some other programs incorporated only parents so that counselling can be given to them to specifically address psychosocial issues of these kids.

In each WhatsApp group, one of us in the team, always made sure we replied to the questions posted by the parents or grown up children, without any delay. Most frequently asked questions during Covid pandemic were related to stress and anxiety of children including abnormal/aggressive behaviour, uncontrolled glucose, reluctance with insulin injections and glucose monitoring. We also had to arrange exclusive counseling sessions with psychologist to address the multiple emotional issues of the kids/caregivers. We also created educational videos addressing different aspects of type 1 diabetes and Covid based on the frequently raised questions and concerns.

MERITS

1. All their concerns are addressed even during the middle of the night.
2. Could avoid multiple episodes of DKA
3. Could successfully avert/treat multiple episodes of life-threatening hypoglycemia
4. Dietitians in the groups could advise on diet, specific to individual requirements
5. Diabetes nurses could retrain parents and children on injection techniques whenever found essential, multiple times
6. Questions on stopping insulin or Complementary and Alternate Medicines(CAM), side effects of insulin where not only answered but also explained via videos.
6. Whoever is in short of glucometer strips or needles could get it from community itself or from us without any delay.

DEMERITS
1. The patients in the WhatsApp groups are getting treated in different hospitals and not by the volunteering doctors and healthcare providers in the Whatsapp groups and hence the medical history and records are not with them.
2. Many a time, the patients with uncontrolled glucose might be on an insulin formulation or regimen not suitable for them but the team would not be able to commend on it.
3. Hundreds of parents will be messaging or calling via WhatsApp privately to doctors. However,due to legal implications, they are not replied to unless it is posted in community group.
4. Though there is no hesitancy for the type 1 diabetes community members to open up about disease in the group, there would be many concerns and questions which cannot be posted in a group.
5. Since it is an open community, whatever communications are exchanged; including lab reports are not secure or confidential.
6. The health care professionals(HCPs) will not get a remuneration and there is no funding for this activity; so those getting involved should volunteer out of their commitment to the society.
8. The HCPs may be under tremendous pressure since the patients will have easy and free access to the health care professional.

The WhatsApp community of type 1 diabetes children and their parents were provided support throughout the day and night by the physicians and allied healthcare professionals in each group. This telemedicine model prevented hospital admissions which was widely appreciated by the patient community and it also reduced the overall cost and burden of treatment. However,this model is not free of demerits which may include the legal implications, the errors and mistakes, which can happen in the process of communication and implementation. This advantageous model may not be applicable in many other health systems.

Background and Aims

Pricking of fingertips has always been an impediment in periodic blood glucose monitoring. We compared the benefits of Genteel, a vacuum-based lancing device, in PWD in improving the self-monitoring frequency and HbA1c.

Methods

An open-label, 24-week cross over trial where PWD were matched using propensity score and randomly allocated to GC or CG arm (G- Genteel; C- Conventional). GC exclusively used Genteel for 12 weeks, and then switched to the conventional method of SMBG for additional 12 weeks, and vice versa for CG. A total of 110 patients, including 58 T1D and 52 T2D, were recruited. Both arms were provided with the same glucometer. CG arm used the lancet and lancing device which they were using prior to randomization and GC used Butterfly lancets during the first 3 months. Reduction in HbA1c, %SMBG adherence over 24-weeks and subjective assessment of pain were assessed.

Results

Data from 110 patients (58 T1D and 52 T2D) showed a significant reduction in HbA1c (p<0.05), improved SMBG adherence in T2D (P<0.05) and reported reduction in pain (P<0.05) after using Genteel. A significant number of patients (p<0.05) also reported that they will continue to use Genteel lancing device in the future [Table1].

Conclusions

This advanced lancing device has helped manage the limitations of conventional lancing devices. T2D showed significant increase in SMBG adherence and HbA1c reduction using genteel than conventional device compared to T1D. Percentage reduction of pain and probability of using genteel in both T1D and T2D was approximately same while probability of using conventional device was comparatively less.

Background and Aims

A large subset of PWD assume that physical activity alone can bring glycemic control irrespective of the stage of diabetes. During Covid, there was an increased emphasis on physical activity in PWD. People with uncontrolled diabetes were avoiding physical visits to hospitals due to the fear of contracting the disease. In this scenario, we analysed the effects of physical activity on glycemic control as measured by CGM in terms of TIR.

Methods

We analysed the EMR of T2D patients who performed CGM atleast once from March 2021 - June 2021 after the lockdown period and extracted data on exercise (type, frequency and duration of exercise), BMI and TIR. Out of 603 T2D, 332 (those who performed at least one kind of physical activity) were categorised into the study group (SG) and 271 (those without any physical activity) into the control group (CG).

Results

TIR was compared between SG and CG using analysis of covariance model with TIR as the dependent variable, treatment as a fixed effect and BMI as a cofactor. There was no significant difference (p=0.7305) in TIR between the groups. When taken together, 16.3% achieved a TIR >70% and 6.5% achieved a TIR >90% irrespective of physical activity. Percentage of patients in various TIR categories is shown(Fig.1)

Conclusions

Physical activity alone as an independent parameter may not have a significant role in improving TIR. The findings emphasize the fact that physical acvity should be combined with medical nutrition therapy and therapeutic interventions for better optimal outcomes in the management of diabetes.