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.
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.
Access to Websites
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.
Categories of Nutrition Websites
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.
Content information sites
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.
Behavioral and motivational support sites
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.
Data tracking sites
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.
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.
Decision-point: how can a given website help patients?
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.
Decision-point: how can you judge a website's quality?
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.
Review of Websites
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.
Looking to the Future
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.
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.