Abstract

Background: Rural, medically-underserved, financially-challenged geographical areas lack endocrinologists to provide consultation and management of patients with uncontrolled diabetes. Our prior studies in 139 patients with diabetes attending rural, Federally Qualified Community Health Centers, demonstrated the utility of telemedicine to link patients with endocrinologists and markedly improve glycemic control. However, a critical limitation was the inability to achieve weight reductions, even with nutritional education.
Study Design: This pilot study utilized meal replacements linked to an integrated, technology-driven strategy for management of patients with uncontrolled diabetes in underserved areas. Primary and
secondary goals: Our primary goal was weight reduction and secondarily, improved glucose control.
Result: Eleven patients completed 3 months of the program and 7, the entire 6 months. In the 11 patients evaluated at three months, body weights dropped from 271±16 to 252±11 (SEM) pounds (P=0.002). The meal replacement diet was associated with a decrease in insulin requirements with doses falling from 221±41 to 129±23 (SEM) units daily (P=0.004). Hemoglobin A1c levels declined from 9.85±0.33% to 7.93±0.31% (SEM) (p=0.001). In the 7 patients completing the entire 6 months of the protocol, similar reductions persisted. Mean compliance with meal replacements on a scale of 0 to 10 ranged downward from 8.6 to 7.6 (P=NS) with increasing duration of study.
Conclusion: The study was unique in tailoring a program specifically to rural, underserved areas and demonstrated weight, insulin dose, and HbA1c reductions. The data now require confirmation of the use of meal replacements linked to multiple technologies in a future, randomized trial.

Keywords:Nutrisystem®D® meal replacement; Glucommander-outpatient; Telcare meter; telemedicine; Remote consultation; Federally qualified community health centers

Abbreviations: CDCES: Certified Diabetes Care and Education Specialists