CyberTherapy & Rehabilitation, Issue 4 (3), Fall 2011.

Issue 3 / 2011

Assessing theGlobal Rise inMetabolicDisorders

and much more...

T h e O f f i c i a l V o i c e o f i A C To R

ISSN 2031 - 278

FEATURES:How the Internet Can Aid Weight Lossp 34

Health Coaching and Life-Long Monitoring for Type 2 Diabetesp 38

COVER STORY:

PRODUCT COMPARISON:Devices for Managing Metabolic Disordersp 26

ASK THE EXPERTDon Jonesp 41

COUNTRY FOCUS:The United Arab Emiratesp 51

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The Virtual Reality Medical Center858.642.0267 [email protected]

www.vrphobia.com

1

Letter from the Secretary General and Editor-in-ChiefProfessor Dr. Brenda K. Wiederhold

Dear Reader,

Most of you reading this editorial live in an affluentsociety. You probably have a desk job, which requiresyou to sit most of the day. You probably drive a caror take a train or bus to work rather than walk. Youmay have a long commute, which may tempt youto pick up fast food or convenience food rather thancook healthy meals. The resulting poor nutrition andlack of exercise can lead to obesity, high blood pres-sure, and a general lack of fitness. Obesity predis-poses individuals to heart disease, diabetes, andsome types of cancer.

Another factor contributing to so-called “diseasesof affluence” is advances in medical care. Each gen-eration has less exposure to infectious agents andpathogens and more exposure to antibiotics thanthe last, resulting in a lack of natural immunities.This can lead to diseases such as asthma, allergies,and autoimmune disorders.

Finally, and most germane to our readers, is the tollthat stress makes us pay. Stress, combined with com-paratively independent lifestylesand the absence of strong socialbonds, may lead people to turn toalcohol, tobacco, or other drugs toself-soothe, and depression is com-mon.

Increasingly, we are seeing thesediseases of affluence not just inthe affluent segments of societies,but in the poorest individuals ofaffluent countries. They live in neighborhoods thatdiscourage walking and where fast food is plentifuland cheap. We are also seeing these diseases in-crease in countries experiencing rapid development,such as China and India. In China, the prevalence ofobesity and hypertension almost doubled over the

period 1991 to 2004, and became less concentrat-ed in urban areas. In India, estimated deaths fromnon-communicable diseases are projected to risefrom 40% of all deaths in 1990 to 67% of all deathsby 2020.

A study of allergic rhinitis in Korea found a doublingof prevalence in the 10-year period between 1991and 2001, noting that contributing factors might in-clude exposure to indoor allergens including petdander; outdoor air pollution; decreased consump-tion of fruits, vegetables, and fish; and a more seden-tary lifestyle. A recent review concludes that whilemore data from intervention studies are needed,atopic diseases (hyperallergic reactions such as al-lergic rhinitis, asthma, and dermatitis) “appear, atleast in part, to be the price paid for our relative free-dom from infections and parasitic diseases in afflu-ent societies.”

I encourage our readers to pay special attention tothe psychological costs of affluence. The proportion-ate share of the global burden of disease represent-ed by psychiatric and neurologic conditions is pro-

jected to rise from 10.5% in 1990 to 14.7% in 2020.In some countries, even wealthy adults must stillovercome the stigma associated with seeking helpfor mental health issues. Children in affluent fami-lies may manifest more substance abuse, anxiety,and depression.

“While society has evolved and our life expectancy hasincreased, our stress system remains mired in old evolutionarypatterns. Malfunction of the stress system may impair growth,development, behavior, and metabolism, leading to variousacute and chronic disorders.”

“A recent study showed that psychologicaldistress has been rising over time, and maybe associated with being overweight. Halfthe British population view themselves asoverweight , and happiness and mentalhealth are worse among overweight peoplein both the UK and Germany.”

A recent study showed that psychological dis-tress has been rising over time, and may be as-sociated with being over-weight. Half the Britishpopulation view them-selves as overweight, andhappiness and mentalhealth are worse amongoverweight people in boththe UK and Germany. Foreach 10-point rise in BMI,there is a drop in psycho-logical health of 0.3 Gen-eral Health Questionnairepoints. The authors notethat while suggestive, this does not establishcausality.

Many disorders are associated with a dysfunc-tion of the stress system: obesity, metabolic syn-drome, and type 2 diabetes; hypertension; au-toimmune disorders and allergies; anxiety,depression, and insomnia; and pain and fatiguesyndromes. While society has evolved and ourlife expectancy has increased, our stress systemremains mired in old evolutionary patterns. Mal-

function of the stress system may impair growth,development, behavior, and metabolism, leading

to various acute and chronic disorders. As re-searchers and clinicians engaged in cognitive re-habilitation, let us be mindful of the interrela-tionships among psychological and physicalhealth as we work to combat these diseases ofaffluence.

Letter from the Secretary General (continued from page 1)

“I encourage our readers to pay special atten-tion to the psychological costs of affluence ...Many disorders are associated with dysfunc-tion of the stress system: obesity, metabolicsyndrome, and type 2 diabetes; hypertension;autoimmune disorders and allergies; anxiety,depression, and insomnia; and pain andfatigue syndromes.”

Create your own reality!Brenda Wiederhold

2

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Professor Brenda K. WiederholdPh.D., MBA, BCIAEditor-in-ChiefC&R MagazineBelgium

Emily ButcherManaging EditorInteractive Media InstituteUSA

Professor Rosa M. Baños, Ph.D.University of Valencia Spain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Universite du Quebec en Outaouais (UQO)Canada

A.L. Brooks, Ph.D.Aalborg UniversityDenmark

Professor Paul M.G. Emmelkamp, Ph.D. University of AmsterdamThe Netherlands

Professor Luciano Gamberini, Ph.D.University of PadovaItaly

Professor Sun I. Kim, Ph.D.Hanyang UniversityKorea

Professor Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaCroatia

Professor Paul Pauli, Ph.D.University of WürzburgGermany

Professor Simon Richir, Ph.D.Arts et Metiers ParisTechFrance

Professor Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoItaly

Professor Paul F.M.J. Verschure, Ph.D.Universitat Pompeu FabraSpain

Professor Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterUSA

Professor XiaoXiang Zheng, Ph.D.Zhejiang UniversityP.R. China

C&R Editorial BoardGENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute (VRMI), 64 Rue

de l'Eglise, Boite 3, 1150 Woluwe-Saint-Pierre, Belgium and

the Interactive Media Institute, 9565 Waples Street, Suite 200,

San Diego, CA 92121, U.S.A. The magazine explores the uses

of advanced technologies for therapy, training, education,

prevention, and rehabilitation. Areas of interest include,

but are not limited to, psychiatry, psychology, physical

medicine and rehabilitation, neurology, occupational ther-

apy, physical therapy, cognitive rehabilitation, neuroreha-

bilitation, oncology, obesity, eating disorders, and autism,

among many others.

PUBLISHING HOUSEVirtual Reality Medical Institute BVBA

64 Rue de l'Eglise, Boite 3

1150 Woluwe-Saint-Pierre

Belgium

Telephone: +32 2 770.93.33

Fax: +32 2 762.93.33

E-mail: [email protected]

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Brenda K. Wiederhold, Ph.D., MBA, BCIA

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Nyomda

ADVERTISING For advertising information, rates, and specifications please

contact Virtual Reality Medical Institute, 64 Rue de l'Eglise,

Boite 3, 1150 Woluwe-Saint-Pierre, Belgium, Telephone: +32

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REPRINTSIndividual article reprints are available from corresponding

authors. Please contact the publisher for rates on special

orders of 100 or more.

MANUSCRIPTSSubmissions should be addressed to the C&R Managing Ed-

itor, Virtual Reality Medical Institute: [email protected].

COPYRIGHTCopyright © 2011 by Virtual Reality Medical Institute. All rights

reserved. CyberTherapy & Rehabilitation Magazine is owned

by Virtual Reality Medical Institute BVBA and published by the

Virtual Reality Medical Institute BVBA. Printed in Hungary.

With the exception of fair dealing for the purposes of re-

search or private study, or criticism or review, no part of this

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For permission to photocopy an article for internal purpos-

es, please request permission and pay the appropriate fee

by contacting [email protected].

The accuracy of contents in CyberTherapy & Rehabilitation

Magazine are the responsibility of the author(s) and do not

constitute opinions, findings, conclusions, or recommenda-

tions of the Publisher or editorial staff. In addition, the Pub-

lisher is not responsible for the accuracy of claims or infor-

mation presented in advertising portions of this publication.

CyberTherapy & Rehabilitation Magazine is currently indexed with PsycEXTRA.

Cover: Image supplied courtesy of original artist Michelle Del Rosario and revised by Toni Chen.

LETTER FROM THE EDITOR-IN-CHIEFB. Wiederhold p 1

COVER STORYReigning in the Shocking Rise in Metabolic DisordersB.K. Wiederhold, C. Valenti, M.D. Wiederhold p 12

FEATURESmHealth for Diabetes Patients G. Schreier, P. Kastner p 14

Next-generation Obesity Prevention/Treatment ResearchS. Persky p 16

A Telemedicine Initiative for Metabolic SyndromeC.R. Jones, R.B. Cardoso, T. Russomano p 18

Smartphones in Diabetes Care and ManagementM.N.K. Boulos p 20

VR in the Assessment and Treatment of EDG. Riva p 22

Patient-centered Care to Treat Metabolic DiseasesA. Lazzero, M. Romano p 24

PRODUCT COMPARISON CHARTProducts to Treat Metabolic Disorders p 26

Tele-Homecare Systems for Chronic Patient CareA.H. Isik, I. Güler p 28

FDA Denies Approval for Anti-Obesity DrugsE. Butcher p 30

Why Patients Choose to Use TelemedicineH. Park, Y.C. Chon, K.H. Yoon p 32

Weight Loss Via the Internet L. Valentini p 34

Addressing the Global Rise in Eating DisordersA. Ines p 36

Health Coaching and Monitoring for Type 2 Diabetes L. Ribu, M. Lange, G.E. Dafoulas, E. Årsand p 38

ASK THE EXPERTD. Jones p 41

FROM WHERE WE SITG. Riva p 45

FURTHER AFIELDL. Kong p 46

COUNTRY FOCUSThe United Arab EmiratesE. Butcher p 51

TABLE OF CONTENTS

7

VR for the Management ofObesity and Eating Disorders

Due to the sensitive nature of eating disor-ders, assessing real-life behaviors and choic-es can be unrealistic and tedious, but withthe help of Virtual Reality researchers andtherapists are now mimicking real situationsin a clinical setting to assess actions and bet-ter diagnose cases of the debilitating disease.

Telemonitoring and Real-TimeEvaluation of Data

A growing trend in patient-centric care ismade user friendly by the use of mobilehealth devices, including applications forsmartphones that wirelessly collect datafrom a number of self-monitoring devices.Here, a patient transmits his recently meas-ured blood pressure data by bringing hisNear Field Communication (NFC) enabledmobile phone close to the NFC enabledblood pressure device. This field bringstogether diverse companies and will seeexplosive growth in upcoming years.

19-22 June, 2011Gatineau, Canada16th Annual CyberPsychology

& CyberTherapy Conference

Highlights of the

Become Part of the iACToR Community at CYBER17 and Experience the Future Now!

12-15 September, 2012 - Brussels, Belgium - http://www.interactivemediainstitute.com

Keynote Lecture:Frank Biocca

Pre-conference Workshops on Advanced Topics

Poster Sessions

Group Lunches and Networking Breaks

Cyberarium for Research Projects

Conference CoordinatorGenevieve Robillard

Awards Ceremony

Interactive Exhibits

T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n

8

9

The 16th Annual CyberPsychology & CyberTherapy Conference:Evidence-Based Clinical Application of Information Technology(CYBER16), the official conference of the International Associa-tion of CyberPsychology, Training & Rehabilitation (iACToR) washeld June 19-22, 2011 in Gatineau, Canada. Co-organized byBrenda K. Wiederhold, Ph.D., MBA, BCIA of the Interactive Me-dia Institute and Stéphane Bouchard, Ph.D. of Université duQuébec en Outoauais, CYBER16 was truly an international suc-cess setting directions for advancements in the growing disci-plines of cyberpsychology, cybertherapy, training, and rehabili-tation.

The quality and significance of the work presented at CYBER16

reaffirms that advanced technologies are increasingly playing asignificant role in healthcare. CYBER16 further strengthened andadvanced efforts to improve healthcare through technology, andexplored ways to take advantage of remarkable transformationsthat are occurring.

CYBER16’s theme was twofold. First, it explored how technolo-gies are currently being used as enabling tools. This includedthe use of advanced technologies such as Virtual Reality (VR)simulations, videogames, telehealth, videoconferencing, the In-ternet, robotics, brain-computer interfaces, wearable comput-ing, and non-invasive physiological monitoring devices, in diag-nosis, assessment, and prevention of mental and physicaldisorders. In addition, interactive media in training, education,rehabilitation, and therapeutic interventions were discussed.Second, the conference investigated the impact of how new tech-nologies are being used to influence behavior and society. Theconference also began its exploration into how social network-ing tools such as Twitter and Facebook are influencing individ-ual behavior and personal relationships.

Under the direction of Workshop Chair Heidi Sveistrup, Ph.D.,the conference kicked off with pre-conference workshops onSunday, the 19th of June, which focused on multiple aspectsof cybertherapy. Sunday concluded with a welcome receptionat the Les Brasseurs du Temps, a traditional Canadian micro-brewery.

The conference officially began on Monday, the 20th of June,with welcome remarks from the Conference Co-Chairs, Profes-sor Brenda K. Wiederhold and Professor Stéphane Bouchard. Mon-day’s program included a rousing keynote address by guest speak-er Frank Biocca, Ph.D. who spoke on Modulating Presence andEffectiveness in Virtual Health Environments, as well as a wel-come from André Manseau, the Dean of Research at Universitédu Québec en Outaouais and Marc Bureau, mayor of Gatineau.Two parallel sessions in the morning and afternoon, followed bya large poster session made up the remainder of Monday at CY-BER16. The poster session gave opportunities for developers andscientists to demonstrate their work and converse, one-on-one,with interested spectators and colleagues.

A busy Tuesday opened with a presentation by guest speakersFrancis Fortin and Jean-Pierre Gray, Ph.D. regarding new trendsin child pornography research and investigation. Six parallel ses-sions with topics including cybertherapy for anxiety disorders,

outcome trials for anxiety disorders, developing new tools andtechnologies, paradigms and phenomenology of cyberspaces,PTSD prevention and new treatment tools and applications oftelehealth, made up the bulk of the day. An awards ceremonytook place during lunch with three categories of awards givenfor outstanding achievements in CyberPsychology & CyberTher-apy. Included in the award presentation was the 7th Annual Cy-berTherapy Lifetime Achievement Award, the Annual CRC-Clin-ical Cyberpsychology New Investigator Award, and four studentposter awards sponsored by the Virtual Reality Medical Instituteand Mary Ann Liebert, Inc. Tuesday’s scientific program conclud-ed with the 3rd Annual General Assembly of iACToR which wascoordinated by Secretary General Brenda K. Wiederhold and ledby reelected President Professor Giuseppe Riva. The General As-sembly invited members from over 20 countries to convene toreview relationships made with other associations, conferencesand publications. The General Assembly then discussed how tobring about more rapid innovation in the advanced technolo-gies and healthcare arenas. The conference concluded on Tues-day with a social dinner at the Casino du Lac Leamy.

From the full day of pre-conference workshops to the ground-breaking scientific program, CYBER16 continued its role as theleading conference in designing the future of cyberpsychologyand healthcare. It is with sincere appreciation and gratitude thatwe thank the many that made this conference possible. Thisyear’s scientific committee co-chairs, Paul Emmelkamp, Ph.D.,Wijnand Ijsselsteijn, Ph.D. and Giuseppe Riva, Ph.D. were instru-mental in providing one of the best scientific and social pro-grams to date. The conference was also graciously sponsored byinstitutions and organizations whose important contributionsallowed for a vibrant conference including Casino du Lac Leamy,the European Commission, Information Society and Media, Gou-vernement du Québec, Interactive Media Institute, INTERSTRESS(EU-funded project), Istituto Auxologico Italiano, Mary Ann Liebert,Inc., National Institute on Drug Abuse, Université du Québec enOutaouais, Ville de Gatineau, Virtual Reality Medical Center, Vir-tual Reality Medical Institute, WorldViz and 3dVia. CYBER16 fol-lowed in the footsteps of many collaborative efforts that haveallowed for the Annual CyberPsychology & CyberTherapy Con-ference to continue to shape the direction of the cyberpsychol-ogy discipline, a tradition which will continue at the 17th Annu-al CyberPsychology & CyberTherapy Conference (CYBER17).

CYBER17 will be held September 12-15, 2012 in Brussels, Bel-gium. The conference will continue to explore the uses of ad-vanced technologies such as VR, videogames, telehealth, the In-ternet, robotics, brain-computer interfaces, wearable computing,mobile computing, social networking, and non-invasive physio-logical monitoring devices, in the diagnosis, assessment, andprevention of mental and physical disorders as well as assess-ment of interactive media in training, education, rehabilitation,and therapeutic interventions. Locating the conference in Brus-sels provides a unique opportunity to raise the visibility of theseissues throughout the world and to allow CYBER17 to continueits storied legacy of organizing a truly international conference.Prominent academic representatives from Europe, North Amer-ica, and Asia will serve as Scientific Chairs and on its ScientificCommittee. Professor Brenda Wiederhold, who divides her timebetween the U.S. and Europe and serves as Secretary General ofiACToR (http://iactor.ning.com), will serve as the conference’schief organizer and host.


By James Cullen

News from iACT0R MembersOrganization grows worldwide as Special Interest Groups/Regional Chapters are established

Join the iACToR community by visitingiactor.ning.com today!

As the official association of CyberThera-py & Rehabilitation, we will be bringing youupdated news of various special interestgroups and regional chapters of the Inter-national Association of CyberPsychology,

Training & Rehabilitation (iACToR) as theygrow and expand throughout the year. Asthe organization becomes more well-estab-lished, it is further strengthened by grow-ing numbers from around the globe. We

welcome iACToR members, as well as ourreaders, to submit content and updates, aswell as suggestions for new groups. You cando so by reaching the Managing Editor [email protected].

Mexican iACToR ChapterInformation provided by Georgina Cardenas

A Mexican chapter of iACToR is being represented by the VirtualTeaching and Cyberpsychology Lab at the School of Psychology ofthe National Autonomous University of Mexico (UNAM), led byProf. Georgina Cárdenas-López since 2001. The main purpose ofthis laboratory is to create a shared collection of participative knowl-edge for the incorporation of advanced technologies in the virtu-al teaching of psychology and psychotherapy interventions.

The laboratory conducts teaching and research projects focusingon the development of computer-based tutorials and virtual sim-ulators to teach clinical practices in the treatment of anxiety dis-orders and family violence interventions. The current areas of re-search include evaluating an e-therapy program as a trainingscenario and conducting studies to determine its efficiency in Lati-no populations living abroad. The team’s members also focus onconducting studies to understand the relevance of Virtual Reality(VR) cross-cultural validation as a dissemination strategy in thefield and continue to develop virtual environments to treat social-

ly relevant problems in Mexico, such as criminal and family vio-lence, obesity and addictions.

One of the principal objectives of the lab is to open new researchlines devoted to technological development and applied research inpsychology, focusing on solving and addressing psychological prob-lems of high social relevance. This is the case for a project address-ing Posttraumatic Stress Disorder in victims of criminal violence, in-cluding the treatment program for Complicated Grief and Depressionin residents of Ciudad Juarez, among others. It is also an aim of thelab to collaborate with other groups and institutions from differentcountries, and to create collaborative interdisciplinary groups.

The lab is currently made up of 26 members including professors,researchers, graduates and undergraduate students that continueconducting research using advanced technologies and VR in a vari-ety of fields, and are highly motivated in communicating with otherscientists.

Stay abreast of new topics and technology by following or joiningthe group on http://iactor.ning.com.

Student Special Interest GroupSIG Leader: Willem-Paul Brinkman

The International Association of CyberPsychology, Training & Reha-bilitation’s (iACToR) Student Special Interest Group (SIG) has recent-ly become active in contributing to the CyberTherapy & Rehabili-tation Magazine’s Country Focus column, which features an in-depthlook at mental healthcare in countries around the globe.

As part of their research, Ph.D. Students will have the opportunityto interview experts in the field, exploring ways in which advancedtechnologies are improving healthcare and learning more about thehistory and future of medicine and psychology in their native re-gions. The SIG group aims to foster interaction between establishedspecialists and students by encouraging interaction and exchang-ing of information between the two groups.

iACToR’s Student SIG supports fellow students with their researchand education in this area. Our members are primarily students,

but membership is also open to other iACToR members that liketo help students to become professionals.

The group aims to connect students and encourages the exchangeof information among members that are of interest to students,dealing with issues such as conducting research, publishing yourwork or developing a career in this area. Furthermore, the groupalso helps in bringing members in contact with the leaders ofthe community. It promotes the interests of students in gener-al, and specifically in the association, and the events it organiz-es or endorses.

We encourage interested students to join the group. By joining, youwill have access to online material relevant for students. You willalso be able to develop your international network, and have an op-portunity to interact with your peers.

Become a member today by joining the Student Special Interest Groupon http://iactor.ning.com.

10

Editor-in-Chief Brenda K. Wiederhold, PhD, MBA, BCIA

Impact Factor: 1.591* 2009 Journal Citation Reports® published by Thomson Reuters, 2010

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“Diabetes, just one of the many metabolic disorders common worldwide,demonstrates how crucial prevention is in trying to control the epidemic ... Itwas estimated that 6.4% of the world’s adult population suffered from dia-betes in 2010, and in the next twenty years that number is projected toalmost double. Prevention and management facilitated through the use ofremote monitors, wireless technology and cell phone apps will encouragepeople to take action in their own health.”

12

Reigning in the ShockingRise in Metabolic Disorders

By Brenda K. Wiederhold, Christina Valenti & Mark D. Wiederhold

With drastically increasing numbers ofpeople dying from diseases such as dia-betes, obesity and heart disease, it hasbecome evident that metabolic disordersare a field in need of a large amount ofattention and research. The term meta-bolic disorder describes any conditionthat disrupts the metabolic process orcauses it to malfunction in any way.While some of these conditions arehereditary, many metabolic disorders to-day are developed as a byproduct oflifestyle and could be, idealistically, pre-vented. In addition, metabolic disordersstem from a multitude of factors, ratherthan a single gene or mutation, increas-ing the chances of developing more thanone medical condition. This domino ef-fect of comorbidity, along with the grow-ing number of people exhibiting symp-toms characteristic of developing ametabolic disorder, called metabolic syn-drome, is forcing healthcare providers tomake prevention as well as treatment amain priority.

Diabetes, just one of the many metabol-ic disorders common worldwide, demon-strates how crucial prevention is in try-ing to control the epidemic. Accordingto the International Diabetes Federation,it was estimated that 285 million people,or 6.4% of the world’s adult population,

suffered from diabetes in 2010, and inthe next twenty years that number is pro-jected to almost double to 438 million.Diabetes too, is not just an issue afflu-ent countries are encountering, wheremeals consist of sugary foods packed withsimple carbohydrates, but is affecting de-veloping nations as well; India and Chi-na are the current leaders with the high-est number of people diagnosed withdiabetes. People are also beginning todevelop an impaired glucose tolerance(IGT), or elevated levels of glucose, great-ly increasing the risk of developing dia-betes as well as cardiovascular disease.In addition, with the vast majority of cas-es of diabetes being Type 2, efficient andcost-effective ways of preventing and con-trolling the disease are a must.

Patient-centric care, based on providingpatients with easy and convenient waysto monitor their own condition, will notonly encourage people to take a more ac-tive role in their health, but will also helpreduce healthcare costs. Small wearabledevices, like the CommanderFlex, moni-tor important information needed tomanage conditions such as diabetes, highblood pressure and cholesterol, chronicobstructive pulmonary disease (COPD),chronic kidney disease, and renal disease,by monitoring nutritional intake and

physical activity. This information canthen be wirelessly transmitted to health-care providers. Also, a new form of mo-bile health is developing, as shown by theproduct created by Ford Motor Compa-ny and WellDoc, a company devoted toimproving technology for managingchronic conditions. The two have recent-ly teamed up to design the WellDoc Di-abetesManager® System: an in-car sys-tem that helps manage diabetes byallowing the driver access to their med-ical information, like vitals and medica-tions, as well as wireless capabilities fromtheir car, bringing constant care to pa-tients as they drive.

Countries and research labs throughoutthe world are also teaming up to test thelarge-scale efficacy of telemedicine serv-ices. Renewing Health, a collaborationbetween nine European regions and theEuropean Commission, is a project con-sisting of real-life trials that will evaluatepersonalized telemonitoring services forthe management of chronic disorderslike diabetes, COPD, and cardiovasculardiseases. Large-scale implementation oftelemonitoring systems could help theoverall management and prevention ofchronic diseases, as well as alleviate theburden of healthcare costs by facilitatingaccess to care from remote locations.

COVER STORY


A staggering number of related applicationsfor smartphones are being developed aswell, efficiently utilizing a device users car-ry everyday and adopting it into one thatmonitors medical conditions on-the-go. TheAustrian Institute of Technology has devel-oped a system, DiabMemory, that utilizesKeep in Touch (KIT) technology allowingusers to access health-related informationfrom different monitoring devices, like a glu-cose monitor, through an application ontheir smartphone. Patient in your Pocket,designed for healthcare professionals anddeveloped by the Computer Science Corpo-ration (CSC), is a mobile application for Black-Berry smartphones and PlayBooks thatsends updates on patients in real-time tothe device, and allows the user to update in-formation as well as schedule and keep trackof appointments. These and similar apps,like the WaveSense Diabetes Manager Appfor the iPhone, iPad, and iTouch, are avail-able for only a few dollars or even free. Us-ing everyday devices like smartphones helpsusers take small steps to take control overtheir condition.

Since prevention for these diseases is key,education about the role that obesity andovereating play in developing metabolic andother chronic disorders has become the fo-cus of many prevention programs. Weightloss pills and workout regimens are not lack-ing by any means, but no universal methodhas been developed that will ensure lastingresults. Part of the reason why losing weightand keeping it off is so hard to achieve, andwhy there is no one way that guarantees suc-cess, is because the factors that lead toweight gain are different for every individ-ual. Genetics, lifestyle, money, environment,and psychological health intersect in infi-nite ways, and all need to be consideredwhen assessing one’s condition. Personal-ized routines designed to fit each individualand thorough care are necessary to reduc-ing one’s weight, rather than a one-size-fits-all workout or diet plan. In addition, obesi-ty is more than just a physical condition; itis now being considered a psychological oneas well. Biological science can tell us aboutthe metabolic processes that contribute toweight gain, but psychologists have foundthat it can be a mental concern, as much asa biological one, when trying to devise meth-ods of prevention and treatment, and mod-ifying behavior is powered by the mind.

Cognitive behavioral therapy (CBT), whichhas been proven effective for treating sub-

stance abuse addictions and other psycho-logical issues like anxiety, depression, andphobias, is now being applied to obesity bychanging behavior gradually and modify-ing attitudes towards food and eating. Theidea behind CBT for weight loss is thatone’s eating habits are learned, and there-fore can be re-taught through small shifts

in one’s behavior that increase as progressis made. CBT programs start with an as-sessment by a physician of a patient’s over-all condition and lifestyle, from medical his-tory to daily routine, as well as theindividual’s environment, to determinewhat factors trigger overeating. From there,gradual goals are set for the patient thatare altered as therapy progresses increas-ing the likelihood of long-term sustainabil-ity, whereas drastic cuts in diet and rigor-ous exercise can be unhealthy and harderto maintain over extended periods of time.Support from healthcare professionals, aswell as the people that surround an indi-vidual, is also emphasized in CBT, and pa-tients are encouraged to join supportgroups. Mobile and wireless communica-tions like IM and video chat also make sup-port more accessible, further increasingchances of success.

Virtual Reality (VR) is being used in con-junction with CBT in an effort to modifybehavior in a setting that reflects reality,yet one that is private. VR is increasinglybeing used in cases where psychologicalcauses, for example, eating disorders likebinge eating and purging, are associatedwith weight gain, body dysmorphia, andnegative perceptions of self. VR works wellalongside CBT because it too can easily bedesigned to fit the specific needs of a pa-tient. By immersing patients in a life-likesetting, VR aims to identify what cues con-tribute to one’s habits, help the patientidentify how the cues make him or her feel,and then, with the help of a healthcare pro-fessional, develop self-efficacy by findingways to overcome the triggers and nega-tive emotions associated with them. Newstrategies are devised throughout the

process to discover the best solution forthe patient, and gradual modifications aremade to one’s activity and diet. What givesVR its edge, though, is that it is done in anon-threatening environment, where thepatient can cope with their issues awayfrom public scrutiny. Despite initial start-up investment, using VR in the short-term

to produce long-term effects will outweighthe cost of a lifetime of suffering from adebilitating condition.

Prevention and management facilitatedthrough the use of remote monitors, wire-less technology and cell phone apps willencourage people to take action in theirown health. In addition, CBT and VR ther-apy target the roots of harmful habits thatinevitably cause people to develop lifechanging medical conditions. With the suc-cess of many current mainstream meth-ods of treatment faltering, hope for reha-bilitation lies in the development of newconvenient telemonitoring devices andwithin the confines of virtual worlds. To-gether these innovations could bring peo-ple who suffer from metabolic and chron-ic disorders all over the world the reliefthey’ve been waiting for.

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Small wearable devices monitor important informationneeded to manage conditions such as diabetes, high bloodpressure and cholesterol, chronic obstructive pulmonary dis-ease chronic kidney disease, and renal disease, by monitoringnutritional intake and physical activity.”

[ ]Brenda K. Wiederhold, Ph.D.,MBA, BCIAVirtual Reality Medical InstituteBrussels, [email protected]

Christina ValentiInteractive Media InstituteSan Diego, California

Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterSan Diego, [email protected]

www.vrphobia.eu

COVER STORY


“

The management of patients with chronic diseases in gen-eral and diabetes mellitus, in particular, requires a dedi-cated infrastructure to support patients and doctors incommunication and intensive collaboration, without theneed for frequent face-to-face meetings. Pervasive health-care is a term that draws on mobile communication de-vices and the Internet as well as concepts like ubiquitouscomputing and ambient intelligence. The term “mHealth”is being more and more commonly used to encompassthese ideas of patient-centered, prevention-oriented, anddecentralized health management and treatment of chron-ic conditions using mobile and wireless communicationtechnologies.

During the last decade the eHealth & Ambient AssistedLiving team of the Austrian Institute of Technology (AIT)has developed and evaluated a variety of mHealth solu-tions for people with chronic conditions, among them pa-tients with:

1. Metabolic diseases (diabetes, obesity)

2. Cardiovascular diseases (chronic heart failure, hy-pertension, pulmonary arterial hypertension)

3. Dermatological diseases (psoriasis)

and, in general, also for elderly people that need assistivetechnologies, e.g., to improve medication compliance.

About a year ago we started with a proof-of-concept tele-diabetes project in collaboration with the Austrian Insur-ance Institution for Railways and Mining Industry. In thecourse of this project diabetes patients are equipped witha mobile phone-based telemedicine system based on theKeep In Touch (KIT) technology. KIT is a concept for intu-itive human computer interfacing that uses smart objectsand wireless technologies like Near Field Communication

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DiabMemory – mHealth forDiabetes Patients Based onKeep In Touch TechnologyChronic conditions, such as metabolic disorders including diabetes, call forlong-term adherence to treatment on the patient’s behalf. “mHealth” worksto address this need and “is being more and more commonly used toencompass these ideas of patient-centered, prevention-oriented, and decen-tralized health management and treatment of chronic conditions usingmobile and wireless communication technologies.”

FEATURES

Figure 1: A patient transmits his recently measured blood pressure val-ues simply by bringing his Near Field Communication (NFC) enabled mo-bile phone close to the NFC enabled blood pressure device (UA 767 plusNFC, A&D Company, Tokyo, Japan).


By Günter Schreier & Peter Kastner

(NFC) and Radio Frequency Identifica-tion (RFID). KIT enables people to col-lect information from health-relateditems of their daily life by simplytouching those things with their NFC-enabled mobile phones.

Patients are equipped with NFC-en-abled mobile phones with a pre -in-stalled diabetes application and a vary-ing set of medical measurementdevices (glucose meter, blood pressuredevice, weight scales), depending ontheir disease conditions (type 1 or type2 diabetes mellitus, type of therapy andmedication). A dedicated mHealth serv-ice platform provides for mobile phoneand Web-based access for patients anddoctors and features a diabetes specif-ic electronic patient record, communi-cation via E-mail and Short MessageService (SMS), data storage and process-ing, and trend curve visualization, aswell as support for device managementand logistics. The whole system is des-ignated “DiabMemory.”

The project will be subject to an ex-tensive evaluation program. Amongthe issues to be assessed are variousmeasures of patient compliance. SinceMay 2010, more than 250 patientshave been enrolled in the program. Ini-tial results indicate that most patientsstay in the program and do send ahigh percentage of the measurementsas compared to the predefined record-ing and transmission schedule. Thisindicates that the concept is well ac-cepted by the patients.

Currently, physicians use the dedicat-ed Web accessible system using theirindividual credentials. In the future,we will provide them with a more di-rect access to the system by linkingthe DiabMemory system to the up-coming Austrian national electronichealth record system.

DiabMemory, i.e., the combination ofthe KIT-based user interface and theunderlying Closed Loop Healthcare

services, is a step towards pervasivehealthcare that allows to not onlybridge barriers with respect to space(“anywhere”) and time (“anytime”) butalso with respect to “anything.” All rel-evant items that are important for agiven monitoring scenario like sensors(e.g., medical measurement devices)and actuators (e.g., medication blis-ters and dispensers) become “smartobjects” and thus can be a part of thepervasive health and care infrastruc-ture that supports patients and elder-ly people with various chronic condi-tions (“anyone”).

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[ ]Günter SchreierPeter KastnerAIT Austrian Institute of Technology GmbHAustria

[email protected]

FEATURES


Figure 2: Keep In Touch (KIT) provides for

intuitive and seamless acquisition of various kinds of monitoring data just by touching icons and sensor devices with a

Near Field Communication (NFC) enabled mobile phone.

Scientific discovery in the field of ge-nomics is accelerating and will increaseunderstanding of how genetic makeuptogether with behavioral factors con-tributes to obesity and its co-morbidi-ties. However, determining how to op-timally incorporate this new knowledgeinto medicine and public health to pre-vent and treat obesity will be a consid-erable challenge in coming decades.Currently, we know very little about howpatients and health care providers willrespond to genomic information andthe impact it will have on their deci-sions and behavior. To ensure effectivetranslation, researchers need to evalu-ate possible impacts of genomic knowl-edge ahead of its application. Our re-search group in the Social andBehavioral Research Branch of the Na-tional Human Genome Research Insti-tute uses immersive Virtual Reality (VR)research tools to do exactly that.

In our Immersive Virtual EnvironmentTesting Area, we explore these antici-pated situations through VR-enabled re-search. My collaborators and I attemptto identify optimal ways of integrating

genomic information into clinical en-counters with patients who are over-weight or obese. We aim to discoverways that this information can promotepositive social outcomes, for example,reducing stigmatization of patientsbased on their weight. At the sametime, we also investigate if and how ge-nomic information can promote healthydietary and physical activity behavior.

To explore these issues, we developeda basic VR-based clinical encounter sim-ulation. Using this tool, my collabora-tor Dr. Collette Eccleston and I investi-gated how providing information aboutgenetic underpinnings of obesity tomedical students effected patient careand treatment. Because the patient inthe study was virtual, we could manip-ulate whether she appeared to be obeseor not while holding all other variablesconstant. The virtual patient told med-ical students about her symptoms andconcerns, and medical students wereasked to advise and make decisionsabout the patient’s care while wetracked their responses and behaviors.This research demonstrated that pro-

viding information about the geneticunderpinnings of obesity as part of aclinical encounter with an obese pa-tient reduced the extent to which med-ical students stereotyped and avoidedeye contact with that patient. At thesame time, however, it also reduced therates at which they recommendedhealth behavior and weight manage-ment consultation as part of her care.The latter outcome raised concerns thatdissemination of genomic knowledgecould undercut efforts to engage pa-tients in health-promoting behaviors.

In current work, my collaborators andI examine the effect of physician-pro-vided genetic information on patientswho are overweight. In the virtual clin-ic, patients encounter a physician whoadministers weight counseling infor-mation while using different commu-nication approaches. In this way, we caninvestigate whether these communica-tion approaches might mitigate nega-tive social or behavioral consequencesor amplify positive consequences ofproviding patients with genetic obesi-ty risk information.

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Next-generationObesity Prevention andTreatment Research“The application of Virtual Reality (VR) tools for obesity prevention and treat-ment research is still relatively rare. Our goal in the Immersive VirtualEnvironment Testing Area is to build a collection of VR research scenariosthat will enable us to investigate new questions related to genomic applica-tions for weight management and obesity prevention as they emerge in stepwith scientific advancement.”

By Susan Persky

FEATURES


We initially chose to employ VR meth-ods for this research as opposed to moretraditional ones (e.g., hypothetical vi-gnettes, standardized patient or clinicianactors) for a few important reasons. Inthe VR clinic our participants can direct-ly experience and respond to situationsthat are forecast to occur in the future,but are not yet a reality. At the sametime, we can study aspects of the sce-nario (e.g., the type of genomic informa-tion introduced, the communication ap-proach of the clinician) in a manner that

is standardized between participants. Wealso use VR to embed measures of be-havior, like a clinician’s level of eye con-tact with a virtual patient, in the researchcontext.

Moving beyond the clinical context, wehave also developed immersive VR en-vironments that serve as stand-alone be-havioral measures. We recently createda VR model of a buffet restaurant for anongoing study in collaboration with Dr.Colleen McBride. The study investigates

how the provision of genomic informa-tion about a young child’s obesity riskaffects mothers’ food choices for thatchild. In the virtual restaurant mothersfill a plate with various foods. We meas-ure calorie content of the food choicesto provide a rigorous behavioral out-come. Although the VR restaurant cur-rently lacks some sensory modalities(e.g., smell), it does offer practical ben-efits and allows sensitive measurementof mothers’ engagement with the food(e.g., food choice order).

The application of VR tools for obesityprevention and treatment research is stillrelatively rare. Our goal in the ImmersiveVirtual Environment Testing Area is tobuild a collection of VR research scenar-ios that will enable us to investigate newquestions related to genomic applica-tions for weight management and obe-sity prevention as they emerge in stepwith scientific advancement.

17

FEATURES


[ ]Susan Persky, Ph.D.National Human Genome ResearchInstitute, National Institutes of HealthUSA

[email protected]://www.genome.gov/27533900

Figures 1, 2: Screen shots from the Immer-sive Virtual Environment Testing Area featur-ing the clinical encounter simulation (below)and VR model of a buffet restaurant (right).

“In the virtual clinic ... we can investigate whether these com-munication approaches might mitigate negative social or be-havioral consequences or amplify positive consequences of pro-viding patients with genetic obesity risk information.”

Metabolic syndrome describes a collec-tion of risk factors that are primarily as-sociated with the development of dia-betes and coronary artery disease, buthave also been implicated in non-alco-holic fatty liver, stroke and certain can-cers. Chronic non-communicable dis-eases such as these are responsible for60% of global deaths and cardiovasculardiseases are leading the way. The mor-bidity and mortality attributable to theseconditions are enormous and highlightthe need for expeditious managementand risk factor prevention. Worryingly, thenumber of people displaying features ofthe metabolic syndrome is increasing allover the world. Specifically, 25% of theadult population in Europe and the Amer-icas are thought to meet the syndrome’scriteria.

Most patients with metabolic syndromecan be adequately managed within pri-mary care, where the family physician willaddress each component individually inorder to prevent future problems. How-ever, there will be some complicated cas-

es that require specialist input, such asevaluation by a cardiologist or an endocri-nologist, in order to prevent or treat com-plications. A recent overhaul of the Brazil-ian health system has improved primarycare access to a level that would previ-ously have been unimaginable and theconsequent progress in public health isencouraging. Nevertheless, problems stillremain – Brazil is a country of continen-tal proportions that experiences signifi-cant social and health inequalities andaccess to specialist care is poor outsideof big cities. This provides the perfect are-na within which eHealth can flourish.

The eHealth revolution is upon us. Tech-nology has penetrated every aspect ofhealthcare at an unprecedented rate, froman organizational and administrative lev-el to the front-line delivery of services. Itis simultaneously enhancing the qualityof healthcare provided and reducing costs;thus it comes as no surprise that eHealthis working its way up the political agen-da, both nationally and internationally.

At Pontifícia Universidade Católica do RioGrande do Sul (PUCRS) we have organizedseveral successful telemedicine projectsover the last five years. The focus has been

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eHealth Initiatives Can Improve Access to Healthcare in Remote Areas

A New Approach to the Managementof Metabolic Syndrome:A Telemedicine Initiative

“The eHealth revolution is upon us. Technology has penetrated every aspectof healthcare at an unprecedented rate, from an organizational and adminis-trative level to the front-line delivery of services. It is simultaneously enhanc-ing the quality of healthcare provided and reducing costs; thus it comes asno surprise that eHealth is working its way up the political agenda, bothnationally and internationally.”

“One of the key barriers to the adoption of In-ternet-based telemedicine initiatives in manycountries is a lack of bandwidth; some remote areasdo not enjoy any Internet coverage. On the otherhand, the mobile network is present almostuniversally.”

FEATURES


By Christopher R. Jones, Ricardo B. Cardoso & Thais Russomano

on specialist second opinion delivery in re-mote areas of Brazil covering dermatology,cardiology, odontology, ophthalmology andpharmacology. In July 2010, we conducteda multidisciplinary eHealth assistance proj-ect in a remote region of the Brazilian Ama-zon in collaboration with the State Univer-sity of Amazonas (Figure 1). Through thisproject we were able to provide rural Brazil-ians with access to secondary care withoutthem having to leave their communities.There were many patients with features ofmetabolic syndrome, some of whom werenot being managed optimally. Recommen-dations were made for future managementthat will hopefully help to prevent the de-velopment of serious com-plications.

An underlying theme ofour work in Brazil hasbeen to provide people liv-ing in remote areas withaccess to specialist carevia telemedicine that theymay otherwise not receive(Figure 2). Although Brazilhas good access to pri-mary care, the area ofmedicine that traditional-ly caters to the components of metabol-ic syndrome, many countries in the worlddo not. Rural healthcare in such countries

is delivered by non-medically trained com-munity health workers. Our model couldbe used by community health workers tointeract with physicians and optimizemanagement of patients. Furthermore, itprovides a reliable source of informationfor those community health workers wish-ing to further their knowledge. We believethat our multidisciplinary eHealth modelcould potentially be adapted and appliedin any setting around the world with ac-cess to an Internet connection.

One of the key barriers to the adoption ofInternet-based telemedicine initiatives inmany countries is a lack of bandwidth;

some remote areas do not enjoy any Inter-net coverage. On the other hand, the mo-bile network is present almost universally.Mobile device technologies (e.g., mobilephone, PDA) for healthcare, or “mHealth,”have been used in many different contexts.Not only are they relatively cheaper, net-work coverage is also more extensive andreliable than the Internet. Furthermore,more than 75% of the world’s populationuse a mobile phone. They have been usedfor ongoing medical education, communi-

ty and clinical data collection, real-timemonitoring of vital signs and second opin-ion delivery using transmitted images. Inmore affluent countries iPhones have be-come commonplace within hospitals.

The potential of eHealth is encouragingand will undoubtedly offer effective solu-tions for some of the current inefficienciesin healthcare delivery in many regions ofthe world. It is of the utmost importance,however, that any initiative is carefully con-sidered to ensure that it is culturally andcontextually appropriate. Any interventionshould be designed based on the specificarea within which it will operate. A one-size-fits-all approach will inevitably fail.

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“Brazil is a country of continental proportionsthat experiences significant social and healthinequalities and access to specialist care is pooroutside of big cities. This provides the perfect are-na within which eHealth can flourish.”

FEATURES


[ ]Dr. Christopher R. Jones, BMBSEng. Ricardo B. Cardoso Prof. Thais Russomano, M.D., MSc, Ph.D.Pontifical Catholic University of Rio Grande do SulBrazil

[email protected]

Figure 2 (left):A summary ofthe process fol-lowed within ourproject.

Figure 1 (above): Acommunity in a re-mote region of theBrazilian Amazon

that participated inthe eHealth project.

Smartphones are increasingly being used as handheld com-puters rather than mere phones due to their powerful on-board computing capability, capacious memories, large col-or screens, and open operating systems that encourageapplication development. A Morgan Stanley presentation pub-lished in 2010 is predicting that mobile Web access via smart-phones and other small form factor Internet devices, such asthe iPad and clones of small touch-screen tablets, will over-take conventional desktop Internet use by 2015. Smartphonesare rapidly and radically transforming healthcare, enabling itto become more mobile at the point of need and more par-ticipatory by engaging all involved stakeholders, including pa-tients, non-clinical caregivers, the general public, cliniciansand various organizations. The role that smartphones canplay in the care of patients with a long-term condition suchas diabetes has been the subject of many published papersin the peer reviewed research literature ever since the earlydays of smartphone precursors, the basic mobile phones, withlimited monochrome screens and basic Short Message Serv-ice (SMS) and Wireless Access Protocol (WAP) Web access ca-pabilities, which were featured in research projects such asthe European-funded M2DM-Multi-Access Services for telem-atic Management of Diabetes Mellitus project (2000-2002).Today, one can easily find hundreds of diabetes-related apps(smartphone applications) in the different smartphone appstores for the major smartphone platforms that are current-ly available, namely the iPhone, Android and Blackberry, NokiaOvi and Windows Phone 7 (Figure 1). The potential of manyof these apps in reducing healthcare costs and improving clin-ical outcomes is huge.

WaveSense Diabetes Manager App

One of the most popular smartphone apps for diabetes careand management is the WaveSense Diabetes Manager, a freeiPhone app from AgaMatrix. The app can track a diabetic user’sglucose results, carbohydrate intake, and insulin doses. TheWaveSense Diabetes Manager helps the user quickly enterhis/her information, review the data with convenient color-cod-

ed charts and graphs (Figure 2), and gain a new perspective onhis/her diabetes management. The user is also able to watcheducational videos from within the app to learn about healthyeating, lifestyle choices, and hear from others who are livingwith diabetes. Second opinion is “one E-mail away,” as the appoffers an option to E-mail results to the user’s trusted health-care team. The main functions and features of the app include:

• Glucose results recording by time of day (logbook);

• Carbohydrate/insulin data recording, in addition to bloodglucose results (carb/insulin tracking);

• The user can put his/her glucose results in context byadding tags about food, exercise, medicine, or health is-sues (tagging);

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Smartphones in DiabetesCare and Management“Today, one can easily find hundreds of diabetes-related apps (smart-phone applications) ... The potential of many of these apps in reduc-ing healthcare costs and improving clinical outcomes is huge.”

By Maged N. Kamel Boulos

FEATURES


Figure 1: The colorful icons of some diabetes-relatedapps available for Windows Phone 7 in the WindowsPhone Marketplace.

• A visual representation of users’ glu-cose results over time (trend chart -Figure 2);

• Color-coded results enabling theuser to easily spot when he/she goesinto high or low ranges;

• The app is fully customizable, al-lowing users to set custom targetranges, hypo/hyperglycemic limits,and mealtime schedules;

• Educational video content courtesyof dLife (http://www.dlife.com/); and

• A function to E-mail diabetes infor-mation to the user’s family andtrusted healthcare team for review(E-mail reports). The user has fullcontrol over what gets sent, towhom, and when.

Connecting a Glucometer to the iPhone

Besides manual data entry by the user(which might be perceived as a bit te-dious and might pose some long-termpatient compliance issues), Agamatrix hasproduced and tested a “WaveSense Di-rect Connect Cable” to enable automat-ic blood glucose data uploading to theWaveSense Diabetes Manager app run-ning on the iPhone. The Direct Connect

Cable connects a WaveSense Jazzmeter/blood glucose monitoring systemto the iPhone, making it the first med-ical device to connect directly to Apple’siOS platform, which includes the iPhone,iPad and iPod. FDA 510(k) approval of theDirect Connect Cable is still pending asof May 2011.

Another closely related device that canalso connect to the WaveSense DiabetesManager app and automatically uploaddata to it, is the recently announced (Sep-tember 2010) ultra-compact “iBGStarPlug-In Glucose Meter for the iPhone,”co-developed by AgaMatrix and Sanofi-aventis. Like the WaveSense Direct Con-nect Cable, the iBGStar Plug-In GlucoseMeter is not yet available on the marketas of May 2011.

Which Smartphone Platform?

The WaveSense Diabetes Manager apponly runs on the iPhone platform. Port-ing apps to other platforms such as Win-dows Phone 7 and Android is not a triv-ial task and can prove costly for appdevelopers. Cross-platform coding is cur-rently most successful for mobile Webapps (apps that run in smartphone Webbrowsers and/or are using Java for Mo-bile Devices, and are thus generally smart-phone-platform-neutral), which can part-ly solve this developer’s “platformdilemma.” However, Web apps can some-times prove a bit restrictive (in what theycan be coded to do) compared to thefunctionalities that can be implementedin native apps (apps designed for a spe-

cific smartphone operating system andCPU—Central Processing Unit). A goodexample of a diabetes-related Web appfor all smartphone platforms is Handy-Logs Sugar. Nevertheless, a Web app canstill do many things and with the emerg-ing cross-platform app creation servicessuch as Conduit Mobile, the task of cre-ating such apps is becoming much easi-er than ever before.

A Glimpse into the Future of Smartphones

While smartphones are already “lightyears ahead” of conventional desktopcomputers in terms of mobility, thecoming years are expected to carry fur-ther innovations in this respect, withsmartphones becoming even more mo-bile, lighter, thinner, and, hopefully,smarter with the help of technologiessuch as cloud (server-side) computing.Technophile readers unable to wait andeager to see this happen can have aglimpse into what the next generationsof smartphones might look like bywatching the thin-film, flexible “paper-phone” prototype video and photos athttp://tinyurl.com/3pvapxs.

21

FEATURES


[ ]Maged N. Kamel Boulos, MBBCh,MSc, Ph.D., SMIEEEFaculty of HealthUniversity of PlymouthU.K.

[email protected]

Figure 2: The blood glucose Trend Chart function in WaveSense Diabetes Manager. The hor-izontal axis represents time; the vertical axis represents glucose level in mg/dL. A white dotindicates that the reading is equal to or within the user-defined hypoglycemic and hyper-glycemic limits. A pink dot indicates that the reading is below the user-defined hypoglycemiclimit, while a yellow dot indicates that the reading is above the user-defined hyperglycemiclimit. The light blue band indicates the target range for pre-meal low and post-meal highreadings that are set by the user. The white vertical centerline indicates the reading of thatpoint that is being displayed in the reading bar (in this example: 100 mg/dL on 17 July 2010at 6:26 AM). A highlighted point has a gray circle around it. The time range button on the

reading bar can be used to change thezoom-level of the graph; zoom options are1, 7, 14, 30 and 90 days.

The recent convergence between tech-nology and medicine is offering newmethods and tools for behavioralhealthcare. Between them, an emerg-ing trend is the use of Virtual Reality(VR) to improve the existing cognitivebehavioral protocols for different psy-chological disorders, including the as-sessment and treatment of eating dis-orders.

The exact cause of eating disorders isunknown. Genetic, psychological, trau-ma, family, society, or cultural factorsmay play a role. In this context, VR of-fers different opportunities for the as-sessment of eating disorders. A first ap-proach was proposed by the Spanishresearch group led by Gutiérrez-Maldon-ado. This group investigated the effecton body satisfaction – a key feature ofeating disorders – produced by food-related VR experiences involving sub-jects with eating disorders. In a recentstudy, 85 female patients with eatingdisorders and 108 students were ex-posed to four virtual environments: akitchen with high-calorie food, a kitchenwith low-calorie food, a restaurant with

high-calorie food, and a restaurant withlow-calorie food. Results demonstratedthat participants with eating disordershad significantly higher levels of body-image distortion and body dissatisfac-tion after eating high-calorie food thanafter eating low-calorie food, while con-trol participants reported a similar bodyimage in all situations.

In a different study a group of re-searchers headed by Alessandra Gorinirecently tested whether virtual stimuliwere as effective as real stimuli, andmore effective than photographs in theanxiety induction process in these pa-tients. Specifically, the study tested theemotional reactions, assessed usingboth psychological and physiologicalcriteria, to real food, VR food (see Fig-ure 1) and photographs of food in twosamples of patients affected, respective-ly, by anorexia and bulimia nervosacompared to a group of healthy sub-jects. Real and VR food both induceda comparable emotional reaction in pa-tients, higher than the one elicited bythe photos. Instead, no differences werefound in the healthy subjects.

In summary, both studies suggest thepotential of VR as an experiential as-sessment tool: only patients reportedpsychological and physiologicalchanges after the exposure to VR food.This suggests the possible use of VR ex-posure as a screening tool in cases ofsuspected eating disorders.

Distorted body image, negative emo-tions, difficulty in maintaining long-term positive outcomes and lack offaith in the therapy are typical prob-lems of eating disorder patients. To tar-get these issues, different groups aretrying to enhance traditional cognitivebehavioral therapy (CBT) with the useof a virtual environment.

The first approach is offered by Expe-riential Cognitive Therapy (ECT). Devel-oped by Giuseppe Riva and his groupinside the VREPAR and VEPSY Updat-ed European funded projects, it is a rel-atively short-term, patient-oriented ap-proach that focuses on individualdiscovery and proprioceptive changes.Alongside CBT, ECT shares the use of acombination of cognitive and behav-

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Virtual Reality in theAssessment and Treatmentof Eating Disorders“The exact cause of eating disorders is unknown. Genetic, psycho-logical, trauma, family, society, or cultural factors may play a role.In this context, Virtual Reality offers different opportunities for theassessment of eating disorders ... [Furthermore], different groupsare trying to enhance traditional cognitive behavioral therapywith the use of a virtual environment.”

By Giuseppe Riva

FEATURES


ioral procedures to help the patient iden-tify and change maintaining mecha-nisms. However, it is different due to theinclusion of ten VR sessions. All the vir-tual scenes, included in a free virtual en-vironment, NeuroVR, can be downloadedfor free from the NeuroVR Web site,http://www.neurovr.org, and can be cus-tomized by the therapist adding signifi-cant cues (images, objects, and video) re-lated to the story of the patient (seeFigure 2).

This approach has been tested in vari-ous controlled studies. The first involved20 women with Binge Eating Disorderswho were seeking residential treatment.The sample was randomly assigned toECT or to CBT based nutritional thera-py. Both groups were prescribed a 1,200-calorie per day diet and minimal physi-cal activity. Analyses revealed thatalthough both groups were binge free atone-month follow-up, ECT was signifi-cantly better at increasing body satisfac-tion, self-efficacy and motivation tochange.

In a second study, the same randomizedapproach was used with a sample of 36women with Binge Eating Disorders ob-taining similar results.

A second approach was investigated bythe Spanish research group led by Cristi-na Botella. The group led by Botellacompared the effectiveness of VR to tra-ditional CBT for body image improve-ment in a controlled study with a clin-ical population. Specifically, theydeveloped six different virtual environ-ments, including a 3-D figure whosebody parts (arms, thighs, legs, breasts,stomach, buttocks, etc.) could be en-larged or diminished and placed in dif-ferent contexts (for instance, in thekitchen, before eating, after eating, fac-ing attractive persons, etc.).

In a trial 18 outpatients, who had beendiagnosed as suffering from eating dis-orders (anorexia nervosa or bulimia ner-vosa), were randomly assigned to one ofthe two treatment conditions: the VRcondition (CBT plus VR) and the stan-dard body image treatment condition(CBT plus relaxation). Patients treatedwith the VR component showed a sig-nificantly greater improvement in gen-eral psychopathology, eating disorderspsychopathology, and specific body im-age variables. Furthermore, these resultswere maintained at one-year follow-up.

In conclusion, the present results en-

courage the use of VR in clinical (expo-sure therapy) and even non-clinical (tasklearning) settings in which a highly cus-tomizable and controllable simulationis preferred to a real-life experience.

Moreover, these results provide evidenceof the potential of VR in a variety of ex-perimental, training and clinical con-texts, its range of possibilities being ex-tremely wide and customizable. Inparticular, in a therapeutic perspectivebased on a cognitive behavioral ap-proach, the use of VR instead of realstimuli facilitates the provision of veryspecific contexts to help patients tocope with their conditions. Finally, theresults indicate that even a relativelycheap (less than 3000 ¤/4000 US$) PC-based platform using a VR software likeNeuroVR can be used to screen, evalu-ate, and treat these patients.

FEATURES


[ ]Giuseppe Riva, Ph.D.Istituto Auxlogico ItalianoItaly

[email protected]

Figure 2 (right): Exposure to food in virtualworlds can be used to measure the emotional reaction of subjects, allowing for results to

aid in diagnosing eating disorders.

Figure 1 (below): NeuroVR’s virtual environ-ment has a limitless number of virtual scenes

which can be customized by the therapist.

23


FEATURES

The global vision of healthsystems in the world ischanging. Developed countries have to address the epidemic of chronic diseasesdue to aging populations and developing countries have to bridge the gap for themodernization of their social and healthcare systems. In this demanding perspec-tive healthcare providers, public health and social services agencies are called todeliver higher quality care to more patients and citizens at a lower cost. Severalcomplex factors have to be faced and modern, sustainable healthcare systemsrequire a comprehensive reassessment.

By Alberto Lazzero & Maria Romano

As recently reported by the World Health Or-ganization’s World Health Statistics 2011 thatanalyzed the health status of 193 countriesby measuring over 100 health indicators,chronic non-communicable diseases, suchas heart diseases, diabetes and tumors, ac-count for almost two-thirds of global deathsand for 70-80% of healthcare spending.

Metabolic diseases, rising in Western coun-tries as well as in the rest of the world, are awell-known risk factor for cardiovascular dis-eases and neoplasms. The high prevalence,high incidence, chronicity and long-term im-plications for health and healthcare costsmake diabetes a major concern for the Eu-ropean Union (EU) and the U.S. In particu-lar, diabetes has more than tripled in the U.S.– from 5.6 million to 19.7 million – from1980 to 2009. However, a major portion ofthe numerical increase in diabetes is predict-ed to occur in working-age and older adultsin developing countries causing an increas-ingly large clinical and financial charge in thefuture. A recent International Diabetes Fed-eration (IDF) report presented the followingscenario: a 98% increase, from 12.1 to 23.9million sufferers, in Africa; a 94% increase,from 26.6 to 51.7 million, in the Middle East

and North Africa; a 72% increase, from 58.7to 101.0 million, in South-East Asia; a 65%increase, from 18.0 to 29.6 million, in South-and Central-America. Therefore, by 2030, thevast majority of individuals with diabetes willreside in developing countries.

Such an increase in chronicity, associatedwith population aging, will challenge healthservice organizations regarding demand ofboth economic and human resources. Thiswill occur as a countertrend to the short andmedium term expected reduction of physi-cians and health personnel, and of econom-ic resources contingency. A change in howthe health and social care system respondsto future needs is therefore strongly andquickly required and envisaged.

In this challenging panorama, new e-Healthtools and systems promise great improve-ments in efficiency and encourage new per-spectives to address the burden of metabol-ic and chronic diseases.

Four key action areas have been identified:

• Prevention to reduce the incidenceand progression of the disease and its

associated complications and co-mor-bidities.

• Early detection and early treatment,which can improve health outcomes.

• Integration and continuity of preven-tion and care.

• Monitoring and self-management.

Diet, obesity, and lack of physical activity arecontributing factors in contracting a metabol-ic disease. Change in lifestyle has crucial ef-fects in prevention through a correct under-standing of the disease including risk factorsand co-morbidities. Diabetes often goes un-diagnosed because many of its symptomsseem so harmless. New instruments like aneducational portal, diabetes risk test, and in-teractive educational games can increase peo-ple's sensitivity to the problem and lead to ear-ly detection of diabetes symptoms andconsequently, to early diagnosis and treatment.

Innovative chronic care management pro-grams emphasize the patient’s central rolein self-managing their own healthcare, butincluding it in a wider strategy of integrated

Examples of how new technologies and

patient-centered care can address the chal-

lenge of a sustainable healthcare system

The Burden of MetabolicDiseases

24

25


FEATURES

disease management that, with the supportof technology, allows effective care coordi-nation.

Four principal orientations towards diabetesand its management were identified: re-sisters, identity resisters, consequence ac-cepters, identity accepters, and consequenceresisters and accepters. Therefore, peoplewith diabetes have varying orientation andpreferences towards forms of both educa-tion and self-management which have beenidentified and should be taken into account.Diabetics should take an active role in theircare plan, in a sort of therapeutic complici-ty as a personalized alliance between the pa-tient and the diabetes care team. The careplan should include a program of diabetesself-management education (DSME), whichguarantees, through the use of differentstrategies and techniques, appropriate edu-cation on how to solve problems connect-ed with the management of the disease. Theself-monitoring of blood glucose (SMBG),shared with the diabetes team, is an indis-pensable component of the managementof diabetes.

Recent exciting research foresees applica-tions in Virtual Reality (VR) technologies(human interaction with computer-simu-lated environments) having a possible im-pact on healthcare even greater than thatoffered by the new communication tech-nologies, broadening its use to the man-agement of patients affected by metabol-ic diseases. VR was first developed andapplied to surgical procedures (robotics,technical training, treatment from remotesites), and was subsequently extended tothe fields of rehabilitation (cerebrovascularand Parkinson’s disease) and psychology(substance abuse disorders and behavioralmedicine). Some investigators have recent-ly qualitatively evaluated how interactivegames can promote behavior change inprevention, treatment indication and self-management for people newly diagnosedwith type 2 diabetes. Other researchers eval-uated the efficacy of “alternative reality”games in promoting healthy eating and ex-ercise using sensors dedicated to measur-ing heart rate and other devices. Finally, VRis expected to induce sustainable behaviorchange implementing therapeutic guid-

ance on the optimal diet and physical ac-tivity for weight control, and adherence totherapy linking visual and other sensory as-pects of food and exercise with the patient’scognitive and emotional states.

The scientific community’s support for theuse of VR technologies in the education ofmetabolic patients is rising, as testified bythe grant’s call recently published by theNational Institute of Health. The potentialareas for hypothesis-testing and develop-mental research are expanding, and hope-fully leading, in the near future, to newmethods and technologies.

[ ]Alberto Lazzero, M.D., MSc, DUZOHE, E-Health Open ZoneMaria Romano, MSTelBios S.p.A. Italy

[email protected]

IDF Regions and global projections for the number of people with diabetes (20-79 years), 2010-2030

REGION2010

Millions2030

MillionsINCREASE

%

acirfA 98%

Middle East and North Africa 94%

South-East Asia 72%

South and Central America 65%

Western Pacifi c 47%

North America and Caribbean 42%

eporuE 20%

dlroW 54%

23.951.7

101.029.6

112.853.266.2

438.4

12.126.658.718.076.737.455.2

284.6

IDF Diabetes Atlas, 4th ed. © International Diabetes Federation, 2009

26

PRODUCT / DISEASE

Patient In Your Pocket

for chronic and long term

disease management

Raisin Personal Monitor

for chronic heart failure

and diabetes manage-

ment

WellDoc DiabetesMan-

ager® System for Type 2

Diabetes

AiperMotion for weight

loss for Type 2 Diabetes,

prediabetes, and meta-

bolic syndrome patients

Metabolic Syndrome US-

EU for metabolic disor-

ders

COMMANDER FLEX for

heart failure, hyperten-

sion, COPD, diabetes,

chronic kidney disease,

end stage renal disease

WaveSense Diabetes

Manager App for dia-

betes management

www.kilocoach.at

for weight management

DiabMemory for diabetes

management

DESCRIPTION OF PRODUCT

a mobile application for BlackBerry smartphones and PlayBooks that

sends patient details to healthcare providers in real-time, providing

accurate and up-to-date information and improved quality of care

wireless health device taken in the form of a pill, remotely transmits in-

formation on heart rate, physical activity, body position, patient-logged

events, and ingested drugs, via Bluetooth to be recorded and analyzed

on any computerized device, providing real-time physiologic data

FDA-approved project utilizing Ford’s SYNC® voice-activated in-car

mobile connectivity system – allows patients to verbally enter medical

information into the system within their vehicle to help manage their

condition; healthcare providers also have access to this information via

cell phone, in-office computers, or in their own car

small rectangular device worn on a belt, monitors calorie intake, ac-

tivity, and nutrition which is entered into the device and compiled in

a nutrition log that then calculates an energy balance; can easily be

transferred to a PC for analysis by healthcare providers

application that assesses users risk for developing metabolic syndrome

by analyzing waist circumference, blood pressure, HDL cholesterol, fast-

ing glucose and triglyceride levels

modular device with LCD graphic display equipped with integrated

blood pressure and heart rate sensing – can measure an array of vital

signs; using Bluetooth® Wireless Technology and two-way messaging,

patients and healthcare providers can be updated and communicate

quickly, and in a portable way, to manage medical conditions

free Apple touch app that measures carbohydrate intake, glucose and

insulin levels and allows the user to record additional information like

diet, exercise, and medication; analyzes results over time with easy to

read graphs and includes integrated E-mailing of data

online lifestyle management platform includes database of nutrition-

al data, practical analysis of diet and daily activities and logs data fa-

cilitating remote interaction with experts; personalized program rec-

ommended for each user

diabetes telemonitoring system consisting of Near Field Communica-

tion equipped mobile phones with diabetes management applications

and medical measurement devices, stores data and facilitates long-

distance communication between healthcare providers and patients

through E-mails and texts

MANUFACTURER

Computer Science

Corporation (CSC)

Proteus Biomedical

Ford Motor Company and

WellDoc

Aipermon

Minoru Oishi

CARDIOCOM

AgaMatrix

Kilo Coach ™

Gesundheitsdialog

Product Comparison Chart:Metabolic Disorders

PRODUCT COMPARISON

RESEARCHER:

Christina Valenti, Editorial DepartmentC&R Magazine

www.vrphobia.eu, [email protected]

Wounds of War IV: Pain Syndromes: FromRecruitment to Returning TroopseDITeD By:Professor Dr. Brenda K. Wiederhold, Ph.D., mBA, BcIA

WOUNDS OF WAR IV: PAIN

SyNDROmeS – FROm RecRUITmeNT

TO ReTURNINg TROOPS

On September 30-October 2, 2011 theNATO Advanced Research “Wounds of WarIV: Pain Syndromes – From Recruitmentto Returning Troops” will draw over 25eminent experts from 11 countries to dis-cuss the topic of increased PainSyndromes in our service men andwomen.

To be held in Sudkärnten, Austria at theHotel Amerika-Holzer, discussion topicswill include increased Pain Syndromes as aresult of missions, as well as how PainSyndromes may be prevented. Researchhas shown that those who have served inboth combat missions and peacekeepingoperations are at an increased risk forPain Syndromes. The ultimate aim of theworkshop will be critical assessment ofexisting knowledge and identification ofdirections for future actions. The co-organizers of the workshop alongsideProfessor Brenda K. Wiederhold includeProfessor Kresimir Cosic, Professor MarkD. Wiederhold and Colonel Carl Castro.

Full papers will be published with IOS PressTO ORDeR: [email protected]

The Interactive Media Institute9565 Waples Street, Suite 200 – San Diego, CA 92121

phone: (858) 642-0267 – fax: (858) 642-0285 – www.interactivemediainstitute.com

The post-conference book will reflect the key topics

discussed in the four sections at the workshop:

First Session

Vulnerability to Pain SyndromesSecond Session

Diagnosis and Assessment of Pain SyndromesThird Session

Treatment of Pain SyndromesFourth Session

Clinical Updates on Pain Syndromes

“Tele-homecare is a key solution for chronic patient care. One of the mainaims of tele-homecare is to provide quality healthcare for patients, especiallyelderly patients, through advanced technology. The main areas to apply tele-homecare in chronic patient care are diabetes, heart disease and chronicobstructive pulmonary diseases.”

28


FEATURES

Wireless TechnologyBased Tele-HomecareSystems

By Ali Hakan Işik & İnan Güler

Chronic diseases are long lasting or repetitively occurring dis-eases that are the leading cause of mortality and disabilitythroughout the world. For instance, chronic diseases accountfor approximately 80% of deaths in some countries. Thesediseases include a wide range of health problems which causenegative side effects on a patient’s life. It is important to de-

velop an assessment and management plan with multidimen-sional and multidisciplinary perspectives in order to providesustainable treatment for chronic patient care.

Chronic patient care requires more effort but patients arenot always compliant. In this context, tele-homecare is a keysolution for chronic patient care. One of the main aims oftele-homecare is to provide quality healthcare for patients,especially elderly patients, through advanced technology.The main areas to apply tele-homecare in chronic patientcare are diabetes, heart disease and chronic obstructive pul-monary diseases.

Information and communication technologies help to im-prove the quality and features of tele -homecare. For in-stance, a mobile device can connect and gather physiolog-ical data from ECG, spirometry and pulse oximeter devices,etc. By using wireless technology such as Bluetooth tech-

“It is important to develop an assessmentand management plan with multidimen-sional and multidisciplinary perspectivesin order to provide sustainable treatmentfor chronic patient care.”

Figure 1: Bluetooth-enabled pulse oximeter.

nology, no wires need to be attachedto the patient’s body. In this way, thepatient is not disturbed and ease ofuse is improved. As shown in Figure 1,the patient can measure his or herown oxygen saturation and heart ratewith a Bluetooth enabled pulse oxime-ter. In most cases, these data are con-verted into XML type and transmittedto remote locations by means of a mo-bile device. In remote locations, allphysiological data are stored in a data-base. These data are evaluated to helpaid in decision-making. During the de-cision-making process, generally, rule-based and heuristic algorithms suchas an artificial neural network, a vec-tor support machine is used. When thepatient’s physiological data extractedfrom the decision support systemshows the patient’s condition is wors-ening, an emergency Short MessageService (SMS) is sent. Conversion ofthe evaluated data result to the SMSXML template is performed on a Webserver that is located in a remote lo-cation.

In addition, many different kinds ofsoftware designed to run on a mobiledevice have emerged. This easy-to-usemobile assessment tool allows data tobe collected daily and facilitates pro-

longed assessment over time. It alsorequires less effort. Another importantcomponent of tele-homecare is Web-based monitoring of physiologicaldata. As shown in Figure 2, data froma patient’s acceptable pulmonary func-tion test (PFT) result performed at thepatient’s home are sent to a remote

database. This page provides access toall the patient’s data, so doctors canfollow their patients and send an E-mail or Web-based SMS related to the

evaluation of the disease. In this way,statistical data about the developmentof the disease is easily obtained; as aresult, chronic pulmonary patients aremore informed and aware concerningtheir disease, and their quality of lifeis increased. Lastly, the costs of treat-ment are reduced.

Tele-homecare systems also provide asignificant improvement in reducingthe numbers of visits to the doctor’soffice, an important figure for healthexpenditure in the field of chronic pa-tient care. It is believed that tele-home-care provides effective self control andremote management of chronic pa-tients.

This work was supported by Gazi Uni-versity scientific research project (BAP-07/2010-55).

29


FEATURES

[ ]Ali Hakan Işik İnan GülerGazi UniversityFaculty of Technology,Department of Electronics andComputer TechnologyTurkey

[email protected]

Figure 2: Web-based tracking of pulmonary function test (PFT) results.

“Information and communication tech-nologies help to improve the quality andfeatures of tele-homecare. For instance, amobile device can connect and gather phys-iological data from ECG, spirometry andpulse oximeter devices, etc.”

The FDA’s advisory committee has a re-cent history of exercising unusually highsafety standards for new pharmaceuti-cals aimed at treating obesity, but thatdidn’t prevent the shock many expressedthat the three most promising drugspoised to hit the market, backed by Are-na Pharmaceuticals, Vivus, and OrexigenTherapetics, were not approved due toinsufficient data presented on effective-ness, as well as potential risks shown bythe detection of tumors found in ratswho had received high doses of one ofthe drugs. The pharmaceutical industryhas yet to find an effective weight lossdrug and has run into a list of complica-tions and setbacks, including the infa-mous fen-phen scare of the ‘90s; weightloss drugs have been blamed for side ef-fects ranging from damage to heartvalves to depression and suicidalthoughts. This is not entirely surprisingsince the brain-body link is arguably oneof the reasons it can seem nearly impos-sible to shed pounds; many prospectivedrugs have negatively affected hormonesand neurotransmitters associated withcognition, information processing, andemotions.

Despite these upsets, the implementa-tion of an effective weight-loss drugcould not only generate billions in rev-enue, but also save a staggering amountin healthcare costs each year – a study

conducted partly by the federal Centersfor Disease Control and Prevention esti-mated that treating obesity and obesity-related diseased totaled nearly $147 bil-lion in 2006 in the U.S., accounting for9% of overall healthcare spending. Onceconsidered strictly a Western, affluent af-fliction, the ripple effects of the diseaseare quickly spreading to countries likeJapan, India and Brazil. Besides the po-tential lucrative gains, increased qualityof life could affect a large percentage ofthe global population who now struggleswith the effects of being overweight orobese.

Despite millions of potential users, obe-sity drugs are rarely covered by insurancecompanies, and doctors are often hesi-tant to prescribe them, stressing that dietand exercise are the most effective long-term solution to maintaining a healthyweight. Furthermore, experts point outthat some non-obese users may chooseto buy the drug, finding a quick fix todrop those last five pounds. To combatthese fears, the companies emphasizethat their products are not meant for cos-metic purposes, but aim to control andprevent diseases such as diabetes, car-diovascular disease and high blood pres-sure, among other related conditions.

Undoubtedly, pharmaceutical companieswill continue to push forward with new

medicines and work to tackle existingproblems, but the decision may ultimate-ly lead to heightened support for alter-nate therapies, such as the increasinglysupported theory that any effective formof weight loss management includes atleast some form of behavior modifica-tion. Weight Watchers, aimed at main-taining long-term behavioral changes,was found to be the only effectiveweight-loss program of eight popular pro-grams evaluated by the Annals of Inter-nal Medicine in 2005.

These landmark decisions will likely fos-ter support for a combination of ap-proaches and treatment. The FDA seemsto favor bridging the gap, and asked Are-na Pharmaceuticals to submit more in-formation on studies using the drug incombination with behavioral health mod-ifications. So for now, the search for the“magic pill” continues and for the timebeing, some old-fashioned sweat mayprove to be the most effective treatment.

Since the fen-phen scare of the ‘90s, consumers have been urged to bewary of diet and weight loss pills, but that hasn’t slowed the demand for aquick-fix solution to America’s biggest health concern. Since the much-anticipated obesity drugs were recently struck down by the FDA, the ques-tion remains: will a “magic pill” be found, and more importantly, are drugsreally the best solution to an overwhelming epidemic?

FEATURES

FDA Denies Safety Approval forAnticipated Anti-Obesity Drugs

By Emily Butcher

[ ]Emily ButcherInteractive Media InstituteU.S.A.

[email protected]

30

9565 Waples Street, Suite 200

San Diego, CA 92121

Phone: (858) 642-0267

E-mail: [email protected]

Telemedicine is the conversion technolo-gy which is expected to improve quality ofcare while improving the efficiency of thedelivery of care, and the management ofchronic conditions with the technology isof particular interest as the size of the agedpopulation increases rapidly (Figures 1 and2). However, attempts to introduce telemed-icine in South Korea during the past 20years have been largely unsuccessful dueto various reasons: regulations designedfor traditional medicine, immature tech-nology, physician reluctance to change, andlack of patient willingness to pay for andadapt to the new mode of care. As regula-tory issues and technological limitationsare overcome through the Korean govern-ment’s efforts and technology advance-ment, establishing a sustainable revenuemodel and designing a service that attractspatients have become important factorsfor the successful implementation oftelemedicine. Patients’ willingness to payhas a particular significance in South Ko-rea since national health insurance cover-age allows patients easy access to special-

ty care in clinics and hospitals, althoughpatients’ waiting time is long and consul-tations with doctors are insufficient in largeteaching hospitals preferred by patients.

In a conjoint survey conducted throughface-to-face interviews, we asked patientsresiding in the Seoul metropolitan areawho visited medical school affiliated ter-

“Attempts to introduce telemedicine in South Korea during the past 20years have been largely unsuccessful due to various reasons ... As regulatoryissues and technological limitations are overcome through the Korean gov-ernment’s efforts and technology advancement, establishing a sustainablerevenue model and designing a service that attracts patients have becomeimportant factors for the successful implementation of telemedicine. ”32


FEATURES

Factors Affecting Patients’Preferences of Telemedicine:Design of DiabetesManagement Care

By Hayoung Park, YuCheong Chon & Kun-Ho Yoon

Figure 1: Framework of the telemedicine service.

tiary care hospitals and clinics for dia-betes care about their preferences amongtelemedicine service alternatives wherethe alternatives differed in price and nineattributes derived from dimensions ofservice quality: type of service provider,service scope, personalization of consul-tation, service hour, reply time, assuranceof service, type of telecommunicationplatform, system reliability, and level ofconfidentiality assurance. We analyzed atotal of 118 responses with the rank-or-dered logit model based on the randomutility model to find the patients’ valueand preferences for each attribute oftelemedicine service for diabetes man-agement.

We found that all 10 attributes of dia-betes management care using telemed-icine significantly affected patients’ val-uations and preferences. Price was themost important attribute for patients inchoosing a telemedicine service alterna-tive. The next most important attributeswere: the comprehensiveness of servicescope that includes care for other com-plicating and comorbid conditions andconsultations for diet and exercise as wellas glucose control, the availability of mo-bile phone-based service delivery, gener-al hospital-based providers, and assur-ance of services. We found that patientswere less concerned about the reply timeand information security than the otherattributes. Although patients were mostconcerned about price, they were willingto pay a monthly fee of over $10 USD toattain the service attributes they valuesuch as the comprehensiveness of serv-ice scope, mobile-phone based service,

and general hospital-based provider. Wealso found that demographic and diseasecharacteristics made a difference in pa-tients’ valuations and preferences for the

attributes. Females were more sensitiveto assurance than males; older respon-dents were more accepting of office-houronly service than younger respondents;and respondents with higher educationpreferred Internet-based service morethan others. Patients with complicationsor comorbidities cared more about gen-eral hospital-based providers for the as-surance of care quality and mobile-phonebased services for easier access to carethan other respondents did.

We draw four implications from the studyfindings for the formulation of an adop-tion policy and the design of services us-ing telemedicine. First, potential benefi-ciaries of the technology were mostconcerned about price among the serv-ice attributes studied, and the govern-ment or insurer may need to considercovering services with evidence of cost-effectiveness of the service. Second, thevery feature of the technology – indirectdelivery of care through telecommuni-

cation devices – strengthened the im-portance of the quality domain of serv-ice assurance, and service developersmay need to institute a mechanism intheir service design that ensures patients’trust. Third, it appeared that the levelsof confidentiality and system reliabilitythreshold of 1-5% failure were acceptableto patients although information safetyand confidentiality have been indicatedas obstacles in the adoption of informa-tion and communications technology(ICT) in healthcare, and researchers mayneed to quantitatively study patient pref-erences and concerns to attain knowl-edge that can guide the design of serv-ices. Lastly, patients’ demographic anddisease characteristics influenced theirpreferences, and policy makers and serv-ice developers may need to approach dif-

ferent patient groups with differentstrategies tailored to their needs and pref-erences.

Author Notes: The article is based on thestudy published in Telemedicine and e-Health: Park H, Chon Y, Lee J, Choi I,Yoon K. Service design attributes affect-ing diabetic patient preferences oftelemedicine in South Korea. Telemedi-cine and e-Health 2011;17:442-451.

33


FEATURES

[ ]Hayoung Park, Ph.D.Seoul National UniversityYuCheong Chon, M.S.Korea Institute of S&T Evaluationand PlanningKun-Ho Yoon, M.D., Ph.D.Catholic University of Korea Republic of Korea

[email protected]

Figure 2: Scheme of the Internet-based GlucoseMonitoring System (IBGMS).

“Although patients were most concerned aboutprice, they were willing to pay a monthly fee of over$10 USD to attain the service attributes they valuesuch as the comprehensiveness of service scope,mobile-phone based service, and general hospital-based provider.”

Cardiovascular diseases, such as stroke andmyocardial infarct, are the main cause ofdeath in the Western World. In Europe theyaccount for 42% of all deaths in the totalpopulation. Prevention, delay in onset andreversal of cardiovascular diseases, there-fore, can benefit a large segment of thepopulation and the health system in gen-eral. Obesity due to poor nutrition and lowphysical activity is the main underlyingcause for cardiovascular diseases. Effec-tive, low-cost and broadly available toolsto reduce weight by improving lifestyle arethus dearly wanted.

Conventional in-person weight loss pro-grams can be powerful tools, but due toavailability, inconvenience and costs,these programs cannot offer access tothe masses. As over 75% of Americansand Europeans have Internet access, theWeb has emerged as a promising way tooffer self-help options for non-medicalweight loss treatments through conven-tional PCs, tablet PCs and smartphonesthat are cost-effective, save time, and areeasily integrated into everyday life. Elec-tronic approaches can offer the flexibili-ty needed to handle individual nutrition-

al approaches to self-reliantly empowerhumans to very specifically improve theirdietary intake.

First Generation of Simple Weight Loss Platforms

Typical features of first generation self-helpplatforms are made up of static informa-

tion like weight loss information, informa-tion on physical activity, recipes, menu plan-ners, caloric information on food items,diaries for recording food consumption(without automatic calculation of energyintake), bulletin boards to offer support,shopping lists of healthy foods, motivation-al tips, exercise expenditure counters, por-tion size charts, and dining out guides. The

platforms provide mainly static informa-tion with minimal interaction.

Commercial weight loss Web sites arewidespread, and most of them belong tothe first generation category; the effec-tiveness of very few of these platformshas been validated. Previous investiga-tions showed that under study conditions

first generation platforms produce atbest half the weight loss achieved witha structured face-to-face weight loss pro-gram. These results are promising butnot enough to be recognized as seriousintervention tools by health profession-als. The same evaluations revealed thatdynamic self-monitoring “feedback fac-tors” like visual display of goal progress,

“

“Conventional in-person weight loss programs can be powerful tools, butdue to availability, inconvenience and costs, these programs cannot offeraccess to the masses ... the Web has emerged as a promising way to offerself-help options for non-medical weight loss treatments through conven-tional PCs, tablet PCs and smartphones that are cost-effective, save time,and are easily integrated into everyday life.”

34


FEATURES

Weight Loss Via theInternet:

By Luzia Valentini

Obesity due to poor nutrition and low physicalactivity is the main underlying cause for cardiovas-cular diseases. Effective, low-cost and broadly avail-able tools to reduce weight by improving lifestyleare thus dearly wanted.”

can contribute to improved lifestyle

How advanced technologies

immediate evaluation of eating behav-iors and physiological calculators are piv-otal for effectiveness. Motivators are alsoimportant.

Second Generation of More Sophisticated and Technically

Advanced PlatformsThe second generation of weight loss Websites are highly interactive and provide in-

formation beyond the potential of in-per-son face-to-face support, such as immedi-ate analysis of food intake.

Our working group started with a first gen-eration platform. After evaluating the feed-back of our study participants, wescreened the German speaking onlineweight loss programs and identified oneplatform, KiloCoachTM (www.kilocoach.at),that was distinctively different from theother platforms. This platform was moreinteractive and highly resembled the vi-sion of our study participants for futureplatforms. We started to incorporate thisplatform in our research and are now

about to test its efficacy in a prospectiveclinical trial. We expect to receive resultsabove the 5% weight loss achieved withprevious weight loss platforms.

One key feedback and teaching tool ofthis platform is the immediate analysisof dietary intake taking into account theamount of physical activity (not onlysports, but also physical activity integrat-

ed into everyday life) needed to achievethe target energy intake needed to lose0.5 kg of weight a week. This means thatdietary intake must be precisely enteredby users who are not nutritional profes-sionals, and an immediate feedback hasto be provided to the user, otherwise hecannot counteract (through physical ac-tivity) a possible excess of caloric intakewithin an appropriate time interval. By fa-miliarizing themselves in detail with theirown dietary habits, individuals automat-ically learn the nutritional facts of the foodproducts they consume, become confi-dent judging portion sizes and evaluatingthe adequacy of their nutritional intake.

Such high quality platforms require im-mense investments in comprehensivefood and nutrient databases. Currently,the database of this respective platformcontains over 30,000 food items, and isupdated daily. This database allows usersto quickly find exact food products byname so that entering a full food diary av-erages only 10 minutes a day and is veryprecise. The platform is well accepted onthe market and is currently used daily by2,000-3,000 subscribers; if proven effec-tive, the program may be a starting pointfor future weight loss platforms.

In summary, the Internet offers unique op-portunities for weight loss interventionsparalleled with general improvements inlifestyle habits. Future public Internet in-terventions will utilize high-quality, dynam-

ic Web sites with a high volume of auto-matic feedback. Such platforms, however,are work intensive and require scientifi-cally sound specifications. This poses alarge responsibility to the platformprovider. Future models to use such plat-forms can comprise pure self-help tech-niques and cooperation with primaryphysicians.

35


FEATURES

[ ]Dr. rer. nat. Luzia ValentiniCharité-Universitätsmedizin Berlin

[email protected]

Figures: Adopting healthy lifestyle habits has been shown to bepositively influenced by the use of new online weight loss pro-grams. Photos provided courtesy of KiloCoach e.U.

Eating disorders (EDs) have been provento affect the global population of womenwhile discussions of these disorders re-main taboo in most countries. Despite be-ing one of the top contributors to prema-ture deaths of all mental disorders, thenature of EDs and the urgency to find bet-ter treatments remain mysterious to many.EDs affect five times as many people asdoes schizophrenia and twice the numberof people affected by Alzheimer’s disease,yet are appropriated a fraction of the me-dia attention and funding by the govern-ment. EDs, such as anorexia nervosa, bu-limia nervosa, binge eating disorder, andeating disorder not otherwise specified(EDNOS), are shockingly prevalent and thehighest rates are found in the U.S. Howev-er, there is a rapid emergence of EDsamong women in industrialized countriessuch as Italy, Brazil, and Japan; EDs affectnearly 69 million women worldwide.

The media in the U.S. has fostered a fem-inine culture centralized around the pur-suit to be thin. Girls are at a vulnerableage when they are initially exposed to thisideal and are ultimately influenced by theimportance the media has attributed toweight loss, fad diets, and counting calo-ries. In fact, the earliest onset age in theU.S. for an ED is 12 years old, while neg-ative self-images among girls emerge as

early as eight years old. Nearly 1% ofwomen in America are anorexic; up to4.1% suffer from bulimia; 3.5% of womenare diagnosed with binge eating disorder;and anywhere from 5%-13% of womenhave EDNOS, a category of EDs that doesnot meet the Diagnostic and StatisticalManual of Mental Disorders (DSM IV) cri-teria for any specific ED. Four percent ofanorexics, 3.9% of bulimics, and 5.2% ofthose with EDNOS (including binge eat-ing disorder) die from their disorders. Sui-cides account for 0.6%, 0.9% and 0.5% ofthose deaths, respectively.

The thriving fashion industry present inItaly plays a huge role in the rise of EDsamongst Italian women. Until recently, noone larger than a size 0 graced the run-ways in Italy during fashion week and anumber of brand name designers believethat the addition of healthier-looking, full-bodied models imposes limits on theircreativity as artists. There are about threemillion reported cases of EDs amongwomen in Italy – 0.8% of women areanorexic; 1.7% are bulimic; and 8% suf-fer from EDNOS. Immersed in a culturethat has a reputable love for food and anadmiration of high fashion, Italian womenmay feel trapped between the choice toeat plenty and the choice to remain skin-ny and fashionable, all while fearing and

dealing with the criticisms of an Italianfamily.

Brazilian women are also at high risk ofdeveloping an ED. Growing up in a soci-ety that praises a Westernized version of“beautiful,” women living in Brazil arepressured to fit into the sexy, exotic,Brazilian, supermodel prototype. In astudy performed among girls 7-14 yearsof age in Southeast Brazil, “at-risk” indi-viduals did not differ from their controlsin body mass index (BMI) but were ofhigher social economic status, suggest-ing that there is a stronger preference forthinness among more Westernized so-cial groups. With a television set in al-most every household, everyone in thiscountry, from the poor to the rich, areexposed to the trend to be skinny.

Similarly, the rise of EDs in Japan is linkedwith the media as well as with their tra-ditional gender roles. Girls are taught atthe beginning of their education the sep-aration between male and female roles,and that womanhood is achievedthrough motherhood. These womencommonly aren’t given an intermediatestage between childhood and mother-hood, nor are they taught the life skillsto mature as a female outside this par-ticular framework. This impaired devel-

“Eating disorders affect five times as many people as does schizophreniaand twice the number of people affected by Alzheimer’s disease, yet areappropriated a fraction of the media attention and funding by the govern-ment ... Promising new technologies, including cognitive behavioral therapyaided by the use of Virtual Reality, have led researchers and healthcareproviders to explore treatment options in previously unexplored fields.”

36

FEATURES

Addressing the GlobalRise in Eating Disorders

By Allison Ines

opment leaves women prone to the be-lief that not eating is a less embarrass-ing way of “opting out” of an unhappymarriage and coping with their “failures”as a woman in Japanese society. Becauseof this, as well as the pursuit of thinnesspresent in more industrialized areas inthe country, 10% of Japanese women intheir 20s, 16% of women in their 30s,and 18% of female students report a BMIof less than 18.5 kg/m2, which is veryclose to the diagnostic weight thresholdfor anorexia.

On the other end of the spectrum liesobesity, a medical condition affecting300 million women worldwide. With35.5% of American women, 44.0% ofSaudi Arabian women, and 39.5% ofEgyptian women suffering from obesity,the highest numbers of affected popu-lations, obesity affects high- and low-in-come countries alike. Obesity can leadto other comorbid medical conditions,

such as a number of cardiovascular dis-eases; musculoskeletal disorders such asosteoarthritis; and some cancers such asendometrial, breast, and colon cancer.

Due to various sociocultural backgroundsand differing biological makeup of suf-ferers, it is evident that there are count-less factors that can lead to an ED. Notwo patients with an ED are driven totheir condition in the exact same way –as a result, a single, one-size-fits-all treat-ment plan has been deemed insufficient.Treatment must be handled by a thera-pist on a one-on-one basis to assess thediverse psychological states experiencedby each individual. One option utilizesa proven effective treatment method,cognitive behavioral therapy, creating in-dividualized treatment plans aiming toaddress the root causes of EDs. An eval-uation of patients’ attitudes towards foodand eating are made, and goals areachieved in a step-by-step fashion which

is helpful in the long-run for preventingrelapse.

The undeniable rise in EDs calls for proac-tive treatment and further attention, aswell as increased funding. Promising newtechnologies, including cognitive behav-ioral therapy aided by the use of VirtualReality, have led researchers and health-care providers to explore treatment op-tions in previously unexplored fields.Changing cultural ideals and gender roles,as well as improving education on thesubject for young girls, can also help tocombat this growing global epidemic.

[ ]Allison InesInteractive Media InstituteU.S.A.

[email protected]

The world population has become vulner-able to lifestyle diseases such as Type 2 di-abetes. Although new and more effica-cious diabetes medications and improvedmedication delivery systems have beendeveloped, the majority of people with di-abetes do not achieve optimal metaboliccontrol, leading to poor health outcomes.Telemedicine services can make health-care more accessible to people, and canbe a useful tool in providing diabetes careand diabetes self-management. Studies,however, are still needed to examine theimpact of this technology on patients.

In order to deal with the lack of solid evi-dence nine European regions, supportedby their national governments and withco-funding from the European Commis-sion, have joined forces in the RenewingHealth project (www.renewinghealth.eu).The project will implement real-life large-scale trials – and recruit about 8,000 pa-tients – to validate and evaluate telehealthservices for major chronic diseases includ-ing diabetes during 2011 and 2012. It cov-ers 20 pilot programs organized into nine“clusters,” each of them covering a homo-geneous type of telehealth service.

The validation and evaluation process isbeing conducted in the form of a random-ized controlled parallel-group unblindedtrial. Potential participants are selected byscreening electronic healthcare records in

the municipality and hospital databases.Randomization is performed separatelyfor each country by specialized depart-ments or research organizations. The ob-jective is to evaluate whether the intro-

Although “Telemedicine services can make healthcare more accessible to peo-ple, and can be a useful tool in providing diabetes care and diabetes self-man-agement,” the authors point to the fact that a lack of related studies and evi-dence is still hindering the widespread adoption of Telemedicine. To solve theproblem, nine European regions have joined together in a large-scale project

aiming to validate and evaluate telehealth servicesfor the management of major chronic diseases.38


FEATURES

Health Coaching and Life-Long Monitoringfor Persons with Type 2 Diabetes –

By Lis Ribu et al.


duction of large-scale personalized andtechnology supported telemonitoring andhealth coaching intervention (in some tri-als only) produces benefits in terms of clin-ical outcome, health-related quality of life,health status and empowerment of thesepatients in managing their health condi-tions. In addition, all the trials in Renew-ing Health evaluate the economic and or-ganizational impact of the new services,and examine their acceptability by patientsand health professionals.

Six of the 20 trials covered by RenewingHealth are dedicated to diabetes. Theyhave been organized into two “clusters,”because of differences in the type of in-tervention foreseen in the various pilots.

The aim in Cluster 2 “Life-long monitor-ing” of patients with diabetes is to evalu-ate whether patients with diabetes melli-tus can be followed by simplified,centralized and large-scale telemonitoringof blood glucose levels and blood pressure.It will also assess whether this interven-tion produces health and economic ben-efits when introduced without majorchanges to the existing care process of alarge provider of primary healthcare serv-ices (Berlin, Germany) or a secondary carecenter (Trikala, Central Greece).

Cluster 1 – "medium-term health coach-ing and lifelong monitoring" – is made

up of four pilot sites. In Norrbotten, Swe-den, participants receive PCs with dedi-cated software that manages the collec-tion and transmission of their diagnosticmeasurements. Measurements are per-formed on a regular basis by the partici-pants, and equipment will be installed inparticipant’s homes. The participants canreview all their measurements in a graph-ical display. The telemedicine applicationwill be integrated with the local Health In-formation System.

The intervention in South Karelia, Fin-land, consists of regular measurementsof physiological and health parameters.Participants receive equipment and amobile phone with specific software formanual and/or automatic reporting ofdata to a central server. Measurementsare taken regularly on a personalized ba-sis, and are entered in personal healthrecords via a Web application. In addi-tion, the self-management server willsend participants feedback and re-minders on the basis of the reportedhealth parameters and in compliancewith the self-management plan.

In Northern Norway the patients will re-ceive a smart phone with a diabetes di-ary application (the "Few-Touch Applica-tion”), a self-help tool that consists of fivemain elements that are accessible to theuser (food habits registration, blood glu-

cose data management system, physicalactivity registration, personal goals settingand general information). Patients are re-quested to self-monitor their blood glu-cose levels, eating behavior and physicalactivities on a daily basis, but at intervalsthat they feel are beneficial and manage-able. While blood glucose data is automat-ically transferred to the phone from theblood glucose meter, activity data andfood habits have to be manually enteredby the user.

In Carinthia, Austria the intervention aimsto ensure a close monitoring of partici-pants' vital parameters and lifestyle habitsin addition to a better fine-tuning of themedical therapy and regular treatment re-minders. The monitoring occurs throughthe integration into and the adoption ofthe existing Health Information Systemwith dedicated Web portals or smart-phones for the participants. Diagnosticequipment is provided at the patient’shome. Measurements can also be collect-ed and transmitted through nursing staff.

In all these pilots, a personal health coachor health coaching team motivates andempowers the participants to reach rec-ommended lifestyle changes with theo-ry-based health counseling.

The results of these trials will be publishedduring the last quarter of 2012, and infor-mation will be released on a regular ba-sis at www.renewinghealth.eu.

FEATURES

[ ]Lis RibuOslo University CollegeNorwayMarc LangeEHTELBelgiumGeorge E. Dafoulas, M.D.e-trikala SAGreeceEirik ÅrsandNorwegian Centre for IntegratedCare and TelemedicineNorway

[email protected]

39

Ask the Expert:Don Jones

Brenda K. Wiederhold: What is your cur-rent position at Qualcomm?

Don Jones: VP of Wireless Health, GlobalStrategy and Market Development, Qual-comm Labs.

BKW: What first interested you in wirelesshealth? What is your background?

DJ: Before joining Qualcomm to head upour Wireless Health initiative, I developedand grew various healthcare enterprisesfor 22 years. I was Chief Operating Officerof MedTrans, which was renamed Ameri-can Medical Response (AMR), the world’slargest emergency medical and physicianservices provider. I have also founded, runand held various senior executive roles athealthcare companies in consumer mem-bership primary care services, women’shealth, and housecalls. I was first interest-ed in wireless health when I realized mybackground in emergency services provid-ed a great deal of relevant knowledgeabout mobile healthcare and the use ofwireless technologies. We started usingwireless technologies with electrocardio-graph medical devices in the 1970s. In be-tween sales of companies, I had an oppor-tunity to advise one of Qualcomm’sbusiness units on the use of wireless tech-

nologies in healthcare and this led to thedevelopment of a platform that servescompanies like CardioNet today. Later,Qualcomm’s CEO asked if I might joinQualcomm and take a look at the entirefield of wireless technologies in health-care. After leading multiple successfulstart-ups, I thought working with Qual-comm might present some really inter-esting opportunities for companies topartner in wireless health.

BKW: Tell us more about the aims of yourtrade organization, Wireless-Life SciencesAlliance.

DJ: I founded the Wireless-Life SciencesAlliance (WLSA) because there was not avenue for the leaders of the wireless andhealthcare industries to get together anddiscuss collaboration. Today, WLSA is theworld’s first organization focused on do-ing just this – accelerating the conver-gence of the wireless and healthcare in-dustries. WLSA produces global forumsthat bridge the gap between the wirelessand health industries by enabling newbusiness models and improvements inconsumer health, fitness, clinical services,medical devices, and healthcare IT. To seeWLSA become the world's foremost in-dustry organization in the wireless health

space is something I am very proud of, butdidn't necessarily anticipate. Today WLSAoffers members a May Summit targetingthe investor and senior executive com-munities and an October Symposia fo-cused on engineering and clinical integra-tion which has university participationfrom six continents, the first of its kind inthe world. Both events are located in SanDiego. Participating companies comefrom medical device, pharmaceutical,health services and consumer product ar-eas, and is an interesting mix includingJ&J, St. Jude, P&G, Sanofi-Aventis and manyearly stage companies.

BKW: You say that one of your favoritemantras is: “Wireless health collapses timeand space in healthcareSM.” Can you ex-pand on that?

DJ: Wireless technologies collapse timeand space (location) in healthcare, in thatit enables things to happen faster thanthey otherwise would. For example, Tel-care's 3G-enabled blood glucose meter(BGM) will allow diabetics to send theirblood glucose readings to caregivers andreorder their supplies (testing strips, in-sulin, lancing devices, etc.) in real-time.Tools like Telcare's BGM make managingchronic diseases seamless and easy. Wire-

41

Vice President of Wireless Health, Global Strategyand Market Development, Qualcomm Labs

&

“We are seeing an increased focus on the consumer when new wireless health devices

and services are being designed. Gaming, socialnetworking and digital media are all coming

into play to ensure that these innovative healthsolutions are widely adopted by consumers.”

INTERVIEW

less Health collapses space in healthcare inthat it enables "healthcare" to take place out-side of traditional healthcare settings. Thatis, healthcare isn't just inside the hospitalanymore, as wireless technology is bringingit to consumers’ homes, to remote villages,etc. Wireless fitness devices enable consumersto be proactive about their health, and im-prove wellness through personalized healthfeedback loops that only wireless connectiv-ity provides. Remote monitoring solutionslike the Corventis patch are replacing large,in-hospital machinery with peel-and-sticksmart band-aids, allowing for monitoring, di-agnoses and therapy management to takeplace in a patient's home, or even in rural ar-eas that didn't have access to health special-ists and equipment before.

BKW: You also speak to the importance oftaking charge of one’s own health. How doeswireless health fit in?

DJ: We believe in empowering consumers totake charge of their own health. Currently welive in a “sick care system” where physiciansand hospitals make money when people aresick, and consumers react to health problemsas they occur. Wireless health and fitness de-vices can provide consumers with informa-tion about their current state of health thatthey have not had before. Integrating wirelessconnectivity into health devices and servicesprovides users with real-time feedback andhealth statistics – “our numbers,” so to speak.How many steps have I taken today? How ismy weight trending? And more. As more de-vices and services become available in themarketplace, we will see these numbers ag-gregated into personalized health dashboardson our phones, tablets and health devices, giv-ing users more knowledge about their healththan was ever possible before.

BKW: Tell us more about how Qualcomm’sInternet of Everything Modules (IEM), whichyou describe as “a low-power, compact wire-less module that’s designed to enable a newwave of highly personalized mobile experi-ences and services” can improve healthcare.

DJ: Qualcomm's Internet of Everything Mod-ule (IEM) design is one of the smallest mod-ules in the world, about the size of a U.S.Quarter or a European Euro, and was origi-nally designed for wearable medical devices.The module design has an accelerometerand GPS, voice and data capabilities, whichallow for many health use cases. From falldetection, to emergency response, to loca-tion tracking, this module supports many ofthe functionalities a health sensor needs. Itssize, advanced capabilities and power man-agement optimize the design for health and

fitness solutions. The IEM has passed PTCRBCertification and has become a referencemodule for the OEM module industry to helpcompanies take advantage of the size foot-print and technology integration that is pos-sible. As we move to a world of “an Internetof Things,” integrated modules like this whichfacilitate the wireless enablement of manydevices, even very small devices, open up aworld of connected health possibilities.

BKW: What are you most proud of in yourcareer?

DJ: I am most proud of raising the bar inhealthcare services. I’ve been fortunate to beinvolved in founding, growing and runningmany healthcare companies that changedcare and improved outcomes for millions ofpeople. Early in my career I created a newservice offering called Critical Care Transporta-tion. It’s now a $2.5 billion market sector inEmergency Medical Services (EMS). Growinga small, San Diego-based EMS company intothe global, multi-billion dollar giant, AMR, wasanother eventful part of my experience. Theconsumer-facing, multi-billion dollar compa-ny I founded in Mexico, EMME, was perhapsthe most interesting. EMME now employshundreds of physicians, serving hundreds ofthousands of members in Monterrey andGuadalajara, with a very unique business mod-el that is not very different than a cell phonesubscription. I’m attracted by opportunitieswhich are not just a “me too” offering, butwhen new services and products can bebrought to the table that enhance the userexperience and bring value.

The conception of the West Wireless HealthInstitute, and joining with Eric Topol, M.D.and Gary and Mary West to make it a realitywas another key set of events in my life. Ienjoy bringing all the components – thetechnology, the people and the service con-cepts – together to improve offerings be-yond the status quo.

BKW: What do you predict as the new trendsfor technology & healthcare for the nextdecade?

DJ: One trend we're seeing is the shiftingfrom a "sick care" system to a health im-provement system. Currently consumers en-gage with healthcare systems or their health-care providers when they are sick. Physiciansand hospitals make money when patientsare sick, and there are no incentives for keep-ing patients healthy, or for consumers to keepthemselves healthy.

Similarly, we are seeing health move fromthe hospital to the home. As more wireless

health devices, services and apps enter themarket consumers are being proactive abouttheir health, and using these tools to improvetheir fitness and wellness.

There is also an increased focus on the con-sumer as new wireless health devices and serv-ices are being designed. Gaming, social net-working and digital media are all coming intoplay to ensure that these innovative healthsolutions are widely adopted by consumers.

BKW: Do you feel most people are willing toembrace new technologies?

DJ: Absolutely. In fact, research is showing thatnot only do consumers want these technolo-gies, but that they are willing to pay for themtoo. It is projected that 400 million wearablesensors will be in the market annually by 2014.Additionally, in the U.S. alone, out-of-pocketspending (OOP) on healthcare rose from $380billion in 2009, which is 13 percent of the to-tal amount spent on health. Consumers aredesperate for health solutions and servicesthat enable them to manage their own healthinstead of paying high prices for treatment inhealthcare systems and institutions.

BKW: Anything you’d like to add?

DJ: We are at the cutting edge of a brand newdecade of digitally connected services inhealthcare. These services will impact the tra-ditional healthcare fields, the physicians, hos-pitals and service providers, but will ultimate-ly have a much more profound impact onthe end user, the consumer, who will becomemore empowered to manage their ownhealth. If a consumer suffers from a health-care condition and can monitor their statuswith wireless health tools, they can assist intheir own diagnostics and therapy manage-ment. The key in the future will be the abil-ity to combine data from different devicesand sources to create real self-managementsolutions.

Qualcomm is actively working on the tech-nologies to make this a reality – to enablemedical device companies, health softwarecompanies and health analytics to all play amore convenient and relevant part in our liveswhile adding real value. We have a great teamat Qualcomm and within our Qualcomm Wire-less Health group, and I am proud to be a partof laying the groundwork. We have a uniqueopportunity to partner with the healthcare in-dustry and enable care, services and solutionsbeyond what currently exists or is even envi-sioned. I think consumers will be thrilled withthe solutions they will see. This is the nextchapter of health – and is one I expect to beequally as proud of my work in.

42

ASK THE EXPERT Don Jones

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For many of us,metabolic diseasesare the outcomeof an energy im-balance: more/lessenergy input thanexpenditure. How-ever, our waistlinesare growing inspite of the huge

amount of treatments, diets and fat-free/low-calorie products available to copewith them. As noted by many experts,“Fresh ideas are needed to push the fieldforward.” In this issue we have seen thata possible strategy for improving the ac-tual treatment of metabolic diseases is theuse of advanced information technologies.Specifically, different technologies – theInternet, Virtual Reality (VR), and mobilephones – have the potential to improvethe assessment and treatment of thesedisturbances. Nevertheless, these devicesare not perfect.

On one side, they typically try to changebehaviors and cognitions at a more gen-eral level, rather than focusing on actualsituations or the “real” context in whichthey happen. For example, even if VR is avery promising technology for the treat-ment of obesity and eating disorders, it isa distinct realm, separate from the emo-tions and behaviors experienced by thepatient in the real world; the behavior ofthe patient in VR has no direct effect onreal-life experiences, nor are the emotionsand problems experienced by the patientin the real world directly addressed in theVR exposure.

On the other side, these devices are usu-ally used in manualized approaches thatallow for a limited amount of customiza-tion to be made according to the specif-ic characteristics of a given patient. In real

life, however, patients’ most immediate,pressing problem may change from weekto week, and the technology is not usual-ly able to effectively refocus on the newneed or problem.

A possible path for solving these issues isthe use of communication technologiesto establish a link between the real worldand the technological one: (a) the patient’sbehavior in the physical world influencestheir experience in the technologicalworld; and (b) the patient’s behavior us-ing the technology influences their expe-rience in the real world. Using this ap-proach, usually defined as “Interreality,” itis possible to modify the patient’s rela-tionship with his/her dysfunctional behav-ior and think through more contextual-ized, experiential processes.

In summary, bridging multimedia experi-ences (fully controlled by the therapist,used to learn healthy behaviors and cop-ing skills) with real experiences (the ther-apist can identify critical situations andassess coping skills in real life) – using ad-

vanced technologies (virtual worlds, ad-vanced sensors and smartphones) may bea feasible way to address the complexityof these disturbances (see Figure 1).

Obviously, any new paradigm requires alarge amount of effort and time in orderto be assessed and properly used. Withouta real clinical trial with patients, the Inter-reality paradigm will remain an interest-ing, but untested concept. However, directand indirect costs of metabolic diseasesare huge, and some new studies suggestthat when managed and organized well,the use of Interreality technologies maylead to cost savings and improved outcomefor both patients and health services.

45

By Giuseppe Riva

Giuseppe Riva, Ph.D.Istituto Auxlogico ItalianoItaly

[email protected]@auxologico.it

FROM WHERE WE SIT:Europe’s Initiative in Using Interreality to Treat and Prevent Metabolic Diseases

[ ]

46

Metabolic syn-drome exhibits acomplex, multifac-torial etiology. Re-search comparinggenetically differ-ent populationsindicates thatboth genetics andlifestyle issues are

major factors in its development. Approx-imately 20-30% of the middle-aged pop-ulation in highly industrialized countriesexhibits symptoms of metabolic syn-drome. The symptoms of metabolic syn-drome are multilayered. For example, a di-agnosis of high blood pressure could alsoindicate high blood glucose, abnormal lipidlevels, inflammatory disease, or obesity.Similarly, insulin resistance, urine proteins,heart disease, stroke, kidney failure, depres-sion, and cancer could indicate metabol-ic syndrome as well. Among these symp-toms, insulin resistance is considered tobe the underlying factor in the mechanismof metabolic syndrome by the WorldHealth Organization (WHO). Insulin resist-ance, denoted by hyperinsulinemia or thecondition of excess circulating insulin inthe blood, can lead to type 2 diabetes,which can result in macrovascular disease.The complications of diabetes are difficultto avoid for any diabetes patient. Accord-ing to statistics from the American Dia-betes Association (ADA) in 2010, the riskof complications for a diabetic patient ofthree years is over 46%, for a patient offive years is over 61%, and for a patient ofover 10 years is 98%. Complications in-clude kidney disease, system edema,headache, nausea, vomiting, oliguria, andthe deadly uremia. Other conditions, suchas mental illnesses, are indirectly associ-ated with metabolic syndrome due to theincreased likelihood of cardiovascular dis-ease, obesity, and other metabolic syn-

drome criteria spurred by the condition orthe consequent change in lifestyle.

Diabetes is no longer considered a west-ern disease. It has spread around the worldto become a significant global problem.The International Diabetes Federation es-timates that by 2025 the number of dia-betics will be 380 million, compared to240 million in 2007. Over half the num-ber of patients will be in Asia where theyoung and middle-aged will be the mostaffected age group, as compared to theelderly population in Europe and NorthAmerica.

Health systems in Asia are battling anepidemic of obesity and diabetes that

many are unable to handle. In countriessuch as India and China, urbanizationand economic development have led togreat shifts in the health risks of theirrelated populations. Life expectancy hasdramatically risen and infection rateshave significantly dropped. However, alifestyle transformation has also accom-panied accelerated industrialization.Physical activity has decreased and theavailability of food has increased; togeth-er, these two changes have resulted inincreased rates of degenerative diseasessuch as diabetes and cardiovascular dis-ease. The prevalence of diabetes in Chi-na has almost surpassed the 5.5% preva-lence rate in Europe and North America,despite the rate being approximately 1%

thirty years ago. Currently, there are ap-proximately 92 million diabetics in Chi-na and 148 million pre-diabetic patients.Soon, China will overtake India as theworld’s most diabetic country by sheernumber. Together, the diabetic patientsin China and India account for over halfof the total diabetics in the world.

The Asian diet has transformed from oneof primarily stir-fried, barbequed, andsteamed vegetables and rice to one simi-lar to the western diet of cereals and sug-ars, as well as vegetable oils and animalsources. Urbanization has tripled withinthe last half-century which correspondswith decreases in physical activity relatedto a rural lifestyle. The number of cars,

which is associated with weight gain, hasalso risen with the development of cities.Moreover, the increase in general wealthhas led to greater access to tobacco andalcohol, both of which can contribute tometabolic syndrome. The average num-ber of cigarettes per capita went from oneto 15 cigarettes within forty years; alcoholconsumption quintupled in that sametime.

In addition, with the improvement in qual-ity of life, rates of overweight and obesechildren have risen. A new study showsthe prevalence of metabolic syndromeamong school children is 6.6% overall,and 33.1% in obese children. Childhoodobesity rates correlate with high blood

FURTHER AFIELD:The Changing Landscape of Metabolic Syndrome and Diabetes in Asia

By Lingjun Kong

“Health systems in Asia are battling an epi-demic of obesity and diabetes that many areunable to handle. In countries such as India

and China, urbanization and economic devel-opment have led to great shifts in the health

risks of their related populations.”

[ ]

pressure, dyslipidemia, and especially, in-sulin resistance. In Asian Indian familieswith a history of type 2 diabetes in a first-degree relative, a child with a high waist-to-hip circumference ratio can have upto an 86.4% chance of developing type 2diabetes.

Population-wise, Chinese women tend tohave lower instances of cardiovascularproblems, potentially due to the differinguse of tobacco and alcohol within the cul-ture’s social context. However, the culturemay have developed and supported anoverweight image within the wealthierclass. This also correlates to the higherprevalence of metabolic syndrome in the

highly urbanized regions of the country,specifically with the upper-class. Stress andother factors related with city life furthercontribute to this trend.

Diabetes comes with a huge monetarycost as well. The WHO predicts that Chi-na alone will lose at least $558 billion inhealthcare costs due to heart disease,stroke and diabetes over the next decade.Several medical organizations have beenaware of the rising trend in metabolic syn-drome in Asia for many years and havebeen searching for methods to reverse thechange. They are establishing physical fit-ness programs, recommending doctors toemphasize the importance of eating right

and being active, and also urging townsto grow their own food to avoid the influ-ence of the western diet. Although imple-mentation is difficult for countries of suchsevere infrastructure and healthcare, ma-jor steps have already been made. India,Pakistan and China are the top leaders ofinsulin manufacturers in the world, espe-cially with the increased need of human,animal, and analogue insulin for their lo-cal markets. Wireless health monitoringand healthcare devices have become moretechnologically advanced and accurate.Most importantly, with more than half ofthe diabetes patients in the world resid-ing in Asia now, science has strengthenedthe understanding of this complex disease– the first step in battling it.

Europe’s leading health policy conference

Over the past decade the European Health Forum Gastein has developed into an indispensable institution in the scope of European health policy. Held for thefirst time in 1998, it has made a decisive contribution to the development ofguidelines and above all the cross-border exchange of experience, informationand cooperation. It has the overall aim of providing a platform for discussion for the various stakeholders in the field of public health and health care.

About 600 leading experts participate in the annual conference held in theGastein Valley in Austria in October. The unparalleled mix of participantsincluding leading country- and EU-level representatives from theareas of health policy, administration, science, business andpatient organisations, are especially critical to the success of this event.

More information can be found at: www.ehfg.org

European Health Forum Gastein

“The EHFG is a uniqueplatform to meet and for the transfer ofknowledge and opinionsbetween various interestgroups. The events of theEHFG and the issuesformulated there oftenshape EU health policy in subsequent years.”

Günther LeinerEHFG President

“Diabetes comes with a huge monetary costas well. The WHO predicts that China alonewill lose at least $558 billion in healthcarecosts due to heart disease, stroke and dia-betes over the next decade.”

Lingjun Kong, PMPVirtual Reality Medical CenterU.S.A.

[email protected]

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A lack of resources and funding in the United ArabEmirates’ mental healthcare sector have led to growingconcern among experts and residential healthcareproviders. The Dubai Health Authority and UAE Ministry ofHealth, along with several public and private healthcareorganizations, are launching an aggressive campaign toimprove the state of care, as well as giving attention to thedrastic increase in metabolic disorders in the region.

[ ]C&R in the UAE

s recently as 2007 local mentalexperts spoke to the lack of pro-visions in mental healthcare serv-

ices in the United Arab Emirates (UAE),quoted in an Arabian Business article say-ing the severe shortage of certified psy-chologists had contributed to the regionhitting “rock bottom.” The “absolute lackof resources, ” they said, further encour-aged existing stigmas and continues to re-sult in many sufferers remaining undiag-nosed and untreated.

Like many Middle Eastern and Asian coun-tries, mental health in the UAE has tradi-

tionally been a taboo subject. The stigmahas led to a lack of counselors and special-ists in the field; many residents still be-

lieve mental diseases are contagious, andfemale psychologists are rare due to thefact that they will find it nearly impossi-ble to marry if they obtain a related de-gree. In a country with a population of 4.8million inhabitants, a scant 180 specialpsychiatrists were practicing in 2009, asnoted by Dr. Bahjat Balbous, a psychiatristat Al Amal Hospital, in a 2009 KhaleejTimes article.

The lack of specialists and hospitals ded-icated to caring for psychiatric patientsmeans that no standardized means offunding treatment have been devised;

most private insurance plans do not cov-er mental healthcare services and possi-ble solutions explored include private con-

tributions, a charity fund, government as-sistance or insurance coverage, as a possi-ble means for financial support. Manyhealthcare providers and government of-ficials stress the need for welfare initiativesto prevent and treat cases involving men-tal illness.

Although plans have been enacted to com-bat these problems, the scarcity of valid,reliable and culturally relevant psychiatrictools for research in the Arab world hasled to complications, including a lack ofreliable epidemiological base line data;large-scale community surveys are rarelyused. Methodological problems with as-sessment and evaluation as well as cultur-ally divergent concepts of mental disor-ders has hindered an improvement orfurthered understanding of the shortcom-ings of the system.

While depression and anxiety are the mostcommon mental disorders in the UAE, sim-

A

> COUNTRY FOCUS


50

AUTHORS:

Emily ButcherManaging EditorC&R Magazine

[email protected]

“The UAE has the second highest rate of diabetes – 18.7%in 2009 – and cardiovascular disease is the main causeof death, making up 28% of total deaths each year.”

51

> COUNTRY FOCUS

ilar to other countries around the globe, sui-cide rates are exponentially higher than oth-er developed countries. A large concentra-tion of Indian migrant workers subjected tosocial abuse and desperate financial situa-tions resulted in a suicide rate of one everythree days in 2010, leading to a large amountof media coverage and public attention. Aswell as tackling issues of social abuse andunethical practices, a growing need for coun-seling services in the camps has been rec-ognized.

The stigma does little to help the problemwith the number of people suffering frommental health issues and depression due toeveryday stress, lack of sleep, and drug abuse,numbers that continue to rise steadily.

Rising Rates of Obesity

Another major health concern facing theUAE is rapidly rising obesity rates. The coun-try was recently ranked #18 on the Forbes’

list of fattest countries, and 68.3% of its res-idents are currently categorized as over-weight. Furthermore, the UAE has the sec-ond highest rate of diabetes – 18.7% in2009 – beat only by the tiny Pacific islandnation of Nauru where one-third of the pop-ulation suffers from the disease.

A 2009 survey conducted in the UAE byVLCC, a private, multinational lifestyle man-

agement organization, recorded respon-dents’ opinions on the topic. Top reasonscontributing to rates of obesity were list-ed as Dubai’s sedentary lifestyle, lack ofknowledge about the disease, poor diet,

cultural or genetic predisposition, and ad-verse climate.

As well as being linked to comorbid condi-tions like diabetes, recent research has high-lighted the negative effect that being over-weight can have on quality of life. Eightypercent of the survey’s respondents agreethat being overweight negatively affects day-to-day activities.

Several public and private healthcare organ-izations are launching preventative healthinitiatives to help raise awareness of theproblem. “Slimming programs” offered bycompanies such as VLCC focus on lifestyle

C&R in the UAE


4.765

78

1.9

31

59

78%

2.8%

4%

190

3.75

6.2

70%

2.8%

0.66%

Population (Million)

Life Expectancy (Years)

Fertility Rate

Population Median Age (Years)

Population Density (Persons Per Sq Km)

Percentage of Urban Population

Annual Population Growth Rate (%)

Unemployment Rate

Hospital Beds (Per 100,000)

Psychiatrists (Per 100,000)

Annual Rate of Suicide in Dubai Between

1992 and 2000 (Per 100,000)

Indian Migrant Worker Suicides

(% of Total Cases of Suicides in Dubai)

Total Expenditure on Health

(as Percentage of GDP)

Out-of-pocket Expenditure as a Percentage

of Private Expenditure on Health

“In 2009 a week-long awareness drive was held inOctober to educate nurses and doctors about their criti-cal role in caring for psychiatric patients as well as to fur-ther educate the public and aim to eliminate the stigmasurrounding the issue [of mental healthcare].”

and behavioral modification using a cus-tomized program implemented with thehelp of a specialized team of doctors,nutritionists, counselors and physiother-apists.

Moving Forward

Recognizing the need to promote aware-ness, The Dubai Health Authority hastaken important measures to change tra-ditional misconceptions and launcheda Mental Health Campaign at RashidHospital on World Mental Health Day onOctober 10 in 2008. The same year theUAE Ministry of Health launched a proj-ect to initiate research into the status ofexisting mental healthcare services, aswell as to start screening patients formental health disorders at the primarycare level. Primary healthcare centershave been recognized as key compo-nents in the goal to diagnose a largernumber of patients suffering from men-

tal disorders and the first step has beenrecognized as educating primary care-givers, who often times fail to under-stand underlying mental health issuesand simply treat patients for physical ail-ments. It is estimated that 60% of casescould be diagnosed and treated at thislevel, but only 25% of diagnosed patientscurrently receive treatment.

The following year, a week-long aware-ness drive was held in October to edu-cate nurses and doctors about their crit-ical role in caring for psychiatric patientsand further educate the public and aimto eliminate the stigma surrounding theissue. A “Mental Health Challenges atWorkplace in the UAE” seminar was alsoheld during the drive urging Human Re-sources managers and other companyrepresentatives to actively screen em-ployees to pick up on early signs of de-pression and other mental health disor-ders. To discourage stigmatization of

these individuals, employers were askedto support them in getting treatmentand welcome them back to the work-place after treatment.

These practices were supported by theIndian Consulate in response to thealarming number of suicides and unde-tected cases of depression and mentaldisorder in the Indian work camps. Freecounseling services are offered to thecommunity, who are directed to call acounseling helpline in times of distress.Counseling services will continue to bepromoted and strengthened at thecamps in the future.

52

> COUNTRY FOCUS

Sources:

World Health Organization and the Or-ganization for Economic Cooperationand Development.

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