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I am a friend of an insulin-dependent (type 1) diabetic patient. So that I could better understand how the human body reacts to glucose, insulin distribution, exercise, sleep, and carbohydrate absorption in patients with diabetes mellitus I decided to search the Internet for information. I was pleased to find the glycaemic control modelling software (AIDA) available for download at no charge.
Of all the information I have found concerning this very complex disease, the AIDA software is for me the most educational I have seen to date. AIDA offers a hands on approach to understanding some of the variables involved in maintaining tight blood glucose control in the type 1 diabetic patient. For me learning by application is much easier than trying to absorb mounds of abstract information. From reading, conversation, and observation I had what I thought to be a good understanding of diabetes mellitus; however, using the AIDA software has given me a quantitative approach to the disease.
Using the forty supplied case scenarios, and having the ability to create my own example cases has taught me a great deal. For example, I enjoy cooking. By using the AIDA software I have learned how small changes in the dietary habits of patients with diabetes, relative to their insulin regimen, can profoundly effect their blood glucose level.
As a lay person I have found AIDA most useful and I hope that the software will find wide acceptance and use as an educational tool, for health-care professionals, diabetic patients and their carers. As a carer it is my observation that in particular many health care professionals could actually benefit from this type of educational modelling approach. Although AIDA may be considered complex, and despite the fact that it takes a little while to become familiar with all the program's functions, this should not deter prospective users from experimenting with the software. After all, the diabetes condition is also complex, and it takes even longer to 'get to grips' with its day-to-day management.
Reno, Nevada, U.S.A.
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My daughter is 16 years old and has had diabetes for three years now. When she was first diagnosed, we were immersed in a great deal of information about what insulin is, and what is important for managing blood glucose levels. It was a challenge to understand all of this, and we did not appreciate the reality that management of diabetes is a dynamic process. Each time a new blood glucose value is taken, one needs to consider what the next course of insulin therapy should be. Unlike some who want to take charge of their disease, my daughter wants to be left alone. And so I embarked on a journey to understand in a practical way what it means to manage diabetes. Early on in this journey I obtained a copy of AIDA for free and began to learn interactively from the different case studies provided.
I now have an understanding of what the activity profile of NPH insulin looks like over time, and experience with modifying the trial cases. Much of this knowledge is useful for the collaboration I have with my daughter, as we manage her disease together. My daughter has little interest in AIDA, but AIDA has been valuable for me to understand the possiblities for modification of her therapy. Most of the time we check this out with our case worker, but we are becoming more confident of our own decisions within certain limits. We still have much to learn, but diabetes, like other aspects of life, is a continuous learning process. AIDA provides an important source of information, and offers a valuable demonstration of what can be accomplished through commitment and understanding.
Dr. Glenn Vonk, PhD
Raleigh, North Carolina, U.S.A.
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My 11 year old son has had diabetes for the past 7 years. Unfortunately he has a very unstable form of the disease - we have to 'fight' with his high and low blood glucose (BG) values. His BG levels are different day after day although his meals and insulin stay the same. For more than a year I have had access to the Internet, and so I have tried to find some information from it. However what I have searched for I have not found until now - a PC program which can really help me understand WHY are BG values often so different from what we expect.
The AIDA program seems to be getting near to what I am looking for. AIDA did not help me all at once (and the authors do not promise it). AIDA is not able to accurately simulate and predict BG processes in my son's body, but AIDA does help in my understanding of how to manage diabetes in a general way. By means of AIDA I found very quickly my common mistake of giving my son an insulin shot before lunch in cases of high BG. Increasing the insulin caused a big depression in BG levels after the meal. I can now appreciate more fully why.
I can recommend the AIDA program for diabetic patients who are familiar with PCs for learning quickly about interactions between insulin and diet in diabetes without any risks from experimenting with changes in insulin regimens in real life.
Prague, Czech Republic
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AIDA, an educational simulator for insulin dosage and dietary adjustment in diabetes, was recently reviewed by several of the nurse educators and medical staff of the Newcastle Diabetes Education Centre regarding its potential use in diabetes education.
Our initial impression of the program was that it is quite complex; it takes some time to thoroughly review the excellent written manual provided before you can begin using it effectively. In its present form it is not possible to have a quick 'play' with the software unless you are well versed in the mechanics of the program.
Several features of the program were thought to be worthwhile in diabetes education. Once the new user overcomes the problem of grasping the basic concepts of the program it is interesting to alter the inputs for insulin dose and carbohydrate intake and see an immediate change in the blood glucose level as a result of these changes. With practice users tend to become immersed in the program, testing out their ideas. Being able to modify or add case scenarios allows patients to make the program relevant to their particular educational needs.
The software will be useful to many of the adolescents and younger patients that we see at the diabetes centre, but a reasonable level of computer literacy will be necessary for people to get the most out of the program. Many of those in the older age groups might have a problem using the program as they would first have to overcome their aversion to using computers; this problem might be eased a little by developing a Windows-type graphical user interface for the software.
Nevertheless, interpretation of the screen output is not difficult once the basic operational concepts are grasped by the user; overall, the software design is quite sophisticated, and with increasing operator experience the application becomes a pleasure to use. The approach used offers realistic data output following changes in input variables and the often subtle changes that are elicited by the operator make this one of the highlights of the program. Further development of this feature to expand analysis of the effects of exercise and stress on changes in blood glucose levels should be both interesting and useful. We suggest breaking the program up into easy, moderately difficult and difficult levels of interaction. This may prevent the user losing interest in the program before being introduced to its many benefits.
If used in the Newcastle Diabetes Centre as an adjunct to diabetes education it would be essential to have someone conversant with the program give hands-on instructions to the first time user. If the person being shown the program is reasonably computer literate this should not be too difficult. However poor computer literacy could make this an ineffective process. Once the basic concepts of the program are grasped, it is easy to become absorbed in the program and be keen to explore all options available.
Feedback from staff members using the program was positive - they liked the program. They felt that the overall concept was good and the software had some excellent features that were useful for teaching purposes. The software was recently trialled under nurse educator supervision by 4 adolescents attending our Young People's Diabetes Clinic. Again, overall reaction was favourable, with 3 of the 4 expressing an interest to enter their own data and to monitor progress themselves.
Dr. Kerry Bowen, MB BS PhD FRACP
and Jane Scorer, BA RN
Director and Research Nurse
Newcastle Diabetes Education Centre,
New South Wales, Australia.
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The Diabetes Control and Complications Trial has demonstrated the benefits of good blood glucose control, however, achieving these results in the wider type 1 diabetic patient population is a challenge. One definite message is that diabetes education of both patients and healthcare workers needs to go beyond broad guidelines and that a sound understanding of insulin and carbohydrate interaction is fundamental.
AIDA is based on a physiological model and as such provides a realistic simulation of glucose values and can demonstrate the effects of changing carbohydrate or insulin amounts (or timing). When discussing methods of improving blood glucose levels most clinicians concentrate on adjusting the insulin dose. Using AIDA with the different case scenarios provided, it becomes evident that dose adjustment is not always the answer and that changes to type or timing of insulin administration or to the distribution of carbohydrate intake may offer a better solution.
AIDA can be used as an educational tool either individually or in groups. When used as a demonstration/teaching tool it has provided a starting point for discussion on other topics such as the pros and cons of tight blood glucose control, advantages and disadvantages of various insulin regimens, age-related limits, methods of testing and the treatment of hypoglycaemia. As well as having a favourable response when showing patients, AIDA has also been useful for teaching medical students on their diabetes attachments.
Hypoglycaemia is the downside of maintaining tight blood glucose control and with the advisory function in AIDA, resolution of the hypoglycaemia takes priority over all other treatment options, as it does clinically. However, not all hypoglycaemic episodes are recognised clinically and by looking at the simulated glucose curve generated by AIDA potentially vulnerable periods during the day, for a given scenario, can be identified.
No computer program can hope to mimic the full range of factors which influence glucose homeostasis in vivo, and while certain variables like alcohol or exercise have not been included, the effects of these are easier to contemplate once a good grasp of the basics has been obtained.
AIDA provides a risk-free opportunity to experiment with different aspects of blood glucose control. While trial and error are a significant part of any learning curve, the principles acquired from using AIDA are invaluable. I have no hesitation in recommending the program as an educational tool to patients and students, as well as endocrinologists and other healthcare workers.
Dr. Kathleen Hopkins, MD FRACP
Formerly from Division of Endocrinology, Middlesex Hospital, London, U.K.
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Thank you for your fine AIDA. The program has been used for teaching audiences of would-be Doctor or Diabetes Specialists, general practitioners, as well as technicians. The program's simulations provide a very convenient 'back to real life' sense for technical lectures.
The non-endocrinologists especially found the demonstration of the need for gradual adjustment of calorie intake, timing and combination of fast- and slow-acting insulins, very instructive. They made use of the adjustable normoglycaemic ranges in a 'competition' between two or three people at a time, switching from low-insulin sensitivity patients to high-insulin sensitivity patients. The nurses here, not accustomed to the need for very regular blood glucose determination, are also going to have a demonstration of the software.
In my experience the program is sufficiently sophisticated to convey the effects of regular insulin-dosage adjustments - yet it is simple enough to be used by non-experts. Furthermore most people will be able to use AIDA on their own. However, my experience is that especially in an audience, say of 6-10 people, this program is ideal because discussions about what to simulate next develop very rapidly.
I recognise the need for the warnings at the start of AIDA, but I believe that a program like this could enhance the knowledge of interested diabetic patients early on in their disease. However I have no personal experience in this matter, having only used AIDA for postgraduate teaching. I agree that patients should not by any means see this as a direct way to adjust their own insulin-doses. Rather allowing patients and health-carers to learn basic rules - as AIDA does - seems a very smart and logical addition to other existing teaching methods.
Dr. Bjørn Søeberg, MD
Kommunehospitalet, University Hospitals of Copenhagen
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This program simulates the glycemic effects of carbohydrates and insulin. It is intended to be a training tool, both for the individual diabetic and for the student of diabetes. The student is given cases where the patient is out of control, and asked to prescribe a new regime to achieve euglycemia. Answers are provided.
The individual diabetic can enter carbohydrates ingested and insulin taken, and compare this with actual blood sugar readings to understand, in general, what is happening. The program warns that it's recommendations should NOT be used by the individual for modifying their regime; the only function of the recommendations is for the training described above.
The program is a DOS program with a user interface that is not altogether adherant to modern interface design principles; however, the program is a useful tool for the student and/or diabetic.
I highly recommend it for medical students, interns, and residents. For diabetic educators who want to use it in their training, it may well be a useful adjunct. Some diabetics may also want to experiment with the program for a better understanding of their disease, again, with the caveat that its recommendations are not intended to be used in lieu of a diabetologist.
Reproduced from "Information Technology Resources to Support Persons Involved with Diabetes"
misc.health.diabetes newsgroup (1996)
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DIABETES TECHNOLOGY & THERAPEUTICS
Volume 1, Number 1, 1999
Mary Ann Liebert, Inc.
Diabetes Simulators: Ready for Prime Time?
DARRELL M. WILSON, M.D.
Diabetes is a disease of compromises. Irrefutable evidence demonstrates that good glycemic control significantly reduces the risk for developing many of the devastating long-term complications of diabetes. Conversely, limitations inherent in the current methods for providing insulin replacement make euglycemia a very dangerous proposition for most type 1 diabetics because of the risk of severe hypoglycemia. Normal beta cells within the pancreas modulate insulin secretion, responding in minutes to small changes in blood glucose concentrations. This tight feedback loop maintains blood glucose concentrations with-in a narrow range. Current clinical insulin regimes pale in comparison.
Patients, and often their families, face a substantial challenge as they tread the narrow path between low- and high-glucose concentrations each day. Using a handful of glucose determinations each day, they must integrate diet and activity with a bewildering array of possible exogenous insulin preparations and doses to forge a reasonable level of glycemic control. Given this complexity, patients and providers alike seek a clear-cut set of rules to guide them to euglycemia. Given our increasing understanding of physiology and the massive computing capability on our desktops, an algorithm to predict glucose concentrations does not seem, at first blush, an unreasonable request. With some patient-specific information, shouldn't we be able to accurately predict the glucose concentrations resulting from various dietary and insulin regimens?
In the article elsewhere in this issue , Dr. E.D. Lehmann discusses one such glucose simulator, AIDA v4.0. This program is freely available via the Internet. A DOS program, it ran reasonably well in a Windows 95 environment. The user interface is a bit cumbersome. The program uses a physiology-based, single glucose compartment model to integrate the actions of carbohydrates and exogenous insulin. Glucose enters the compartment by intestinal absorption and liver gluconeogenesis. Glucose leaves the compartment via insulin-independent and insulin-dependent pathways. Hepatic and peripheral glucose utilization are modeled separately so that different insulin sensitivities may be assigned to each. Renal glucose losses occur when the renal threshold is exceeded. Insulin concentrations (from virtual subcutaneous injections) are derived using a two-compartment model. Counterregulatory hormones, exercise, stress, and circadian variations in insulin sensitivity are not included within this model. The technical guide that is included in the program contains a complete description of the equations involved in the model. The author has done some evaluation of the potential clinical utility of this model using patient specific parameters derived from actual historical glucose concentrations. Reasonably large differences were found between predicted and actual glucose concentrations.
Both the program itself and the article discussing the program repeatedly stress that AIDA is not designed to provide patient-specific advice regarding diabetes management but is, rather, strictly an educational tool. The author proposes that this simulator might be helpful in teaching both patients and professionals to control glucose concentrations more effectively. While the author reports some of the feedback he has received regarding this program, the effectiveness of the program to improve glycemic control in either setting has not really been tested.
Features such as occasionally missed insulin doses and random variation in glucose concentrations would improve the clinical realism of the simulation. Finally, improved user interfaces are needed to increase acceptance of simulators as educational tools. Changes in the virtual management regimen must be easy to make and the resulting impact on virtual glucose concentration easy to see and compare. In this regard, computer game-based formats may well be more effective for many patients. As Dr. Lehmann himself states, however, formal trials are essential to demonstrate that this (or other simulators) can actually help improve diabetic management.
Do physiology-based glucose simulators have a role beyond educational aids? The addition of components to the model would increase its complexity and perhaps its ability to predict clinically relevant glucose concentrations accurately in an individual patient. Development of such a model would certainly highlight gaps in our knowledge of the physiology involved in glucose homeostasis, an admirable goal in and of itself. Would random variations, such as in carbohydrate or insulin absorption, preclude glucose predictions accurate enough to guide an individual patient to better control? Absent a practical glucose sensor, are 4 to 8 glucose values per day sufficient to properly "tune" a glucose simulator to an individual patient? I don’t know. Clearly some patients with complete insulin deficiency are able to achieve good glycemic control despite all these random variations and with infrequent sampling. Many of these patients, however, seem to use regimens that incorporate more feedback correction than actual simulation of the impact of management changes on future glucose concentrations.
Simulators are useful endeavors. Simulators that accurately reflect the real world permit exploration of actions that would be difficult or impossible to perform in the real world. Even imperfect simulators can serve to identify important areas where knowledge is insufficient, pointing the way for further study.
Address reprint requests to:
Darrell M. Wilson, M.D.
Chief, Pediatric Endocrinology and Diabetes
S-302 Medical Center
Stanford, CA 94305-5208, U.S.A.
Reproduced from Diabetes Technology & Therapeutics, Volume 1, Number 1, Spring 1999, pp. 55-56, courtesy of Mary Ann Liebert, Inc., publishers, 2 Madison Ave., Larchmont, NY 10538, U.S.A. Phone: (914) 834-3100; fax (914) 834-3771; e-mail: firstname.lastname@example.org; on-line: www.liebertpub.com
 Lehmann, E.D. Experience with the Internet Release of AIDA v4 - An Interactive Educational Diabetes Simulator. Diabetes Technology & Therapeutics 1999; 1: 41-54.
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