2014 IEEE 11th International Conference on e-Business Engineering

A Patient-centered Self-care Support System for Diabetics

Chien-Ho Wu
Department of Statistics and Information Science
Fu Jen Catholic University
New Taipei City, 24205 Taiwan
052845@mail.fju.edu.tw

Abstract—According to WHO statistics there are about 347
million people worldwide having diabetes. Unfortunately cures for
both type 1 and type 2 diabetes have proved elusive to medical
science. The causes of diabetes are a complex, but are in large
part due to rapid increases in overweight, obesity and physical
inactivity. In general to help prevent diabetes and its complications,
people should achieve and maintain healthy body weight, be
physically active, eat a healthy diet, and avoid tobacco use.
Achieving this goal requires a patient-centered approach on the
part of healthcare. In this research we pull together IT in public
domain and propose a system, called ScasDia, with features of
reminders, plotting and advance-warnings that can benefit
diabetics by improving the quality of self-care. ScasDia,
implemented in Java, facilitates the recording of data related to
diet control, physical exercises and diabetes indicators.
Nonetheless it builds ARIMA models with R on selected indicators
so that predictions for the selected indicators can serve as advance
warnings on the status of diabetes care. ScasDia can help
reduce risk factors that contribute to the development of
complications.
Keywords- Diabetes; ARIMA; Java; R
I. INTRODUCTION
Diabetes is a chronic progressive disease. It can be
prevented but is not yet reversible if developed. According to
statistics from WHO there are about 347 million people
worldwide having diabetes. It is predicted to become the
seventh leading cause of death in the world by the year 2030
(WHO 2013).
Diabetes care is a lifelong responsibility and takes round-
the-clock commitment. Careful diabetes care can reduce risk
of serious, even life-threatening, complications. Preventing
diabetes and its complications requires a patient-centered
approach on the part of healthcare.
A diabetes treatment plan usually dictates a patient to
achieve and maintain healthy body weight, be physically
active, eat a healthy diet, and avoid tobacco use. Also
tracking clinical indicators has been shown to improve the
quality of diabetes care, ultimately improving the outcomes
for people with diabetes (NIH 2013, Rossi et al. 2011).
Despite the recognized importance of tracking clinic
indicators and criticality of strict commitment to the
treatment plan, there is no proper tool that is cost-effective
available to the patients to help achieve those tasks. To help
patients of type 2 diabetes track daily measures and achieve
treatment plan, we adopt a systems approach to address the
problem and develop a diabetes care support system called
ScasDia. It is developed using open-source ware with the
ability to analyse daily measures and build ARIMA models
on selected diabetes indicators for forecasting purposes. In
the end ScasDia is able to help improve the quality of self-
care and quality of life for diabetics.
II. BRIEF SURVEY
A. Diabetes
Diabetes is a metabolic disorder of multiple etiology. It is
a noncommunicable chronic disease that occurs when the
pancreas does not produce enough insulin, or when the body
cannot effectively use the insulin it produces.
Hyperglycaemia is a common effect of uncontrolled diabetes
and over time leads to serious damage, dysfunction and
failure of various organs (WHO 1999). Complications
related to diabetes include stroke, kidney failure,
amputations, cardiovascular diseases and premature death et
cetera. Report has also shown that 50% of people with
diabetes die of cardiovascular disease, primarily heart
disease and stroke (Morrish 2001). Good metabolic control
prevents or delays these complications. In fact the overall
risk of dying among people with diabetes is at least double
the risk of their peers without diabetes (Roglic et al. 2005).
There are two major forms of diabetes. Type 1 diabetes
(T1D) is characterized by a lack of insulin production. T1D
usually develops in childhood and adolescence. Patients of
T1D require lifelong insulin injections for survival. Type 2
diabetes (T2D) results from the body's ineffective use of
insulin. T2D usually develops in adulthood and is related to
obesity, lack of physical activity, and unhealthy diets. Other
categories of diabetes include gestational diabetes and other
rarer causes. T2D accounts for around 90% of all diabetes
worldwide (WHO 2013).
Intermediate states of hyperglycemia (impaired fasting
glucose, IFG or impaired glucose tolerance, IGT) have also
been defined. These states can progress to diabetes but with
the possibility of being prevented or delayed (WHO 1999).
In people who do not have diabetes, the normal range of
blood /plasma glucose concentration level is about 70 to 120
mg/dl. Blood glucose goes up after eating but 1 or 2 hours
later returns to the normal range. Blood glucose targets for
most people with diabetes are 70 to 130 mg/dl before meals
and below 180 mg/dl 1 to 2 hours after the start of a meal.
Another test called HbA1c can be done to approximate

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DOI 10.1109/ICEBE.2014.58
metabolic control over previous 2-3 months and to guide
treatment decisions. An HbA1c of 5.7% or less is normal.
For many people with diabetes the goal is to keep the level at
or below 6.5-7% (WHO 2011).
Diagnosis is made by the presence of classic symptoms
of hyperglycaemia and an abnormal blood test. Signs of
diabetes include polyuria, polydipsia, feeling very hungry or
tired, having sores that heal slowly, having blurry eyesight,
or having dry, itchy skin et cetera (NIH 2013).
The overall aim of treatment for both T1D and T2D is to
bring the elevated blood sugars down to a normal range, so
as to improve symptoms of diabetes as well as to prevent or
delay diabetic complications. In general daily care of type 2
diabetes shall focus on the following actions (NIH 2013).
x Develop and follow a diabetes meal plan. Don't skip
meals.
x Be physically active. Physical activity helps stay
healthy. Try to be active almost every day for a total
of about 30 minutes.
x Check blood glucose as recommended. The closer to
normal the blood glucose is, the lower the chances
are of developing serious health problems. Levels of
ketones in blood or urine may be checked to prevent
the risk of having ketoacidosis which can cause
death.
x Take diabetes medicines every day if prescribed.
x Keep daily records. By keeping daily records there is
a better chance of telling how well the diabetes care
plan is.
Monitoring and controlling the levels of diabetes
indicators, including HbA1c, fasting plasma glucose (FPG),
postprandial plasma glucose (PPG), body mass index (BMI),
blood pressure and lipids, is an integral component of
diabetes care (Calvert et al. 2009, Rossi et al. 2011).
B. Systems for Diabetes Care
Since diabetes is one of many types of chronic diseases,
self-monitored care plays an important role in improving and
maintaining the quality of life for diabetic patients. There is
no doubt that proper self-monitored care can not only reduce
the risk of developing complications but also extend
accordingly the life expectance of people with diabetes.
Information technology is a powerful tool that has
profound impacts on all aspects of human society. In
particular, internet-based technology has been used to
improve quality and efficiency of care for patients of type 2
diabetes. Studies have shown that internet-based health care
service can achieve better glycemic control and may provide
effective and safe diabetes management for diabetic patients
(Kwon et al. 2004, Cho et al. 2006, Lim et al. 2011, Kang et
al., 2012).
Although systems approach to supporting self-monitored
care of diabetes has been shown to be effective and
beneficial to diabetics, current systems alike have not yet
included functions for building predicative models on control
indicators such as HbA1c, SBP and DBP etc. It is deemed
that predicative models on control indicators have the
potential of providing information on future directions and
trends of variations of control indicators. This information
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can act as advanced warnings on the possible adverse change
of conditions of people with diabetes.
C. Arima Model
Any finite or infinite sequence of uni-variate
observations {Xt : tT, where T is an ordered set of time} is
called time series. If the time index t can take all the values
in an interval of real numbers, the series is continuous. A
series is discrete when the set of the possible values t is a
discrete set (Dufour 2003). We generally assume that time is
a discrete variable. A time series can be viewed as one
possible realization of its underlying stochastic process (or
data generating process, DGP) defined on a common
probability space (Kunst 2009).
In order to create a statistical framework and to
formalize the problem of prediction, the underlying
stochastic process of a time series is assumed to be stationary.
The stationarity for the corresponding moments of the
stochastic process {Xt} are defined as follows (Kirchgassner
& Wolters 2007).
x Mean stationarity: A process is mean stationary if
E(Xt) = Pt = P is constant for all t.
x Variance Stationarity: A process is variance
stationary if V[Xt] = E[(Xt - Pt)2] = V2 is constant
and finite for all t.
x Covariance Stationarity: A process is covariance
stationary if Cov[Xt, Xs] = E[(Xt - Pt)( Xs - Ps)] =
J(|s–t|) is only a function of the time distance
between the two random variables and does not
depend on the actual point in time t.
A stochastic process is weakly stationary when it is of
mean and covariance stationarity. For most results and
techniques of time-series analysis, this concept suffices.
One of the general objectives of time series analysis is to
develop models for describing the behavior of time series.
ARIMA models are, in theory, the most general class of
models for forecasting a time series. A seasonal ARIMA
model is classified as an ARIMA(p, d, q)x(P, D, Q) model,
where P=number of SAR terms, Q=number of SMA terms,
D=number of seasonal differences. Very often we rely on
ACF and PACF plots to decide on the possible values of (p,
d, q)x(P, D, Q).
The Box-Jenkins approach to building an ARIMA model
consists of the following three steps (Box et al. 2008).
1) Identification: Determining the values of
(p, d, q)x(P, D, Q).
2) Estimation of ARIMA parameters.
3) Diagnostic checking. We should check that the
residuals of the resulting model follow the
assumptions given below.
a) Normality: .
b) Constant variance: .
c) Independence: .
The base, TSA and forecast packages of R provide most
of the functions needed for building and forecasting with
ARIMA models.
 III. SYSTEM DESIGN
Following the NIH guide to diabetes (NIH 2013) and the
idea of advance warnings for prevention we pull together
related open-source ware in public domain and develop a
tentative system, i.e. ScasDia, that can help not only track
daily diabetes records but also build forecast models on
selected diabetes indicators for forecasting purposes.
A. System Functions
Fig. 1 is the use case diagram of ScasDia. At this moment
ScasDia is designed for users that assume roles as either
record keeper or care professional. A record keeper can use
the system to track and maintain daily records about meals,
physical exercises and diabetes indicators such as blood
pressures and concentration levels of blood glucose. Besides
record keeping, users of ScasDia can receive preliminary Figure 2. System block diagram.
recommendations on physical fitness and calories taken from
meals. Furthermore users can plot line charts and time series
charts of selected diabetes indicators. A care professional can IV. IMPLEMENTATION
also exploit the model building function to predict values of
A. Deployment Requirements
diabetes indicators in the immediate future.
ScasDia is implemented in Java with NetBeans IDE as an
application in the Windows environment. Any platform
conforming to the following requirements shall be able to
run the system.
x Java runtime environment (SE. 1.7v or later)
x R statistical software (rJava/jri, RODBC incl.)
x ODBC manager
x MySQL(5.5v or later) with JDBC connector and
MySQL ODBC driver
System environment variables that must be set for the
sake of running the system include R_HOME,
JAVA_HOME, CLASSPATH and PATH.
B. Selected Screen Shots
Selected screen shots of ScasDia are shown from Fig. 3
to Fig. 5. The zigzagged first line in the upper left of Fig. 3 is
the line chart of recorded blood sugar tests 2HR after meal in
the morning and the wiggly second line is the line chart of
Figure 1. Use case diagram of ScasDia
recorded blood sugar tests before meal in the morning. The
line charts on the upper right of Fig. 3 are charts of blood
B. System Architecture sugar tests recorded in the afternoon.
The system contains five modules as shown in Fig. 2.
The GUI model is the interface that interacts with users of
the system. The data collection module is in charge of the
recording of daily details on food taken, physical activities,
and diabetes indicators. Data collected are stored in a
MySQL database. The data maintenance module provides
the house keeping functions for data stored in the database.
By referring to the data stored in the database, the suggestion
module provides recommendations about the suggested
intake of daily calories and preliminary diagnosis on the
frequency and strength of physical exercises. The forecasting
module builds, either automatically or manually, ARIMA
models by invoking model building functions in R through
Figure 3. Line charts of blood sugar and blood pressures.
the jri of rJava package (Venables 2013, Wu et al. 2012, Wu
2013, Wu et al. 2013).

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 Figure 4. ARIMA model summary for sample data.
Figure 5. Time series chart with forecasts for advance warning.
Fig. 4 is the model summaries built for the sample data
on diastolic blood pressures, and Fig. 5 is the time series
chart for the sample data with predictions for advance
warning purposes.
Forecast models for diabetes indicators in ScasDia are
built by invoking R functions. For the same set of data, the
details of a model in ScasDia may be different from those
built by other software such as SPSS or SAS. This
difference may due to the fact that different algorithms are
adopted in different software to compute the estimates of the
model.
V. FINAL REMARKS AND FUTURE WORK
Diabetes is a chronic disease. The overall risk of dying
among people with diabetes is at least double the risk of
their peers without diabetes. According to NIH guide, care
for type 2 diabetes requires patients to be physically active,
eat a healthy diet, achieve and maintain healthy body weight,
check blood glucose, take diabetes medicines if prescribed,
301
and keep daily records. There is no argument that diabetes
care is a lifelong responsibility requiring 24-hour
commitment.
To help reduce the burden of carrying out a care plan and
improve the quality of diabetes care, we have developed a
support system with functions to remind daily activities,
track daily records, plot recorded data, and build forecast
models on selected diabetes indicators with predictions for
advance warnings of possible adverse outcomes. The
tentative system is developed in Java and invokes R for
plotting and statistical functions. No commercially
proprietary code is employed in the implementation. In the
future, this research can be extended in the following
directions.
x Transform ScasDia into a web-based application
(Wu 2014), so that records related to the monitoring
and controlling of the levels of diabetes indicators
can be shared with patient’s care group on a real
time basis. As a result of online sharing of daily
records, risk factors that contribute to the
development of complications can be better
monitored and controlled.
x In light of the rapid growth of mobile devices,
exploring the possibility of porting the GUI module
of ScasDia to a mobile platform would prove
beneficial in the long run.
x Collaborate with dietitians and doctors to provide
functions adapted to their needs so that care for
patients can be more complete.
ScasDia is cost-effective and has the potential to
improve the quality of diabetes care, ultimately leading to an
improvement of life over time.
ACKNOWLEDGEMENT
Thanks to Jei-Wun Jheng and Yi-Ting Miao for
participating in the programming of the system. We are also
obliged to Huei-Ci Jiang, Chia-Hsin Wu and Wan-Jhen Liu [11] WHO, Definition, diagnosis and classification of diabetes mellitus
for helping out with clerical errands. and its complications. Part 1: Diagnosis and classification of diabetes
mellitus (WHO/NCD/NCS/99.2), Geneva, World Health
Organization, 1999.
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