Evaluating the Costs and Benefits of Outpatient Diabetes Education and Nutrition Counseling An automated telemedicine system improves patient-reported well-being. A comparison of diabetes education administered through telemedicine versus in person. Telemedicine improved diabetic management. Web-based telemedicine for management of type 2 diabetes through glucose uploads: a randomized controlled trial. Feasibility of using videoconferencing to provide diabetes education: a pilot study Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial. Brief, Computer-Assisted Diabetes Dietary Self-Management Counseling: Effects on Behavior, Physiologic Outcomes, and Quality of Life Smart Care Based on Telemonitoring and Telemedicine for Type 2 Diabetes Care: Multi-Center Randomized Controlled Trial. Sustained effects of a nurse coaching intervention via telehealth to improve health behavior change in diabetes. Impact of remote management of diabetes via computer: the 360 study--a proof-of-concept randomized trial. TeleHealth Improves Diabetes Self-Management in an Underserved Community Improvements in illness self-management and psychological distress associated with telemonitoring support for adults with diabetes. Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes Effectiveness of a Supportive Telephone Counseling Intervention in Type 2 Diabetes Patients: Randomized Controlled Study Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. The use of TeleMedicine in the treatment of paediatric obesity: feasibility and acceptability.
The Board of Directors of the American Diabetes Association ( ADA ) recently endorsed a resolution recommending third-party payment for outpatient education and nutritional counseling . One of the major rationale s for the statement was that education and nutritional counseling will lead to reductions in health care costs . This article critically review s the 13 studies cited in support of the ADA Policy Statement . Among these studies , only 2 compared a treated group with a control group . Both of the studies with control groups failed to r and omly assign patients to treatment condition . Only 4 of the studies showed an accounting of program costs . Upon close inspection , it appears that some of the programs actually increased , rather than decreased , health care expenditures . Attrition from programs was reported in only a minority of cases , and was large when reported . The effect of the programs upon diabetes control was inconsistent across studies . It is suggested that the rationale for education and nutritional services be based on improved health status . In addition , the execution of a systematic experimental study to evaluate these services is urged BACKGROUND Control of serum glucose levels is essential for the reduction of complications of diabetes . Telemedicine is one strategy through which serum glucose control can be improved . METHODS A total of 35 adult , insulin-treated patients with diabetes ( type 1 and type 2 ) were enrolled in the present study ( 63.0 + /- 10 years of age , 63 % female ) and r and omized to telemedicine monitoring ( including cordless , remote glucose monitor , and transmitter , n =  17  ) , or conventional follow-up ( n = 18 ) . Metabolic parameters were evaluated , and a quality of life question naire was administered both pre- and post-treatment . RESULTS Groups were similar at baseline in terms of demographic , quality of life , and metabolic parameters . Significant differences in post-treatment metabolic parameters were not observed , although serum glucose was marginally elevated in the control group compared to the telemedicine group ( 214 + /- 65 mg/dL vs. 171 + /- 77 mg/dL , P = 0.09 ) . On the other h and , being clinical ly symptom-free ( 71 % vs. 11 % , P = 0.003 ) , having no hypoglycemic events ( 82 % vs. 17 % , P = 0.0001 ) , and having no hyperglycemic events ( 65 % vs. 17 % , P = 0.004 ) were all significantly more frequently reported in the telemedicine group compared to the control group . Compared to the control group , the telemedicine group reported experiencing significantly less anxiety , treatment difficulty , depression , disease-associated life complications , and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose , weight , and overall diabetes . CONCLUSIONS Though post-treatment metabolic differences were not observed between treatment groups , the telemedicine group reported significantly greater post-treatment experiences of improved quality of life and sense of control over the disease . Thus patient satisfaction can be enhanced through the use of telemedicine OBJECTIVE To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators . RESEARCH DESIGN AND METHODS A total of 56 adults with diabetes were r and omized to receive  diabetes education in person ( control group ) or via telemedicine ( telemedicine group ) and were followed prospect ively . The education consisted of three consultative visits with diabetes nurse and nutrition educators . The in-person and telemedicine groups were compared using measures of glycemic control ( HbA(1c ) ) and question naires to assess patient satisfaction and psychosocial functioning as related to diabetes . Outcome measures were obtained at baseline , immediately after the completion of diabetes education , and 3 months after the third educational visit . RESULTS Patient satisfaction was high in the telemedicine group . Problem Areas in Diabetes scale scores improved significantly with diabetes education ( adjusted P < 0.05 , before vs. immediately after education and 3 months after education ) , and the attainment of behavior-change goals did not differ between groups . With diabetes education , HbA(1c ) improved from 8.6 + /- 1.8 % at baseline to 7.8 + /- 1.5 % immediately after education and 7.8 + /- 1.8 % 3 months after the third educational visit ( unadjusted P < 0.001 , P = 0.089 adjusted for BMI and age ) , with similar changes observed in the telemedicine and in-person groups . CONCLUSIONS Diabetes education via telemedicine and in person was equally effective in improving glycemic control , and both methods were well accepted by patients . Reduced diabetes-related stress was observed in both groups . These data suggest that telemedicine can be successfully used to provide diabetes education to patients Effective control of diabetes is known to delay or prevent the end-organ complications of this disease . Can telemedicine improve a patient 's ability to self-manage diabetes  ? Twenty-eight patients entered a study comparing home telemedicine consultation with st and ard outpatient care . A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician , who contacted the telemedicine group once a month . Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study . The hemoglobin A1c ( HbA1c ) and total body weight improved significantly in the intervention ( telemedicine ) group , as shown by a 16 % reduction in mean HbA1c level ( from 9.5 to 8.2 % ) and a 4 % mean weight reduction ( from 214.3 to 206.7 pounds ) . Based on our experience , we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies AIMS To evaluate the feasibility and effectiveness of a telemedicine system based on internet in the follow-up of patients with type 2 diabetes mellitus ( T2DM ) . METHODS A prospect i ve r and omized telemedicine study with two parallel groups was design ed . 114 patients diagnosed T2DM were r and omly divided into telemedicine group and traditional face-to-face visit group as control . 57 cases were included for each group . 108 patients completed the trial , in which 53 cases in telemedicine group and 55 cases in control group . Patients in telemedicine group were taught to use telemedicine software to upload their blood glucose and other metabolic information at home at least every 2 weeks , and the research ers gave proper advices according to patients ' key behaviors . The telemedicine interval is 3 months . RESULTS Compared to control group , telemedicine group exhibited better HbA1c and fasting blood glucose controlling ( P < 0.05 ) . Moreover , telemedicine intervention decreased hypoglycemia risk ( P = 0.044 ) , and contributed to levels of HbA1c less than 7 % which is the target of our study ( P = 0.049 ) . CONCLUSIONS Telemedicine system can provide a tighter glycemic control for the treatment of T2DM patients , especially in cases with difficulties to access to the medical centre We conducted a pilot study of the effectiveness of individual counselling sessions provided by a dietician through telemedicine for patients with diabetes . All participants received a single group education session via videoconference .  Those who were r and omized to the intervention also received two additional follow-up sessions , four and eight weeks later . Glycosylated haemoglobin and total cholesterol were measured at the start and again 16 weeks later . The patients completed diabetes quality -of-life and telemedicine patient satisfaction surveys . Thirty-two participants consented to participate . Complete data were collected on 13 intervention and 13 control patients . There was a 1 % fall in HbA1c in the intervention group from pre- to post- assessment , although this was not significant . The control group showed a significantly larger fall in HbA1c levels than the intervention group ( P = 0.043 ) . Total cholesterol decreased in both groups , although not significantly . All control and intervention group participants indicated that they would participate in videoconferencing nutritional counselling again . The results suggest that providing nutritional therapy via videoconferencing may be useful in assisting patients to manage their conditions BACKGROUND Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems . In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus ( PPDM ) despite clinic-based care , we evaluated a comprehensive telemedicine intervention that we specifically design ed for delivery using existing Veterans Health Administration ( VHA ) clinical staffing and equipment . MATERIAL S AND METHODS We conducted a 6-month r and omized trial among 50 veterans with PPDM ; all maintained hemoglobin A1c ( HbA1c ) levels continuously > 9.0 % for > 1 year despite clinic-based management . Participants received usual care or a telemedicine intervention combining telemonitoring , medication management , self-management support , and depression management ; existing VHA clinical staff delivered the intervention . Using linear mixed models , we examined HbA1c , diabetes self-care ( measured by the Self-Care Inventory-Revised question naire ) , depression , and blood pressure . RESULTS At baseline , the model-estimated common HbA1c intercept was 10.5 % . By 6 months , estimated HbA1c had improved by 1.3 % for intervention participants and 0.3 % for usual care ( estimated difference , -1.0 % , 95 % confidence interval [ CI ] , -2.0 % , 0.0 % ; p = 0.050 ) . Intervention participants ' diabetes self-care ( estimated difference , 7.0 ; 95 % CI , 0.1 , 14.0 ; p = 0.047 ) , systolic blood pressure ( -7.7 mm Hg ; 95 % CI , -14.8 , -0.6 ; p = 0.035 ) , and diastolic blood pressure ( -5.6 mm Hg ; 95 % CI , -9.9 , -1.2 ; p = 0.013 ) were improved versus usual care by 6 months . Depressive symptoms were similar between groups . CONCLUSIONS A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care . Because we specifically design ed this intervention with scalability in mind , it may represent a practical , real-world strategy to reduce the burden of poor diabetes control among veterans Objectives .The objective of this work was to evaluate the reach , effectiveness , adoption , and implementation of a brief behavioral dietary intervention and 2 supplemental components of diabetes self-management support : telephone follow-up calls and community re sources enhancement . Design and Subjects . This was a 2 × 2 r and omized , controlled trial investigating the incremental effects of telephone follow-up and community re sources enhancement with 320 adult type 2 diabetes out patients . Methods .Key outcomes included behavioral ( dietary patterns , fat intake ) , physiologic ( HbA1C , lipids ) , and quality -of-life/patient satisfaction measures and were collected at baseline and 3- and 6-month follow-up . Results .Despite high reach ( 76 % patient participation ) , excellent adoption ( all 12 primary care practice s approached participated ) , and good implementation , there were few outcome differences among treatment conditions . There was significant improvement across conditions in most outcomes in each category at both follow-ups . Conclusions .A brief , computer-assisted , dietary goal – setting intervention basic treatment condition was moderately successful in producing dietary improvements but less so in producing biologic or quality -of-life outcomes . Additions of follow-up phone calls or a community re sources enhancement component did not produce incremental improvements over this basic intervention BACKGROUND This study was performed to determine the effectiveness of the Smart Care service on glucose control based on telemedicine and telemonitoring compared with conventional treatment in patients with type 2 diabetes . MATERIAL S AND METHODS This 24-week prospect i ve multi-center r and omized controlled trial involved 338 adult patients with type 2 diabetes at four university hospitals in South Korea . The patients were r and omly assigned to a control group ( group A , n = 113 ) , a telemonitoring group ( group B , n = 113 ) , or a telemedicine group ( group C , n = 112 ) . Patients in the telemonitoring group visited the outpatient clinic regularly , accompanied by an additional telemonitoring service that included remote glucose monitoring with automated patient decision support by text . Remote glucose monitoring was identical in the telemedicine group , but assessment by outpatient visits was replaced by video conferencing with an endocrinologist . RESULTS The adjusted net reductions in HbA1c concentration after 24 weeks were similar in the conventional , telemonitoring , and telemedicine groups ( -0.66 % ± 1.03 % vs. -0.66 % ± 1.09 % vs. -0.81 % ± 1.05 % ; p > 0.05 for each pairwise comparison ) . Fasting glucose concentrations were lower in the telemonitoring and telemedicine groups than in the conventional group . Rates of hypoglycemia were lower in the telemedicine group than in the other two groups , and compliance with medication was better in the telemonitoring and telemedicine than in the conventional group . No serious adverse events were associated with telemedicine . CONCLUSIONS Telehealthcare was as effective as conventional care at improving glycemia in patients with type 2 diabetes without serious adverse effects BACKGROUND Diabetes educators and self-management programs are scarce in rural communities , where diabetes is the third highest-ranking health concern . The goal of this study was to evaluate the benefits of nurse telehealth coaching for persons with diabetes living in rural communities through a person-centered approach using motivational interviewing ( MI ) techniques . MATERIAL S AND METHODS A r and omized experimental study design was used to assign participants to receive either nurse telehealth coaching for five sessions ( intervention group ) or usual care ( control group ) . Outcomes were measured in both groups using the Diabetes Empowerment Scale ( DES ) , SF-12 , and satisfaction surveys . Mean scores for each outcome were compared at baseline and at the 9-month follow-up for both groups using a Student 's t test . We also evaluated the change from baseline by estimating the difference in differences ( pre- and postintervention ) using regression methods . RESULTS Among the 101 participants included in the analysis , 51 received nurse telehealth coaching , and 50 received usual care . We found significantly higher self-efficacy scores in the intervention group compared with the control group based on the DES at 9 months ( 4.03 versus 3.64 , respectively ; p<0.05 ) and the difference in difference estimation ( 0.42 ; p<0.05 ) . CONCLUSIONS The nurse MI/telehealth coaching model used in this study shows promise as an effective intervention for diabetes self-management in rural communities . The sustained effect on outcomes observed in the intervention group suggests that this model could be a feasible intervention for long-term behavioral change among persons living with chronic disease in rural communities BACKGROUND Previous studies have provided limited guidance regarding the clinical efficacy and cost-effectiveness of interventions using " telemedicine " models in the management of diabetes mellitus . We conducted a study to determine if routine clinical assessment s of diabetes patients could be effectively conducted via computer and telephone interaction with patients and still provide clinical results similar to traditional office care . SUBJECTS AND METHODS We enrolled 100 subjects with diabetes in this 12-month , r and omized , controlled , non-inferiority study . Subjects were r and omized ( 1:1 ratio ) to a control group ( CG ) or study group ( SG ) . Baseline characteristics were similar . CG subjects participated in quarterly office visits ; SG subjects participated in two office visits ( months 6 and 12 ) and two telemedicine interactions ( months 3 and 9 ) . Changes in clinical measurements ( hemoglobin A1c [ HbA1c ] , blood pressure , lipids , body mass index [ BMI ] , and body weight ) and clinician time requirements were assessed . RESULTS Seventy subjects completed the study ( CG , n=37 ; SG , n=33 ) . No significant between-group differences in HbA1c , blood pressure , lipids , or BMI were seen at 12 months . SG subjects showed significantly greater reductions in mean ( SD ) body weight compared with CG subjects : -5.2 ( 1.6 ) pounds versus -0.7 ( 1.5 ) pounds , respectively ( P=0.04 ) . Clinician time requirements for SG subjects were reduced by > 40 % . CONCLUSIONS Our study demonstrated that use of a telemedicine-based treatment protocol in diabetes patients is feasible and efficient and yields similar clinical outcomes compared with traditional , clinic-based protocol s. Telemedicine applications of computer software can potentially exp and access to care for patients and may reduce costs for patients , providers , and payers OBJECTIVE To conduct a 1-year r and omized clinical trial to evaluate a remote comprehensive diabetes self-management education ( DSME ) intervention , Diabetes TeleCare , administered by a dietitian and nurse/certified diabetes educator ( CDE ) in the setting of a federally qualified health center ( FQHC ) in rural South Carolina . RESEARCH DESIGN AND METHODS Participants were recruited from three member health centers of an FQHC and were r and omized to either Diabetes TeleCare , a 12-month , 13-session curriculum delivered using telehealth strategies , or usual care .  RESULTS Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin ( GHb ) in the Diabetes TeleCare group from baseline to 6 and 12 months ( 9.4 ± 0.3 , 8.3 ± 0.3 , and 8.2 ± 0.4 , respectively ) compared with usual care ( 8.8 ± 0.3 , 8.6 ± 0.3 , and 8.6 ± 0.3 , respectively ) . LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care . Although not part of the original study design , GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group ( 9.2 ± 0.4 , 7.4 ± 0.5 , and 7.6 ± 0.5 , respectively ) compared with usual care ( 8.7 ± 0.4 , 8.1 ± 0.4 , and 8.1 ± 0.5 , respectively ) in a post hoc analysis of a subset of the r and omized sample who completed a 24-month follow-up visit . CONCLUSIONS Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population OBJECTIVE The objective of this observational open label trial was to characterize changes in diabetes self-management and psychological distress associated with a mobile health ( mHealth ) interactive voice response ( IVR ) self-management support program . METHODS For 3 - 6 months , 301 patients with diabetes received weekly IVR calls assessing health status and self-care  and providing tailored pre-recorded self-management support messages . Patients could participate together with an informal caregiver who received suggestions on self-management support , and patients ' clinicians were notified automatically when patients reported significant problems . RESULTS Patients completed 84 % of weekly calls , providing 5682 patient-weeks of data . Thirty-nine percent participated with an informal caregiver . Outcome analyses adjusted for study design factors and sociodemographics indicated significant pre-post improvement in medication adherence , physical functioning , depressive symptoms , and diabetes-related distress ( all p values < 0.001 ) . Analyses of self-management problems indicated that as the intervention proceeded , there were significant improvements in patients ' IVR-reported frequency of weekly medication adherence , SMBG performance , checking feet , and frequency of abnormal self-monitored blood glucose readings ( all p values < 0.001 ) . CONCLUSIONS We conclude that the combined program of automated telemonitoring , clinician notification , and informal caregiver involvement was associated with consistent improvements in medication adherence , diabetes self-management behaviors , physical functioning , and psychological distress . A r and omized controlled trial is needed to verify these encouraging findings Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups Objectives This r and omized controlled trial investigated whether a patient-centered supportive counseling intervention comprising monthly telephone-based counseling sessions by practice nurses over 12 months improved diabetes-related medical and psycho-social outcomes above usual care in type 2 diabetes patients with poor glycemic control at baseline ( HbA1c > 7.5 % ) in a primary care setting . Research Design Patients were individually r and omized into intervention ( n = 103 ) and usual care group ( n = 101 ) . The primary outcome was change in HbA1c-concentration after 12 and 18 months . Secondary outcomes were lipid levels , blood pressure , health-related quality of life and symptoms of depression . Follow-up- measurements were carried out after 6 , 12 and 18 months to assess potential immediate and maintained effects of the intervention . For the multivariate analysis , hierarchical linear models were computed for each outcome to assess within-group changes in outcomes over time and between-group differences in patterns of change . Results HbA1c ( in % ) decreased significantly from baseline to 12-month follow-up measurement both in the intervention ( −0.44 ) and the usual care group ( −0.51 ) , but there was no significant between-group intervention effect . Significant improvements in the intervention group along with significant between-group differences were seen for health-related quality of life and , transiently , for systolic blood pressure and depression . Conclusions Although we found no beneficial effect of the supportive telephone counseling in terms of a reduction of HbA1c above usual care , our findings suggest some beneficial effects on cardiovascular risk factors , quality of life and depression . Continuous efforts might be needed to sustain improvements in patient outcomes . Trial Registration Clinical Trials.gov BACKGROUND We examine the changes in waist circumference ( WC ) and body mass index ( BMI ) in older adults enrolled in a diabetes telemedicine program . The subjects were elderly Medicare beneficiaries participating in the rural ( upstate New York ) cohort of Informatics and Diabetes Education and Telemedicine , a r and omized , controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control . METHODS Ninety-two percent of the subjects had BMI > 25 kg/m(2 ) , and 65.8 % had a BMI > or = 30 kg/m(2 ) . Intervention subjects received home televisits with a dietitian or nurse educator every 4 - 6 weeks .  Blood glucose and blood pressure values  were review ed , and lifestyle and medication changes were recommended . Non-intervention subjects received usual care through their primary care physicians . Change in WC , BMI , diet , and exercise behaviors and knowledge were examined at baseline and 12 and 24 months . A mixed-effects path analysis was performed to examine direct and indirect effects . RESULTS The telemedicine participants increased diet and exercise knowledge over time ( P < 0.001 ) . It was estimated that women in the  telemedicine  group reduced their WC over the 2 years by 1.2 cm , whereas women in the usual care group increased their WC by almost 1 cm ( P = 0.02 ) . Path analysis demonstrated that the intervention , through improved diet and exercise knowledge , was related to the decrease in WC ( P = 0.006 ) and BMI ( P = 0.004 ) . CONCLUSIONS Diabetes case management using telemedicine improved self-reported diet and exercise knowledge , practice s , and behaviors , which in turn was associated with reductions in WC and BMI at 2 years To assess the feasibility of conducting empirically supported family-based paediatric obesity group treatment via TeleMedicine .  Seventeen families were r and omly assigned to one of two conditions ( physician visit , TeleMedicine ) . Measures included feasibility , satisfaction and intervention outcome measures such as BMI percentile , and nutrition and activity behaviours . Measures were completed at baseline , post-treatment and at 1-year follow-up . Analyses indicate that both feasibility and satisfaction data regarding the TeleMedicine intervention were positive . Intervention outcome indicates no change in BMI percentile or nutrition and activity behaviours for either treatment group . A behavioural family-based weight loss intervention delivered via TeleMedicine was well received by both parents and providers . Due to the small sample size , null findings regarding intervention outcome should be interpreted with caution . Future research should focus on methods to increase the impact of this intervention on key outcome variables
Results Telemedicine programs that include a nutritional component show similar effect in diabetes management as those programs that do not .
Furthermore , subgroup analysis reveals that nutritional intervention via SMS such as email and text messages is at least as equally effective in reducing HbA1c when compared to personal nutritional counseling with a practitioner over videoconference or telephone .
Conclusion The inclusion of nutritional counseling as part of a telemedicine program does not make a significant difference to diabetes outcomes .
Incorporating nutritional counseling into telemedicine programs via SMS is at least as effective as counseling via telephone or videoconference
Background A growing number of studies and review s have documented the impact of telemedicine on diabetes management .
However , no meta- analysis has assessed whether including nutritional counseling as part of a telemedicine program has a significant impact on diabetes outcomes or what kind of nutritional counseling is most effective .