"Counting carbs to be in charge": A comparison of an internet-based education module with in-class education in adolescents with type 1 diabetes

Abstract

Carbohydrate counting is an essential component of type 1 diabetes education but can be difficult for adolescents to learn. Because adolescents are avid users of technology, an Internet-based education module was compared with an in-class education session in terms of carbohydrate counting accuracy in adolescents with type 1 diabetes. Adolescent participants displayed increased carbohydrate counting accuracy after attending an in-class education session compared with an Internet-based education module. These results suggest that online education is best reserved as an adjunctive therapy to in-class teaching in this population. Carbohydrate counting is a recommended daily practice for the self-management of type 1 diabetes, in conjunction with insulin therapy (1). This method allows for more flexibility in the timing and frequency of eating and the amount of carbohydrate consumed during meals and snacks (1). Accuracy in carbohydrate estimation is required to achieve and sustain adequate glycemic control, and differences of ≥20 g from actual carbohydrate amount have been shown to affect postprandial glucose excursions (2,3). Thus, carbohydrate counting is an essential component of conventional diabetes education, a collaborative process whereby patients gain knowledge and skills to successfully self-manage their diabetes and related conditions (4,5). However, evidence suggests that adolescents with type 1 diabetes do not accurately count carbohydrates (6). In a previous study in adolescents with type 1 diabetes, we reported that, despite using carbohydrate counting for managing their diabetes and receiving in-class education with a dietitian, fewer than half of the sample counted carbohydrates accurately (7). Furthermore, a nutrition education intervention focused on carbohydrate counting in adolescents with type 1 diabetes found no improvement in counting accuracy and glycemic control after 3 months (8). These findings suggest a need to develop more intensive education that is cost-effective and readily available and provides the tools to empower individuals in their day-to-day diabetes management (9,10). Multiple factors have a bearing on the delivery of diabetes care for adolescents with type 1 diabetes; these include a shift in responsibility from parents to adolescents, adolescents' focus on social contexts and peers, developmental inclination toward risk taking, and fatigue from care of a chronic illness (11). Therefore, the approach to diabetes education needs to be engaging, developmentally appropriate, and motivating to encourage appropriate diabetes self-management. Digital technologies are readily used among adolescents, and strategies that incorporate such technologies can potentially help adolescents enhance their skills in diabetes self-management (12,13). These strategies include online educational resources (14), short message service systems (15,16), interactive diabetes management tools (17), video games (18,19), Internet-based communication (20), Internet videoconferencing (21), and mobile device applications (22). Online education for diabetes management may help to reduce the complexity and inaccuracies associated with carbohydrate counting, as well as reduce the barrier of attending face-to-face teaching sessions by being a flexible learning option that can be reviewed at a patient's convenience. There is no evidence indicating the most effective type of educational platform for training adolescents in carbohydrate counting. Although studies of Internet-based educational tools for diabetes self-management have been conducted in adolescents with type 1 diabetes (23), none have focused exclusively on improving carbohydrate counting skills. Furthermore, the current literature evaluating computer-assisted diabetes education has primarily targeted adults with type 2 diabetes (24,25). Therefore, the objective of this study was to evaluate an Internet-based education module on carbohydrate-counting accuracy in adolescents with type 1 diabetes in comparison with the standard of care (in-class education session). We hypothesized that the Internet-based module would result in improved accuracy compared with the in-class session.