How Care for Patients With Diabetes Has Evolved in 25 Years
Q: What options existed for remote patient monitoring around the year 2000? How have they evolved since?
A: Jean Chen-Vitulli, DPM, MS, CDCES, and Anastasios Manessis, MD, FACE, ECNU, ABOM cite additional innovations in remote monitoring like smart insoles, sensor socks, and mobile apps for retinal screening. These tools, they note, extend care beyond the clinic by allowing patients to track sleep, stress, and activity—and correlate those factors with blood sugar fluctuations.
“The increasing integration of digital health technologies enables real-time monitoring of patients’ conditions, thereby improving outcomes through timely interventions,” says Windy Cole, DPM, CWSP, FFPM RCPS (Glasg), the Director of Wound Care Research at Kent State University College of Podiatric Medicine. “With the use of wearable devices and mobile health applications, healthcare providers can track vital signs, ulcer development, and patient adherence to care plans more effectively.”
In the future Dr. Cole believes the profession will see even more advancements in RPM technologies. She says incorporating AI and machine learning can enhance data analysis capabilities, leading to more personalized and proactive care strategies, calling this “the future direction of healthcare.”
Q: Where are we today with RPM for DFU and related pathologies? What lies ahead?
A: Smart socks, smart insoles, and smart temperature monitoring devices can now monitor asymmetric temperature and gait changes, which provides real-time data to prevent DFU in high-risk patients, note Dr. Chen-Vitulli and Dr. Manessis, who practice at Endocrine Associates of West Village in New York City. As Dr. Manessis says, AI-driven wound assessment apps can now assist wound specialists in remotely tracking wound size, tissue types, exudate and healing trajectory. Dr. Chen-Vitulli adds that telemedicine also provides consultations among podiatry, endocrinology and wound care specialists. However, both agree that those strategies for DFU prevention are advancing but not uniformly implemented.
David G. Armstrong, DPM, MD, PhD, says his “smart boot” studies are enabling continuous offloading monitoring in real-world settings.1-3 His “foot selfie” program, which utilizes smartphone images and cloud-based AI, empowers patients to self-monitor foot health at home.4 “This brings care to where people live, rather than asking them to come to us,” says Dr. Armstrong, the Director of the University of Southern California (USC) Limb Preservation Program and the Director of the Southwestern Academic Limb Salvage Alliance (SALSA) at Keck School of Medicine.
Q: In 2000, how did patients and care teams monitor blood glucose?
A: Back in 2000, patients and care teams monitored blood glucose mostly by fingersticks, which Dr. Armstrong remembers as “episodic, cumbersome, and often poorly adhered to.” Dr. Chen-Vitulli and Dr. Manessis note such manual monitoring depended on the patient’s self-discipline in self-monitoring and control of blood sugar.
Twenty-five years ago patients used glucometers to obtain capillary blood, and readings were recorded by logbooks and some glucometers were able to record readings, but Drs. Manessis and Chen-Vitulli note blood sugar values were not shared remotely with providers. During follow-ups for diabetes, physicians reviewed logbooks or spreadsheets with blood sugar, but Dr. Manessis says for those who did not manually track their blood, values were based on memory. Dr. Chen Vitulli notes technology was limited then and there were no continuous glucose monitors to provide alarms for hypoglycemia and hyperglycemia.
The gold standard for blood sugar monitoring is the HbA1c to evaluate blood sugar control of the last three months, which Drs. Chen-Vitulli and Manessis say does not provide patterns and variability. They note this means a patient can have combination of hyperglycemia and hypoglycemia and still have an acceptable HbA1c when medication adjustments are necessary. Without data from continuous glucose monitors, Dr. Manessis says there was no way to look at trends to assess whether a patient’s high fasting blood sugar was due to the “dawn phenomenon” or if the patient had high overnight blood sugar resulting in elevated fasting blood sugar.
“Blood sugar management in 2000 was manual, reactive, and fragmented, resulting in delayed therapeutic adjustments and greater risk for complications,” says Dr. Chen-Vitulli.
With the advent and evolution of continuous glucose monitoring (CGM), Dr. Armstrong is seeing patients (and providers) better understand trends, not just points in time. “In our limb preservation work, we’re now correlating glycemic volatility with wound healing and failure-to-heal trajectories—a frontier that still holds much promise,” he notes.
Q: What trends have emerged with continuous glucose monitoring, especially for DFU prevention and management?
A: Dr. Cole notes increasing numbers of patients with diabetes are utilizing CGM systems, a rise partly due to advancements in technology that have made CGMs more user-friendly and accessible. The ability to track glucose levels in real-time has allowed for better glycemic control and she says patients can view their glucose trends and make immediate adjustments to their diets, medications, or activity levels, which is crucial for those at risk of developing DFUs.5
“Continuous data can help identify patterns of hyperglycemia, prompting earlier intervention and lifestyle changes to mitigate the risk of foot ulcers,” says Dr. Cole.
For individuals who already have DFUs, Dr. Cole says consistent monitoring of glucose levels can correlate with improved healing rates. Maintaining tighter glycemic control contributes to a better healing environment for foot ulcers. She is participating in several DFU randomized controlled trials, collecting CGM data.
Dr. Manessis says CGM has uncovered glucose trends such as the dawn phenomenon, postprandial hyperglycemia, and silent hypoglycemia, which contribute to DFU risk via increased oxidative stress, microvascular injury, and decreased immune response and impaired leukocyte function. Dr. Chen-Vitulli says one can use these data to titrate medications faster without waiting for the three-month HbA1c number and modify behaviors to help patients keep at least 70% of their blood sugar within time in range. They note better glycemic control can slow the progression of neuropathy and provide better wound healing in terms of granulation and angiogenesis. Drs. Manessis and Chen-Vitulli add that well-controlled blood sugar helps prevent wound dehiscence in surgical wounds and surgical wound infection, and that remote monitoring and CGM allow for proactive early intervention to diminish the risks of diabetes-related complications.
Q: What’s next for these types of technologies?
A: Remote monitoring has advanced diabetes care, but Drs. Chen-Vitulli and Manessis agree the technology has challenges, as some older patients are not technology savvy and are intimidated by technology. They note some older patients also do not have smartphones and/or computers, limiting remote monitoring to when patients go to the office to upload their CGM data. However, Dr. Chen-Vitulli says some patients can have family or friends upload their CGM data for remote provider access, and a provider can adjust diabetes medications without waiting for the three-month follow-up. Dr. Manessis adds that some patients will refuse a continuous glucose monitor as they do not want people to see they wear one on their arm.
Insurance may also refuse to cover CGMs as the patient may not be on insulin, or does not have documented recurrent low blood sugar of less than 53 mg/dL, say Dr. Manessis and Dr. Chen-Vitulli. They note not all primary care providers are aware of CGM and its interpretations and cite a long wait time for referral to an endocrinologist as there are not enough diabetes specialists across the United States.
Dr. Armstrong notes RPM and CGM are no longer separate conversations, saying the fusion of biometric data—skin temp, pressure, glucose, perfusion—will pave the way for a more anticipatory, algorithm-enhanced model of care.6
“I believe the next decade will bring us closer to our long-held goal: extending hospital-free, activity-rich, dignity-preserving days for people at risk of diabetic foot complications,” says Dr. Armstrong.7-9
“With the advent of AI and remote monitoring technology, the future of DFU remote monitoring will be proactive as the process undergoes adaptation,” says Dr. Manessis. “It will lead to fewer amputation, fewer hospital admissions, and proactive prevention of ulcerations as foot health is monitored digitally before skin integrity deteriorates.”
“The future does look bright for diabetes and amputation prevention,” says Dr. Chen-Vitulli.
References
1. Finco MG, Cay G, Lee M, et al. Taking a load off: User perceptions of smart offloading walkers for diabetic foot ulcers using the Technology Acceptance Model. Sensors (Basel). 2023;23(5):2768.
2. Park C, Mishra R, Vigano D, et al. Smart offloading boot system for remote patient monitoring: toward adherence reinforcement and proper physical activity prescription for diabetic foot ulcer patients. J Diabetes Sci Technol. Published online January 20, 2022:19322968211070850.
3. Smart boot use to measure offloading adherence. Accessed June 24, 2022. https://clinicaltrials.gov/ct2/show/NCT04460573
4. Swerdlow M, Shin L, D’Huyvetter K, Mack WJ, Armstrong DG. Initial clinical experience with a simple, home system for early detection and monitoring of diabetic foot ulcers: the foot selfie. J Diabetes Sci Technol. Published online October 31, 2021:19322968211053348.
5. Martens T, Beck RW, Bailey R, et al. Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial. JAMA. 2021;325(22):2262-2272.
6. Armstrong DG, Najafi B, Gao W, Klonoff DC, Liu C. Repair, regeneration, and replacement, revisited (redux). J Diabetes Sci Technol. 2025;19(3):605-610.
7. Khan T, Armstrong DG. Ulcer-free, hospital-free and activity-rich days: three key metrics for the diabetic foot in remission. J Wound Care. 2018;27(Sup4):S3-S4.
8. Najafi B, Veranyan N, Zulbaran-Rojas A, et al. Association between wearable device–based measures of physical frailty and major adverse events following lower extremity revascularization. JAMA Netw Open. 2020;3(11):e2020161-e2020161.
9. Cay G, Finco MG, Garcia J, McNitt-Gray JL, Armstrong DG, Najafi B. Towards a remote patient monitoring platform for comprehensive risk evaluations for people with diabetic foot ulcers. Sensors (Basel). 2024;24(10):2979.
