Smart Healthcare for Diabetes: A COVID-19 Perspective
SS MART H EALTHCARE FOR D IABETES :A COVID-19 P
ERSPECTIVE
A P
REPRINT
Amit M. Joshi Urvashi P. Shukla Saraju P. MohantyDept. of ECE Dept. of ECE Computer Science and EngineeringMNIT, Jaipur, India. MNIT, Jaipur, India. University of North Texas, USAEmail: [email protected] [email protected] Email: [email protected]
August 26, 2020 A BSTRACT
Diabetes is considered as an critical comorbidity linked with the latest coronavirus disease 2019(COVID-19) which spreads through Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2). The diabetic patients have higher threat of infection from novel corona virus. Dependingon the region in the globe, 20% to 50% of patients infected with COVID-19 pandemic had diabetes.The current article discussed the risk associated with diabetic patients and also recommendationfor controlling diabetes during this pandemic situation. The article also discusses the case study ofCOVID-19 at various regions around the globe and the preventive actions taken by various countriesto control the effect from the virus. The article presents several smart healthcare solutions for thediabetes patients to have glucose insulin control for the protection against COVID-19. K eywords Smart Healthcare, Healthcare Cyber-Physical System (H-CPS), Internet-of-Medical-Things (IoMT),Glucose Level, Diabetes, Coronavirus, Glucose Insulin Control, COVID-19, SARS-CoV-2
Diabetes occurs when the body of a person finds the difficulty to balance glucose level during various prandial states[1]. Diabetes cases has exponentially increased in the past decades around the world [2, 3]. The unhealthy lifestyleis the prominent factor in magnifying the chance of being a diabetic patient. The unbalanced diet is one of the mainfactors for the occurrence of diabetes Mellitus [4]. An estimated 463 million adults worldwide have diabetes andaddressing their quality of life through smart healthcare technologies can have significant social impact [5, 6]. Themain cause of the diabetes is deficiency of insulin level in the body against the generated glucose. The diabetesproblem may lead to the reduction of blood pressure and other cardiovascular disease.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people around the globeleading to a large number of deaths [7]. The Corona Virus Disease (COVID-19) has been spreading among the peopleworldwide at an exponential rate. SARS-CoV2 affects population of various age groups and person with underneathhealth conditions. The relation of COVID-19 with underneath disease is as shown in Fig. 1.The diabetes was associated as the major risk for the past severe disease such as Severe Acute Respiratory Syndrome(SARS), Middle East respiratory syndrome (MERS) types of infections from the corona virus and the severe influenzaA H1N1 pandemic in 2009 [8]. The diabetes persons are in bigger threat for the infection of the novel corona virusdisease (COVID-19) [9]. In general, the mortality rate of diabetes patients are 2 to 3 times more than other and thechances of intensive care is also higher than non diabetic patients. It is observed that the diabetes patients area athigher risk (up to 50 %) from the virus [10].The studies show higher mortality rates of COVID-19 patients with pre-existing diabetes condition. It is difficult toprovide the treatment for diabetic patients due to fluctuating of blood glucose levels. The reasons for diabetic patientsserious infections by COVID-19 include the following [11]: a r X i v : . [ q - b i o . O T ] J u l iabetes (9.2%) Chronic RespiratoryDisease (8.0%) Cardiovascular Disease (13.2 %) Hypertension (8.4%)SARS-CoV-2 (COVID-19)
Figure 1: Comorbidities with Pre-existing medical conditions for COVID-19.1. The high blood sugar would affect the immunity of the patient which made him vulnerable against the Coronavirus infection as well lead to longer recovery period.2. The virus would thrive in an environment of the increase blood glucose.The rest of the article is organized in the following manner: Section 2 discusses the reasons for high risk for diabeticpatients. Section 3 discusses the challenges for diabetic patients during COVID-19. A summary of various case studiesfor COVID-19 with respect to diabetic patients is provided in Section 4. Section 5 presents some thought on diabetesmanagement during pandemic outbreak to improve quality of life. We discuss the potential roles of selected emergingtechnologies in Section 6. Section 7 presents some solutions for the diabetic population during pandemic outbreaklike COVID-19. We present concluding thoughts in Section 8.
COVID-19 has fostered various challenges for the most vulnerable group of society “diabetic patients” [12]. Humanbody with underlying infection and high temperature inhabits the normal production of insulin. The role of insulin isundoubted in controlling the level of glucose in the blood. This results in a serious diabetes complication known asDiabetic Ketoacidosis (DKA). Here, the body cell don’t get the glucose needed for energy, whereby the body beginsto burn down the body fat for the same which results in production of excess blood acids (known as ketones) [13]. Theimpact of virus on the diabetes patients is shown in Fig. 2.
Unbalance Glucose Insulin Increase the level of DKA SARS CoV2 Connect with ACE2 High Blood Sugar
Figure 2: Impact of COVID-19 on Diabetes Patients.tudies have showed that Angiotensin-Converting Enzyme 2 (ACE2) acts as a cellular receptor for SARS-CoV-2having 10 to 20 times higher binding affinity than the previous existing SRAS-CoV. ACE2 is a natural occurringenzyme present in the cell membrane of lung and enterocytes of small intestine. This duo forms a bond with theirprotein along with a sugar molecule. This dependency of virus leads to hyperglycemia wherein a damage is caused topancreas islets (known as the islet cell of the pancreas) which plays a prominent role for insulin generation for bloodsugar control [14].Hyperglycemia is a characteristic of diabetes and when this chronic metabolic disorder is left untreated causes variousother serious complication like kidney failure, cardio disorders and respiratory complications. This hyperglycemiaenvironment increases the virulence of some pathogens make the patients at high risk. It is reported that phagocytesand chenotaxis are also impaired. Overall immune response is hampered which plays a vital role in fighting COVID-19. Therefore, a good monitoring over the glucose blood levels in patients with COVID-19 is essential [15].
The current epidemic has influenced psychological well being of people around the world [16, 17]. It has massivelyaffected mental state of the people. With thoughts like anxiety of being infected by the virus, trauma of locked downand being away from the loved ones over a long period. At the same time, depression have crept in due to news of socialdamage done by COVID-19 around the globe. Moreover, diabetics people already suffers from anxiety and variousforms of negative emotions that naturally gets intensified amid epidemic situation [18]. The non well being state ofmind would somehow has been reflected in unbalanced glycemic control of diabetes people during this COVID-19period. Therefore continuous counselling is required for self management of blood glucose control during the ongoingpandemic through collaboration with endocrinologists, psychiatrists, physician, nutritionists and diabetes educators.However, the diabetes patients have to take few self-measures and take appropriate consulting through teleconsultationmode for close coordination with physicians ensuring proper care during COVID-19 pandemic.
The COVID-19 has come out as global pandemic which has affected millions of lives around the globe [19].The diabetes mellitus (DM) has appeared as serious comorbidity factor for increased mortality of infected people.Nevertheless, DM has played major role towards the invasive ventilation and/or intensive care unit of COVID-19infected case [20]. The lock down and imposed restriction on the movement by higher authority has made difficultcondition for diabetic patients to control their glycemic profile.
The various challenges faced by diabetes care during COVID-19 include the following: • Lack of Confidence in Self-care : It has been difficult choice to have belief on self-care device for diabetesmanagement. A proper counselling is required that could address to each and individual’s requirement. • Technology Awareness : The patient should be aware of information and communication technologies (ICT)for the use of e-health, mhealth and telemedicine technologies which are clubbed under a big theme ofInternet-of-Medical-Things (IoMT) leading to healthcare Cyber-Physical System (H-CPS) [6]. There shouldbe good scientific materials available in the form of books or video to guide them properly. • Proper Diet Plan : The usage of high carbohydrate and saturated fats should be avoided in their regular meal.One has to set their own diet plan to maintain their calorie goals. • Economic and Social Obstruction : The proper actions from the Government to ensure cost-effectivetherapeutic materials and provision of essential medical care should be main focus from the countrygovernment. • Legal Barrier : The healthcare providers have been always sceptical for the remote monitoring andtelemedicine due to legal barrier in many counties like India. Many Government agencies have issuedguidelines to enable teleconsultations service for the chronicle diseases such as diabetes.
Case Study of Diabetic Patients in COVID-19 Around the World
India has an estimated 77 million people with diabetes [21]. There are several reasons to have better control ofdiabetes during the pandemic times as compared to normal situations. First, doing so will almost certainly improve theoutcomes in case someone does contract the COVID-19. All diabetes is not the same. Poorly controlled diabetes in anelderly person with heart and kidney issues is very different from well-controlled diabetes in a fit, active 40-year-old.The outcome of COVID-19 in the latter’s case could well be compared to those infected but without diabetes. Theseriousness of COVID-19 infection is very likely to get attenuated with better control of diabetes [22]. This itself isenough reason to ensure good sugar readings.The second reason why diabetes control is important is the usual one - It is necessary to have a fix on our numbers(sugar, blood pressure, cholesterol) to prevent long-term complications [23]. With population 1.3 billion, it is verydifficult to maintain social distancing and also stay in lockdown state (or stay-at-home) for a longer period. It is reallydifficult to take precautions like social distancing and staying home for the prevention of COVID-19 spread, speciallyfor diabetes patients. The diabetic people are at higher risk of COVID-19 infection, and have bigger threat in-termsof mortality as well as morbidity. The extra precaution are required for such people to avoid any exposure to outsideworld.A study of patients at China showed that diabetes patients had higher risk in terms of mortality as 7.3% in comparisonof overall rate of 2.3% [24]. Another study in China shows that the infected people of COVID-19 with diabetesreported worse results in comparison with the gender- and age-matched patients without diabetes [25]. The differentanalysis from overall six study from China have observed that out of overall COVID-19 patients the average 9.7%(6.9%-12.5%) patients were pre-existing diabetic patients. There was separate meta analysis was carried out onthousands COVID-19 infected people where around 8% had historical background of diabetes. The main observationwas made that diabetic people of COVID-19 infection have more mortality rate.Russia has thousands of COVID-19 infected people along with the USA, Brazil and India. However, it has the lowerdeath rates. A report suggested that in Russia, the diabetes was observed one of main chronic disease along with heartdisease and chronic obstructive pulmonary disease among the corona virus victims who are in intensive care [26].
The threat for COVID-19 pandemic has been addressed in Australia [27]. The products for diabetic people have beenprovided along with insulin supply and important medicines under National Diabetes Services Scheme (NDSS) toreduce the risk of infection. The people with underneath diabetes have suggested to obtain their regular medicines.Australia has already planned against COVID-19 risk for medical support with tele-healthcare, special assistance forold-age people, home delivery of the medication and better service of remotely located people.The tele-healthcare would be provided by pharmacies to the participant who seeks any service via call. The consultancyservice for telehealth would be provided to all the needed people (pregnant women, aged people over 65 and parentsof new born child) for chronic disease like diabetes. The government Australia provides assistance to diabetic patientfor their safety and health related issues. The government has created one web page for the health related guidelineswhich is updated regularly [28].New Zealand has announced some specific guidelines for diabetes patients [29]. The diabetic people can consulttheir personal doctor or general practitioner for their individual recommendation during the COVID-19 situation. Itis advisable for diabetes people to have flu vaccination to reduce the any risk for co-infection. It is recommended tomaintain the glycaemic control for minimizing the threat of COVID-19 contraction. The age has also been consideredas additional factor for corona virus risk.
It is estimated over 59 millions people being diabetic across 44 countries and territories [30]. A study shows that outof total death in UK due to COVID-19, approximately 26 % suffered from either type-1 or type-2 diabetes [31]. Thus,making recovery of these patients a challenging task.Italy is one of the most affected countries from the COVID-19 pandemic [32]. As per a study of the hospitalizedpatients at University Hospital of Padova suffering from COVID-19, the diabetic people had a 8.9% prevalence rate.Thus, the recovery of such type of people was really a challenging task.he study carried out in Finland have evidently shown that prevention can certainly control the infection to a extendin people being overweight and suffering from glucose metabolism [33]. It also revealed that higher threat amongdiabetic people could able to reduce upto 58% with their daily physical activity and by proper managing their diet.The preventive actions of diabetes could be easily applicable to other non communicable disease like (Cancer andChronic respiratory) which are also at equal risk with diabetes. There are over 60 million diabetes patients in Europeancountries [34]. Out of which about 10.3% of those are male and around 9.6% are female of 25 years and older.However, the rate of prevalence has been increased from past several years among all age people which are at greaterrisk in this COVID-19 epidemic. The studies revealed that daily life style greatly accompanied with unhealthy diet,obesity, overweight and lesser physical movement. These factors have even made difficult to easily recover fromcorona virus.Spain is also one of the most affected country in Europe from COVID-19 along with Italy. As per a study, few thousanddeaths were reported in Spain whereas the rate of prevalence of diabetes was around 12% [35]. As per same report,In Romania, approximately 50% of people who died in COVID-19 were suffering either cardiovascular diseases ordiabetes mellitus [35].Table 1: Pre-existing Health Condition of hospitalised ICU patients in COVID-19.Underlying Condition Italy(%) USA(%) Sweden(%) Spain(%)Diabetes 17 32 23 17Hypertension 49 NA 34 NAChronic lung Disease 4 21 16 6Cardiovascular Disease 21 23 11 30
In USA, more than 34.2 million people are suffering either diabetes or pre-diabetes including 14.3 millions seniorcitizen as per report in 2018 [36]. Elderly patients having pre-existing health condition such as diabetes, heart diseasesand chronic lung disease have been reported. It was observed that 32 % patients in Intensive Care Unit (ICU) due toCOVID-19 had diabetes whereas 24 % hospitalized patients had diabetes [37]. Moreover, only 6% diabetes patientswho were COVID-19 infection did not require any kind medical attention. There is no conclusive evidence aboutthe fact that whether type-1 or type-2 diabetes patients are at more risk for COVID-19. The improper blood sugarmanagement is more so ever reason for COVID-19 infection.People living with diabetes require uninterrupted access to essential medicines, supplies, technologies, and care.Without insulin, a person with type-1 diabetes can potentially fatal health issues in a few days of time, and the lack,or irregular supply, of other diabetes medication, supplies, devices and/or technologies will also adversely affect theability of all people with diabetes to manage their diabetes optimally and prevent the development of potentially fatal,short- and long-term complications.
Brazil is one of the most affected countries in the world due to COVID-19 infection. As per report of 2019, thereare approximately 16.8 million (around 11.4%) of people in Brazil have Diabetes between age 20 to 79 years, whichis the fourth highest in the world [38]. Diabetes has been identified as one of the main threat along with otherNon Communicable Disease (NCD) by SARS-CoV-2. There are approximately 71.2% of diabetes patients in Brazilsuffering for hyperglycemia which would put them in higher threat of infection from COVID-19 [39].
A continuous monitoring of blood glucose level in diabetic patient is required [40,41] for proper diagnosis. The personinfected with virus and having underlying condition of diabetes will find it difficulty in balancing their glycemia profileduring the aliment [42]. Proper insulin dosage becomes essential to mange the glucose level in order to protect againstCOVID-19 infection. With this vision many countries have presented certain guidelines about the self-managementfor diabetes patients.Moreover, due to pandemic around certain self-care practices need to be followed by the homebound diabetes patientswho are unable to carry out their routine visits [43]. One has to be extremely careful with the old ages diabetes patientsuring this COVID-19 crisis who are suffering from comorbidities as renal diseases, pulmonary, cardiovascular andkidney. However, management of diabetes would be a real challenge in such cases and further precaution should betaken for such genre of people [44]. The people with all types (type-1, type-2 and gestational), with some illness aremore prone towards COVID-19.There are several recommendations formulated for diabetic patients during COVID-19 by various as follows [45, 46]: • One has to drink substantial volume of fluid in order to avoid any sort of dehydration. • The glycemic profile has to be maintained by everyone to the target value suggested by concerned doctor.Especially, the female patient with Gestational Diabetes needs a continuous measurement of glucose levelthat could be beneficial to control the glucose profiles [47]. • Continuous monitoring of blood glucose level throughout the day inhibits ketoacidosis and hypoglycemiccondition. In case of type-1 diabetes patients if the value goes beyond 180 mg/dl then it is recommended topump insulin into the blood for maintaining the glucose level. • Personal and surrounding hygienic are inevitable in any circumstances. Specifically, repeated hand washingand proper cleaning all medical equipment’s such as glucometer and insulin pump with alcohol based sanitiserand soap water are important.
Measure Blood Glucose Value If Blood Glucose >180 mg/dl Take Carbohydrates and Sugar Free meal For glucose Insulin Balance Insulin Dosage as per Prescribed by Doctor Yes Maintain Proper Diet Control No
Figure 3: Balance of Glycemic Profile for Diabetes Patients during COVID-19.It is a fact that certain medicine dose could play a crucial role in glucose control [48]. This medicine may work towardsblocking the binding of sugars and proteins. Thereby, high blood sugar value is avoided. This would theoreticallyimpede the virus from interacting with its receptor and modulate the inflammatory response to the virus. Pre-diabetespatients are also requested to have glycated haemoglobin (HbA1c) test which calculates the average glucose level overperiod of 3 months [49].High blood glucose keeps body in a low-inflammation state, thus recovery process in diabetics patients tends to beslower as compared to others. Therefore, the recommendation enlisted above are most important for diabetes peopleand for those who are in close contact with such people. The balanced glycemic profile is imperative as it would helpto improve the immunity [50].Diabetes patient has to take precautions in order to avoid major impact of virus by monitoring the blood glucose atregular interval at home and scheduled proper diet plan accordingly [12]. The good control of glycemic profile wouldelp to boost the immune system of vulnerable population against COVID-19 [51] (see Fig. 3). The insulin secretionwould help in developing immune system with balancing glucose by reducing risk of infection against the virus.The poor control of glycaemic profile may result in serious issues and also make treatment difficult for the patient.Glycaemic control of the infected person may lead to hyperglycaemia stage which makes hard to cure in presenceof high fever and abnormal respiratory issues. Thus, there is a need of continuous monitoring of glucose and takingantidiabetic medication.
The robotic applications have been used extensively in hospitals, restaurants, transportation, airports, hotels, in variousways to ensure the minimum human contact to avoid the spread of COVID-19 (see Fig. 4). A simple example,even robots serving as waiters in the restaurants. The autonomous vehicles, drones and intelligent robots help insterilising public area, delivering materials, the measurement of body temperature, collection of samples from coronavirus patients, providing value added service to patients, and also looking towards security or safety aspects. Theadvancement of technology and various intelligence techniques have helped in tourism and hospitality management.They are useful in providing service such as food delivery, housekeeping, concierge service and other related tasksduring this pandemic situation. Tele robot help in sensing environment and consequently taking necessary reactiveaction automatically through various machine and deep learning algorithms. They are useful in placing and pickingthe things, delivering and cleaning actions. Teleoperator type of robots can be very useful in such epidemic situationwhere tasks can be performed with robotic control mechanism from human. Social robot aid in social activities withinteracting human in an acceptable manner [52]. They can also assist in healthcare, entertainment industry, teachingand providing comfort communal services. If the growth of robotic based application continues with same pace thenit has been predicted that approximately 600 millions jobs around the world and one quarter hospital staff in the USAwould be replaced with robots [53]. The role of robot is very crucial in tourism and hospitality during this crisissituation to improve the quality of service, safety measures and expectations. The embracing of robotic technologyin such situation where social distancing from the human is desired is welcomed. The self-belief in such technologyfrom the people would gradually grow with more trust and minimal risk. The spread of COVID-19 has shown growthof robotic application all over the world. Their role in various field is expected to grow in many areas to improve thesustainability and quality of life.
Robotic in COVID-19
Tele Robots
Robots in
Healthcare
Social
Robot
Transportation with Robotics
Robotics in Tourism/ Hospitality
Figure 4: Role of Robotic during pandemic outbreak. .2 Role of Industry 4.0
The outburst of COVID-19 has evolved the demand of necessary healthcare equipment (insulin pump, glucometer)for diabetes patient who are at higher risk than others (see Fig. 5). The fourth generation industry revolution industry4.0 has potential to cater the demand with advanced digital technology. It would be beneficial to provide smartsystem where real-time information would be processed through Artificial Intelligence (AI), machine learning (ML),intelligent data analytic techniques and Industrial Internet of Things (IIoT) [54]. The automation of technology hasbeen possible with aid smart manufacturing. The development of any medical device/system could be done rapidlywith advances in manufacturing technologies such as 3D printing. The industry 4.0 has made possibility of connectedenvironment where all the technologies are fasten to exchange information for the development of vaccine, healthcarefacility, surveillance systems and necessary measures without much human involvement. Industry 4.0 could detectand predict the prevalence of COVID-19 with acquiring data from the smart systems. It can also allow to tackle thediabetes management in better way through intelligent technological solutions. The security solution with block chaintechnology, through cryptography approaches for peer-to-peer system has resolved the security concerns at variousphysical locations with suitable traceable mechanism.
Smart Manufacturing
Data Processing
Decision Making Data Generati on Information
For control Communication Intelligent Techniques Smart Transportation
Smart Production
Big Data
Figure 5: Role of Industry 4.0 during pandemic outbreak.
Food supply chain is a part of Internet-of-Agro-Things (IoAT) based Agriculture Cyber-Physical System (A-CPS) thatmakes smart agriculture [55]. However, food or diet is important part of smart healthcare and needs discussion. Theconsumption of counterfeit and adulterated foods can also affect the immunity of person and may act as a gatewayof COVID-19 [56]. The good quality of food is really important for the consumers and required some technology toidentify them easily. This is very crucial in this pandemic situation where healthy diet could always help to maintaingood immunity against any kind of virus infection. There are number of food product of fraudulent category whichare available in order to get some financial benefits. It has also been observed that the food contents of packaged foodmay not be the similar as it mention. While in some cases the product itself is counterfeit. In present scenario, peopleare trying to consume immune boosting product to maintain their strong immunity but quality of the same product iscompromised. Therefore, it is required to develop such kind of technology that can identify a safe and authentic foodproduct. It is really challenging task to find such kind of cost-effective solution which will not increase the cost ofproduct.t is essential to develop portable and economical device to provide the quality assurance of food throughout its lifecycle from the production to final consumption stage. This kind of solution would be not only useful in such pandemicsituation but could be useful all the time to have proper diet management. This device should be compact and userfriendly product at consumer end. The solution is also required to be robust in order to its usage at various stages ofthe supply chain. There is not such type of solution is available in the market till date, however few researchers haveattempted with Surface Enhanced Raman scattering (SERS). The days are not far where such type of solutions wouldbe available in the market.
Trading Retails Service of Food Consumption By PatientFarming & Growing Processing Transportation Food
Figure 6: A Vision of Trusted Food Supply Chain: from Farm to the Dinning Table.The blockchain has a potential to make great impact in the food supply chain for smart agriculture [57–59]. Thetechnology could be useful to analyse the quality of the food product through the reliable supply chain managementframework. The sustainable system would be developed using block chain technology which is helpful to developtrust and transparency from its production to consumption. This would be beneficial for diabetes patients to maintaintheir proper healthy diet plan during this COVID19 outbreak.
There is some prediction that the novel corona virus SARS-CoV-2 may not go from the world in near future. Therefore,each and individual has to change their life style and take all the preventive actions against the virus. A diabetes patientsare more susceptible, they have to adopt some healthcare measure in their daily life. There are few smart healthcaresolutions which are useful during this COVID-19 crisis is discussed in the current Section.
The COVID-19 pandemic has made the impact drastically on healthcare organizations all over the globe. Con-sequences of this lockdown for diabetic patients would result in reduced values of insulin and antihyperglycemiccomponents. The mandate on social distancing has also posed the restrictions on routine visits for the patients todoctors. The role of telemedicine is significant during such unparalleled situation which allow patient to manage theirhealth profile for the diabetes alike chronic diseases [60].The telemedicine service could be classified as per the time frame and mode of communication with health serviceprovider (See Fig. 7). The telemedicine could be provided through text emails, Fax, short messaging service, emails,Fax and conversion by chat on social network platforms. There are several video conferencing software. There are fewtraditional way of taking proper medication such as voice over internet protocol, phone etc. This kind of telemedicineervice would be important for situations where less numbers of doctors per person available and would be able toreach rural area where it is scarcity of the health service. The service of telemdicine would be also popular graduallywith the increase of smart-phones day by day. This kind of service for diabetes patients is considered as blessingwhere the vulnerability gets reduced from COVID-19 infection.
Continuous GlucoseMonitoring Tele ConsultancyGlucose InsulinBalance Tele Prescription ForGlucose ControlMedication for Glycemic profile control
Figure 7: Role of Teleedicine during Pandemic Outbreak.Through this any physician can connect with the patient and give him advice by examining his various medicaldiagnosis like prevailing history, self-monitored blood glucose charts (SMBG) and self-monitored blood pressure(SMBP) values. Tele medicine has come a long way and its usage guided diabetic patients. A small study, where 35randomised controlled trials (RCTs) done with aid of telemedicine (like video, phone and email) in China (where apool of (n,3514) population) was given the consultancy for 36 months. This experimentation demonstrated decrease inHbA1c by 0.37% (p < 0.001) in group telemedicine as compared to other. Similar review was conducted by Flodgrenand colleagues,this was done on 21 RCTs of patient with diabetes (n,2768). They were given an interactive sessionthrough (real time video or remote monitoring) in an appendage to only standard care alone. With this measure aoverall decrease of HbA1c by 0.31% (p < 0.001) in patients on telemedicine as set side by side with controls. Areview article recently published showed by 46 studies including both the types of diabetes with patients of type-2diabetes mellitus (T2DM, n , 24000) and type-1 diabetes mellitus (T1DM n , 2052) were experimented with differentmodes of telemedicine. This investigation reported an overall reduction in mean value of HbA1c by T1DM (0.12 to0.86%) and T2DM (0.01% to 1.13%) patients, respectively.India is in its early stage of research on telemedicine and diabetes. The Pilot project known as “Diabetes Rath” (Hindiname of Mobile Vehicle) was started with aiming of spreading knowledge of diabetes care using mobile van facilitatedwith telemedicine (like computer and video conferencing app for transmitting retinal images to ophthalmologist,consult with diabetes foot specialist and diabetologist at a tertiary care centre ) especially in underprivileged areas [61].This study has shown positive results in screening and managing diabetes through telemedicine.There are several general guidelines for telemedicine service as follows: • The confidential and private information should be maintained properly. • The personal information related to patient such as name,age, address should be maintained. • The medical history and records for the patient medical records should be kept with their prescription alongwith the any testing records. • The consultancy charge of the patient could be decided as per his/her medical prescription and the procedureof getting tele-consultancy.elemedicine would allow the possibility to expand the medical facility and healthcare sector every part of the worldwithout any kind of geographic barrier. Consequently, telemedicine platform can help to reach the health relatedservices to places where there is any constraint of physical structures. It would gain massive popularity in the currentepidemic where social distancing is the need of the society. The remote consulting with doctor is really attractivesolution for urban tertiary where medical centres faces real challenge to accommodate each patient with proper pointof care facilities. Telemedicine option is also useful when it is required to coordinate complex multidisciplinary carevia a tumour board conference format among specialists that are geographically separated.
The non-invasive glucose measurement device (such as iGLU, see Fig. 8) would be the state of art solution for frequentglucose measurement [3, 6, 40, 41, 62]. The proposed solution will be useful for continues glucose monitoring and itscontrol with insulin secretion along with integration of Internet of Medical Things (IoMT) based healthcare Cyber-Physical System (H-CPS) framework. iGLU would help to provide instant diagnosis to remote located diabetes patientthrough telemedicine in this crisis situation. The conventional blood picking process would not be an ideal choice forfrequent measurement for older population and children. It has also associated risk with trauma and touching theneedle could be source for infection. For diabetes patients, if the blood sugar goes above 250, then it would be atrisk for ketones. The ketones is considered as the poison for body. During this pandemic, it is very vital to keepthese ketone levels down. The continues monitoring solution would help to balance the glucose profile in the body.The glucose insulin model has been proposed to analyse the plasma insulin variation with proper insulin secretionplan. The proposed insulin delivery system is integrated with IoMT to have prescribed diet and insulin plan under thesupervision of remotely located doctor. The insulin pump would be helpful to have the proper glucose-insulin levelthat is important to improve the immune system to avoid COVID-19 infection.
Continuous Glucose Monitoring through Non invasive Glucometer iGLU Doctor/Care GiverCloud DatacenterInsulin Secretion through Pump Hospital
Figure 8: Our Intelligent Non-Invasive Glucose Monitoring with Insulin Control Device (iGLU) [3, 6, 40, 41].
Unhealthy diet can also cause several health issues. The diabetes patient has to plan their diet to control glycemicprofile. Automatic IoMT-based mechanisms which allow user to monitor their food intake and help to create awarenessabout the right kind of food with suggestions for next diet (see Fig. 9) can be crucial for diabetic people. iLog educateusers for Normal-Eating and Stress-Eating, where Stress Eating defines the uncontrollable consumption of high caloricfoods. It also provide a fully-automated edge level device which is useful to detect automatic stress variation inhealthy lifestyle. The iLog framework uses a mobile platform as a user interface. The images of foods are beingdetected automatically and subsequently quantified foods are compared with the images of stored database [63, 64].he proposed approach could be helpful to have proper glucose-insulin balance for diabetes patients which ultimatelyhelps to minimize the chances of COVID-19 infection. It provides a fully-automated platform for healthy life stylewith monitoring the stress behavioural by virtue of no input from user end.
Reference ImageMobile App Interface IoMT- CloudFood Item
Database
Nutrition DatasetAutomatic Food Intake QuantificationFood Plate Image ClassificationFeature Extraction Food Object Detection
Automatic Next Diet Suggestion
Nutrition Deficit Calculation Next Meal Suggestion
Figure 9: Diet Automatic Monitoring and Control for Blood Glucose Control [63, 64].
The development of rapid, accurate and portable diagnostic technique for corona virus is also required for thediabetes patients. If complications of diabetic patients increase then they are in more danger. The near infrared(NIR) spectroscopy could be the breakthrough for this purpose. The focus is to develop a system for the NovelCoronavirus (COVID-19) detection using optical technique (see Fig. 10). The proposed system shall use light withspecific wavelengths for instant measurement. The proposed technology would help to sense the novel coronavirusfrom saliva of the patient. The proposed system is on chip (SoC) with specific emitters and detectors, analog-to-digital converter (ADC) and acquisition module be embedded to process the sample through saliva. The acquiredvalues would be then processed through machine learning models to detect the presence of corona virus. The obtainedvalues require to be calibrated with standard reference value. The novel system would have higher precision level andstability in measurement compared to traditional measurement. The system would be capable to test patients withinfew minutes. The system is to be integrated with an IoT framework for data storage where remote instant diagnosisis possible through shared server data of the patient. The proposed solution shall be cost-effective and provide instantmeasurement of COVID-19 infection. The similar technology was applied successfully for rapid detection of Zikavirus and hepatitis B and C virus infection [65, 66].
Emitter forSpecific Wavelength Saliva Sampleof Subject Detector of SpecificWavelengthData Acquisition ADC with
Noise
FilteringCalibration with Machine
Learning
ModelsNIR Spectroscopy (Reflectance, Absorption and Transmission)
Post Processing using Machine
Learning Models
Figure 10: Rapid Detection of COVID-19 using NIR Spectroscopy. .5 Wearable Safety-Aware Mobility Tracking Device
An IoMT device easy-band based sensors is useful to sense the presence of another COVID-19 patient within a radiusof 6 to 13 feet [67] (See Fig. 11). It is wearable, accurate and cost effective solution of monitoring COVID-19 patientand would be integrated with IoMT/H-CPS framework. The diabetic patients are of great need of such type of devicewhich would help to track their health in this COVID-19 outbreak.
Easy BandRed Color
Easy Band
Green Color Easy Band Yellow ColorCareful
Warning
Critical Warning No Warning Easy BandGreen Color
Figure 11: Wearable wristband for contact tracing [68].All must have to wear this device for safety aware mobility tracking purpose. The device comprises of three LEDcolors mainly as red (highly suspected), Green (safe) and yellow (mildly suspected) [68]. Every device is capable ofstoring the local information such as timestamp, time period and device ID of those devices which are in contact ofthe present device within area of 6 feet zone. The device is able to store these information upto last 14 days. Thehealthy tested persons (with diabetes or pre-diabetes) would have the access of this device as mobility pass with activegreen light. The person has to wear the device once having the possession of this device and will not attempt for theremoval. In case of such any efforts of tempering, it will be directly reported to concerned authority. If any personcomes in close contact of another COVID-19 person then the device comes at red light state and record the details ofpatient. The information are updated on server at regular basis. Device automatically starts vibrating to alert whenit come in an area of 4 meters (13 feet) in vicinity of yellow or red device. Another alert is generated by a beepsound (critical warning) when it comes in contact with yellow or red device. When a green device spends a long timein close contact with a yellow/red device, its status will automatically change to yellow. This device will also havea temperature sensor (e.g. infrared/IR sensor) to sense the body temperature and measure respiratory of the personfor issuing necessary preventive actions and changes status from green to yellow. This way the device will help thediabetic patients (or any citizen) to stay safe by automatically sensing the suspects. The battery life of the devices hasbeen enhanced with ultra low power operation. To social distance while traveling, one has to sense the colour that popup on the device which can warns people through their signals.With the pandemic around, quarantining a potential carrier of COVID-19 can curb the spread to a certain extend.However, with the difficulty in pinpointing a carrier of virus many countries are adhering to other measures like shelter-in-place, stay-at-home, and lockdown. Prolonged stay-at-home measure has created many other problem such aseconomical crises, unemployment, food scarcity, and mental health problems of individuals etc. Again contact tracingof positive cases and isolating them will be a hectic, unreliable and error prune task. As a result again re-impositionof lockdown is essential. Nevertheless, if the mentioned solution is controlled with a technological approach, it wouldhelp in stabilizing the current scenario. SARS-CoV2 effects more to elderly people, children and person with pre-existing diseases, such pre-diabetes, and diabetes. Such type of safety aware device would be really helpful to diabeticcommunity for their self-care measurement.
Conclusion and Future Directions
The article attempts to spread awareness among the people (specially diabetes patients) with possible recommendationand future technologies for smart healthcare. The case studies around the globe suggest that diabetic people aremore vulnerable to COVID-19 infection and also suffer from more severity in terms of medical complications. Theunderneath diabetic patients have higher risks of two to three times compared to non-diabetic person. The studies showthat a better control over glycemia can be advantageous to the patient simultaneously suffering from both diabetes andviral respiratory diseases such as COVID-19. The proper diabetic care of the person would help in reducing theprevalence of COVID-19 infection. The balance glucose insulin profile could improve the morbidity rate as wellas mortality rate against SARS-CoV-2. It has potentials to reduce length of stay in the infected COVID-19 patientsand also useful in avoiding the wide spared of virus among the community. We have discussed many devices andtechniques available for diet management, stress management, and glucose-level management which can be helpful.Presently, significant effort going on around the globe for the development of vaccine and medicines against novelcorona virus COVID-19 and many agencies across the world are working for the success of the same. However, there isrequirement to have proper planning so it have early access of most vulnerable people such as diabetic, cardiovasculardisease, hyper tension people. Although there has been substantial development of technological solution, there is aneed for smart long term strategy that would require to fight against such pandemic in future in order to minimize thesocial and economical impact. In this respect, IoMT driven healthcare Cyber-Physical System (H-CPS) will play amajor role [69].
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IEEE Consumer ElectronicsMagazine , vol. 9, no. 5, pp. 6–7, September 2020. uthors’ Biographies
Amit M. Joshi (M’08) has completed his M.Tech (by research) in 2009 and obtainedDoctoral of Philosophy degree (Ph.D) from National Institute of Technology, Surat inAugust 2015. He is currently an Assistant Professor at National Institute of Technology,Jaipur since July 2013. His area of specialization is Biomedical signal processing, Smarthealthcare, VLSI DSP Systems and embedded system design. He has published sixbook chapters and also published 50+ research articles in peer reviewed internationaljournals/conferences. He has served as a reviewer of technical journals such as IEEETransactions, Springer, Elsevier and also served as Technical Programme Committeemember for IEEE conferences. He also received UGC Travel fellowship, SERB DST Travelgrant and CSIR Travel fellowship to attend IEEE Conferences in VLSI and EmbeddedSystem. He has served session chair at various IEEE Conferences like TENCON -2016,iSES-2018, ICCIC-14. He has supervised 18 M.Tech projects and 14 B.Tech projects in thefield of VLSI and Embedded Systems and VLSI DSP systems. He is currently supervising six Ph.D. students.
Urvashi P. Shukla received her bachelor’s degree in Electronics & CommunicationEngineering from C. K . Pithawala College of Engineering and Technology, affiliatedunder Veer Narmad South Gujarat University, Gujarat, India. She pursued her M.E fromSarvajanik College of Engineering and Technology, Surat, Gujarat, India under GujaratTechnological University. She completed her Ph.D from NIT, Jaipur, Rajasthan, India. Shehas published papers in reputed journals and conferences. Her research interests revolves toobtain solution for problems associated with hyperspectral Images by incorporating variousoptimization algorithms based on heuristic approach.