Inspiration
My mom has lived with Type 1 Diabetes for more than half her life and all of mine, I've seen firsthand and been educated on the dangers, challenges and stresses; both physical and mental caused by the disease. Watching my mom work for years in diabetes advocacy has made me see how hard it is for those without the condition to emphathize and understand what it means to be a diabetic and how essential it is to find an actual cure, and when we do, have the infastructure in place to get it to as many people as possible. Thus, considering this and after speaking to my mom, and her colleagues at Breakthrough T1D, a consistent theme they wished for was an app that would allow those without Diabetes to be able to understand the psychological stress the disease puts you under and also be educated on what living with diabetes truly is like, and what the concequences truly are, even now.
What it does
180 Decisions is inspired by a study published by Stanford University where researchers found that "Life with type 1 diabetes requires an astonishing number of health-related decisions - about 180 per day." (Digitale, E. (2014). New research shows how to keep diabetics safer during sleep. News Center. https://med.stanford.edu/news/insights/2014/05/new-research-keeps-diabetics-safer-during-sleep.html ). It is also inspired by the Dexcom Continuous Glucose Monitor (CGM) as while it is a incredible, life saving tool. It is also the source of many of the stressors diabetics experience on a daily basis via the auditory and tactile notifications it frequently sends out to alert them of their elevated or low levels of glucose in their blood. This application looks to simulate the experience of having this CGM so that those without diabetes can get a better understanding of the types, quantity and constant nature of the decisions diabetics must make regardless of the time, place, convinience, or privacy of the diabetic. Simultaneously, the application will provide those who are using it with well researched, peer reviewed information regarding diabetes so that they can get an accurate understanding of what the disease is, what it isnt, what its like to live with it, and how they can best support the person(s) in their life with teh condition.
How we built it
180 Decisions in its demo state is a react application with no external dependencies aside from the browser. The CGM alerts are synthesized in real time using the Web Audio API with 4 notification patterns that mimic the clinical severity levels. Similary, Vibration patterns on mobile devices are mapped to the same 4 severity levels. The applications also has context detection which tracks the time of day (in the demo its simulated for the sake of saving time) this then adapts the scenario options accordingly to be as realistic as possible both in terms of expected glucose readings, the context in which the user finds themselves, and the options available to them.
The insulin calculator implements the 500 rule (Insulin-To-Carb Ratio: Bev. (n.d.-b). Insulin formulas. Insulin Formulas - Diabetes Educators Calgary. https://diabeteseducatorscalgary.ca/medications/insulin/insulin-formulas.html ) and the 1800 Rule ( "General Approaches and Recommendations for Insulin Use in People with Diabetes", Practical Insulin: A Handbook for Prescribing Providers) which is known as the Insulin Sensitivity Factor. These are two essential formulas for T1D bolus dosing who account for net carbs, current glucose correction, fat-induced absorption delay and exercise proximity.
The concequence timeline is built from the Diabetes Control and Complications Trial Research(DCCT) / Epidemiology of Diabetes Interventions and Complications(EDIC) Research Group's 30 year trial (Diabetes Control and Complications Trial Research Group; Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M, Rand L, Siebert C. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993 Sep 30;329(14):977-86. doi: 10.1056/NEJM199309303291401. PMID: 8366922.
Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group; Lachin JM, Genuth S, Cleary P, Davis MD, Nathan DM. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med. 2000 Feb 10;342(6):381-9. doi: 10.1056/NEJM200002103420603. Erratum in: N Engl J Med 2000 May 4;342(18):1376. PMID: 10666428; PMCID: PMC2630213.
)and Diabetes Care (2014). HbA1c thresholds from that study determine which outcome tier a user receives.
Glucose unit support covers 70+ countries using the Abbott Diabetes Care International Reference Table ( "Blood Glucose Monitor and Blood Glucose Meter – Blood Glucose Measurement Units FAQ". 6 July 2011. Archived from the original on 6 July 2011) automatically switching between mmol/L and mg/dL based on where the user is from.
Challenges we ran into
I would say the biggest challenge was capturing the authentic lived experience of diabetics. Even having lived with one my entire life there was alot i still didnt know and accuracy is both essential in educating others without the condition, but also in allowing them to really feel what its like and empathize with those who actually live with Diabetes every day. So alot of time was spent thinking of a variety of different situations and options for the user to select in each experience that are realistic given the context of the scenario, aswell as not immediately obvious to both reflect the cognitive impairment those suffer hyper / hypoglycemia are experiencing aswell as the experience of many diabetics being asked to figure out these complex balancing acts without much prior education or support to understand what they mean or what the concequences are.
Also ran into a few coding problems where the app kept refiring the same alert at 4:20 am which turned out was a loop caused by the dismiss function reading an elapsed time value captured at render rather than the true current time. Introducing a reference value that stays in sync with elapsed time independent of the render cycle fixed the issue and now allows for every scheduler callback to always read the correct timestamp regardless of when the closure was made.
Accomplishments that we're proud of
There are a few scenarios where the user must decide what to do when needing to take insulin in a social situation. Im proud of there being no real "correct" answer in any of the options presented as no matter what diabetics do in the real world, there are tangible drawbacks which reflects the immense psychological and social toll the condition takes on those with it. Im also proud of the design decisions all having tracable sources, wether that be the 180 decision figure from Stanford, cognitive impairment data from Rustad and Musselman, the insulin formulae from Walsh and Roberts or the concequence timeline from DCCT / EDIC. Having good quality sources to backup the app behaviour was a real priority that Im happy with what I was able to accomplish considering the timeframe.
What we learned
I learned alot about how essential good HCI principal usage is to creating an experience that relies on the empathy of the user. Were it the case that the answers to the simulated scenarios were obvious then it is likely the case that the user would feel less empathetic than otherwise possible due to them perceiving the challenges faced by diabetics as simple and overblown. Simultaneously, the answers cannot be too essoteric or impossible as that would have a similar effect on the opposite end of the spectrum. Regardless, a core component of this application is developing empathy between the user and the condition and thus accuracy and careful question design among many other things are essential for this feeling to be authentically curated.
What's next for 180 Decisions
There are 3 avenues which id like to explore with this app
Parliment Challenge Being able to deploy 180 Decisions as an app which members of parliment can download and be challenged to would hopefully raise awareness from within the hill of what it is like for those with Diabetes and how essential Federal funding is to get the research needed to finally develop a cure, design, cultivate and build pathways for the cure to be distributed to Canadians across the country with Diabetes and to understand that while Insulin and CGMs are life saving medication which need to be made accessible to every diabetic in Canada, they are not cures and there is still work to be done and money needed for that work.
Personal Challenge At a larger level, the goal of this app would be for someone with diabetes to be able to share it with those in their life who theyd like to understand more what its like to go through life day by day with Diabetes. The hope is that this will develop a iincreased level of empathy, understanding and support to those with diabetes so that if the individual in their life with diabetes is ever in need of help or support as many people as possible are able and willing to do what they can to provide it. It is also hoped that those with diabetes would feel more empowered to share that they have the condition and not feel ashamed or stigmatized as much as many do now. And maybe it can become a trend similar to the ALS Ice Bucket challenge to increase awareness of diabetes across the country.
Legitimacy Challenge Having the scenario engine and health scoring system continually tweaked and edited to reflect the real science behind diabetes will always be the goal and thus having 180 Decisions recognized by endocrinologists and used in medical education would be a goal too! Maybe to be able to train future medical professionals many of whom arent able to do things like administer insulin or recognize severe symptoms associated with Diabetes even now.
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