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DIABETES TECHNOLOGY & THERAPEUTICSVolume 8, Number 1, 2006© Mary Ann Liebert, Inc.

Interactive Educational Diabetes/Insulin Tutorial atwww.2aida.info

KAREN REED, B.Sc.1 and ELDON D. LEHMANN, Ph.D., F.R.C.R.2

ABSTRACT

The World Wide Web now hosts a multitude of diabetes educational materials in various for-mats. Of particular interest is the diabetes/insulin tutorial available at the AIDA Website (ac-cessible directly at: www.2aida.info). The tutorial combines textual or “static” information withan interactive diabetes simulator—AIDA online—to provide an engaging and effective educa-tional tool. AIDA online (accessible directly at: www.2aida.net) enables the simulation of plasmainsulin and blood glucose levels from user-defined insulin injection and carbohydrate intakedata. A haemoglobin A1c value is also computed, giving an indication of overall blood glucosecontrol in the virtual patient with diabetes. The diabetes/insulin tutorial is currently composedof four sections: the first two cover in considerable depth insulin injection regimens and insulindosage adjustment; the third section introduces the principles of carbohydrate counting and,specifically, matching insulin doses to carbohydrate intake; and the fourth section illustrates therelationship between blood glucose levels and renal excretion of glucose. The simulator runsalongside the tutorial, and allows various concepts described in the text to be explored freely bythe user and simulated interactively. This introduces a novel way of learning how injected in-sulin and dietary carbohydrate interact in various insulin injection regimens. A fifth section—for which any offers of assistance would be gratefully received—is planned. This will considerthe use of insulin pumps and rapidly acting and very long-acting insulin analogues. Further im-provements that may strengthen the existing tutorial and/or use of the online simulator are dis-cussed in this column.

INTRODUCTION

AS THE INTERNET HAS BECOME more accessi-ble to the general population, so Web-

based educational material has increased in

popularity. There is no shortage of informationabout diabetes or insulin treatment on theWorld Wide Web. This column overviews aninteractive educational diabetes/insulin tutor-ial, which is freely available at the AIDA Web-

1Reed Biomedical, Rotorua, New Zealand.2Department of Imaging (MRU), Imperial College of Science, Technology and Medicine (NHLI), Royal Brompton

Hospital, London, United Kingdom.The AIDA software referred to in this report is an independent, non-commercial development that is being made

available free-of-charge via the Internet—at a dot org (.org) not-for-profit Website—as a non-commercial contribu-tion to continuing diabetes education. Dr. Lehmann is a co-developer of the AIDA diabetes simulator and AIDA on-line, and Webmaster of the www.2aida.org and www.2aida.net Websites.

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site (accessible directly at: www.2aida.info).The tutorial utilises the Web-based version ofthe diabetes simulation software, AIDA, whichis a freeware computer program that enablesinteractive simulation of plasma insulin andblood glucose levels for educational purposes.Whilst many diabetes educational Websites arehighly informative, most are static in nature,being made up mainly of textual material. Inthis respect, the diabetes/insulin tutorial fea-tured at the AIDA Website stands out as beinga more dynamic approach to Web-based learn-ing.

The diabetes simulator software and theAIDA Website have been reviewed previouslyelsewhere.1–7 In this column, detailed consid-eration is given to the diabetes/insulin tutor-ial. Ways in which it may be further developed,and its educational utility enhanced, are ex-plored.

AIMS OF THE TUTORIAL

AIDA online (accessible directly at: www.2aida.net) is based on the interactions that takeplace in the human body among injected in-sulin, dietary carbohydrate, and blood glucoselevels in people with insulin-requiring dia-betes. The informational content of the tutorialis accordingly centred around insulin treat-ment for diabetes. Balancing injected insulinwith the body’s requirements for insulin, tak-ing diet and other factors into account, formsthe backbone of diabetes management in peo-ple with insulin-dependent (type 1) diabetesmellitus. The tutorial, which has been based inpart on an introductory course for people withtype 1 diabetes,8 aims to demonstrate how in-sulin and dietary regimens work, and how theycan be adapted to optimise blood glucose con-trol.

As with all applications that involve the useof such diabetes simulation software, somecaveats apply that need to be read and under-stood.7 These are largely based on the limita-tions of the model upon which AIDA has beenbased,9 and relate to the fact that the model isnot sufficiently refined for individual patientsimulation.10 No aspect of AIDA should there-fore be applied for personal use or individual

therapeutic planning; this is emphasisedthroughout the tutorial pages, and patients areencouraged to consult with their health-careprofessional before making any changes totheir own treatment regimen.

A further caution that warrants note is thatrecommended treatment approaches may varybetween clinic settings, and especially betweencountries. Thus the tutorial is not intended toprovide a specific or didactic plan for using in-sulin. Rather, it aims to give insight into howvarious treatment options work, and how theymight be fine-tuned for optimum blood glucosecontrol. Integrating the diabetes simulator withthe tutorial pages enables the principles of in-sulin treatment to be learned in an applied fash-ion, without the need to experiment on real pa-tients.

THE TUTORIAL AND DIABETESSIMULATOR IN ACTION

The tutorial can be accessed either by select-ing “Insulin Tutorial” from the bottom menuframe bar of the home page at the AIDA Web-site (www.2aida.org), or directly at: www.2aida.info

The key feature of the tutorial is that the tex-tual or “static” information is linked-in withsimulations of selected case scenarios, whichare run in parallel in a second Web browserwindow. The interactive nature of the onlinesimulator brings the informational content ofthe tutorial to life and greatly enhances thelearning experience.

Four sections of the tutorial are currentlyavailable online, and a fifth section—for whichany offers of assistance would be gratefully re-ceived—is planned (Table 1). The first two sec-tions form the bulk of the present material, andconcentrate on the ins and outs of various in-sulin injection regimens and insulin dosage ad-justments. The third section integrates mealplanning and carbohydrate counting, and thefourth section looks at the relationship betweenthe kidney and blood glucose levels.

Interactive simulations engage the user

Throughout the tutorial, HyperText MarkupLanguage (HTML) links invite the user to sim-

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ulate relevant case examples. The simulatorruns alongside the tutorial in a second Webbrowser window, and the user is free to switchfrom one window to the other, as desired. Inpractice some users may find it easier to splitthe windows—i.e., arrange the two browserwindows on the screen so that both are visibleat the same time (Fig. 1).

In each case, the simulation window displaystwo graphs covering a 24-h period. The firstgraph shows blood glucose levels throughoutthe day, and indicates the time and quantity ofcarbohydrate intake. The second graph showsthe time and dosage of insulin injections, andthe resultant plasma insulin level. A glycosy-lated haemoglobin (HbA1c) value for the sim-ulation is also computed using the formulagiven in Lehmann.11

The preselected case scenario is then de-scribed, along with some hints and sugges-tions, which help to direct the necessarythought processes. This is followed by the dataentry form, in which users can change variablesand re-run the simulation to see the effects ofthe changes on the two graphs. For example,Figure 2 shows the baseline simulation fromFigure 1 following an increase in the morningHumulin S dose from 3 units to 10 units. The

resultant lowering of the blood glucose profileuntil after lunch is clear to see. Usefully, theblood glucose and plasma insulin levels in theprevious run are also indicated on the re-rungraphs, enabling the effects of the changes tobe easily visualised. A new HbA1c value is alsocomputed [in the example in Fig. 2 showing areduction in HbA1c from 10.6% (see Fig. 1) to10.2%].

At this stage the user may wish to continueto explore variations with the case scenario,running further simulations, or to return to thetextual/informational pages and continue withthe tutorial. It is also possible to choose an al-ternative case scenario from the simulator;however, it is pertinent to remain focussed onthe subject matter of the tutorial. It is the ex-perience of one of us (K.R.) that visitors can eas-ily be sidetracked from the tutorial, becomingengrossed with the simulator, so attentionneeds to be redirected back!

Insulin injection regimens

In order to keep things simple, the textual in-formation in the tutorial refers to the action of“regular,” “long-acting,” or “premixed” in-sulin preparations when describing insulin reg-

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TABLE 1. OUTLINE OF CONTENT OF THE DIABETES/INSULIN TUTORIAL AT: WWW.2AIDA.INFO

Section 1: Insulin-dosage adjustment (basics)—15 Web pages• Insulin action profiles and uses; “regular,” “long-acting,” and “premixed” insulins are considered• Insulin treatment: injection regimens• Intensive and conventional insulin therapy• Basal/bolus insulin therapy• “Honeymoon period”• “Dawn phenomenon”

Section 2: Choosing the insulin dose—15 Web pages• Concept of blood glucose control• General algorithms for changing insulin doses• Numerous examples of patient test records illustrating various concepts of insulin-dosage adjustment for a

number of different insulin regimens• Deals with anticipatory and corrective insulin dose adjustments

Section 3: Timing of meals and diet planning—5 Web pages• Carbohydrate counting: matching insulin dose to carbohydrate intake• Basic dietary considerations (“healthy eating”)• Special occasions• Extra carbohydrate to counter effects of exercise

Section 4: Glucose and the kidney—6 Web pages• Filtering of glucose by the kidney• Renal threshold (analogy of a dam)• Glucosuria

Section 5: Rapidly and very long-acting insulins and insulin pumps—16 Web pages (planned—although assistancewith this section would be gratefully received)

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imens. This allows concepts to be describedwithout complicating matters by introducingspecific insulin types, manufacturers, or “brandnames.” However, running the simulator along-side the tutorial text enables the user to exploreand compare the effects of various insulin

preparations, including premixed (biphasic)formulations.

Each example case scenario chosen to runalongside individual pages in the tutorial is dif-ferent, and collectively they demonstrate thewide variation of insulin regimens that are

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FIG. 2. Baseline simulation from the right-hand window from Figure 1 following an increase in the morning Hu-mulin S dose from 3 units to 10 units. The resultant lowering of the blood glucose profile until after lunch is clear tosee. A new HbA1c value has also been computed showing reduction in the HbA1c from 10.6% (see Fig. 1) to 10.2%.

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used today. Advantages and disadvantages arenoted, and illustrated, and in each case the sim-ulator can be used to illustrate how injected in-sulin, plasma insulin, carbohydrate intake, andblood glucose levels relate to each other and in-teract in the “virtual patient with diabetes.”This leads easily into the features of “conven-tional” and “intensive” insulin therapy, and anunderstanding of the concepts of basal and bo-lus (the latter referred to as “booster rate”) in-sulin dosing.

Concepts that patients may have difficulty inunderstanding are dealt with in a relevantmanner. For example, the “dawn phenome-non” is described and explained in detail, witha sound practical approach to determining themost appropriate insulin regimen for optimalnocturnal/early morning blood glucose con-trol.

Insulin-dosage adjustment

The second section of the tutorial begins withan invitation for users to consider their under-standing of the concept of blood glucose con-trol, and how this may be achieved. This pro-vides an excellent opening for the ensuingdiscussion of insulin-dosage adjustment. Sev-eral examples of hypothetical patients’ test re-sults are presented, covering a wide range ofdifferent insulin regimens. In each case, thesimulator allows the user to explore the prin-ciples described in the tutorial text, by chang-ing parameters and re-running simulations.Thus learning is enhanced through individualexperimentation. The scenarios that are exam-ined address both anticipatory and correctiveinsulin-dosage adjustments.

Carbohydrate intake

The third section of the tutorial introducesthe concept of insulin-dose adjustment forchanges in dietary intake of carbohydrate. Al-though no direct links to simulations are pro-vided in this section of the tutorial, the onlinesimulator is still accessible via the AIDA Web-site. If Section 2 has just been completed—andthe user is working through the tutorial sec-tion-by-section, as is advised by the authors—then the simulation window should already beopen, and the user should at this stage be suf-

ficiently familiar with the simulator software tobe able to investigate the effects of varying car-bohydrate intake in various case scenarios. Ifthe user is “entering” the tutorial at Section 3,then the simulator may be launched from thesmall pop-up window that opens when theuser first visits the AIDA Website. If this win-dow has previously been closed, then it can bere-launched by re-loading the frames versionof the Website.

The interactive simulator allows for variationin carbohydrate intake (both quantity and tim-ing), and the effects of meal timing in relationto insulin timing, to be investigated. Other as-pects of diabetes management, such as copingwith changes in daily routines, “special occa-sions,” and exercise, are also considered here.The simulator currently does not specifically al-low for changes in metabolism occurring dur-ing strenuous activity; however, the principlesrelating to increasing dietary intake to avoidhypoglycaemia are still explained.

This section could be expanded to fully em-body the principles of DAFNE (Dose Adjust-ment For Normal Eating), which is a specificprogram of training in insulin-dosage adjust-ment for patients with type 1 diabetes, that iscurrently being piloted in the United Kingdomand parts of Australia (vide infra).12

Blood glucose and the kidney

The fourth section of the tutorial considersthe relationship between the kidney and bloodglucose levels. The filtering of glucose by thekidney is described, and the analogy of a damis used to explain the concept of the renalthreshold for glucose (Fig. 3). The user is in-vited to run a simulation that demonstrateshow blood glucose levels, renal threshold, andglucose in the urine inter-relate. The user canthen change the renal threshold (possible set-tings are low, normal, or high) and observe theeffects.

The “Advanced Display” option of the onlinesimulator can also be used to look at various glu-cose fluxes in more detail; thus changes in renalexcretion of glucose (in mmol/h) can be moni-tored, as the user tries changing various pa-rameters. This is a good example of an intelli-gent applied use of the diabetes simulator.

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INFORMATION TECHNOLOGY & WEBWATCH132

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Additionally, the use of time frames in thesimulations reinforces the fact that measuringurine glucose only provides an indication ofearlier blood glucose levels, and this may notreflect the current status. Thus, this last sectionof the tutorial illustrates the limitations of us-ing spot urine glucose measurements as op-posed to blood glucose monitoring, as a tool toaid insulin-dosage adjustment.

FUTURE DEVELOPMENTS ANDPOTENTIAL IMPROVEMENTS

The AIDA simulator, Website, and dia-betes/insulin tutorial are all ongoing projectsand hold much potential for future develop-ment. New features that may be incorporatedinto AIDA in the future—such as the consid-eration of insulin analogues, and exercise andstress levels—would undoubtedly add to thepotential of the tutorial itself. Indeed, work hasbeen planned on a fifth section—which aims tocover insulin preparations such as Huma-log/lispro, as well as the use of insulinpumps—although assistance with developingsuch an additional section would be appreci-ated. There are also a number of other possi-bilities for the development of the tutorial,which may further broaden the scope of this in-novative educational resource. Some of theseare outlined below.

Newer insulin preparations

New very long-acting insulin analogues havebecome available relatively recently, and theseare becoming increasingly popular with patientsand diabetes health-care professionals alike.Since these have markedly different action pro-files to previously available “long-acting in-sulins,” it will be important that these are con-sidered—in both the tutorial and the simulator.

Glossary of terms

As it stands, the tutorial is concise and suc-cinctly written. However, there are a numberof terms and concepts that could usefully be ex-panded upon for the less educated user. HTMLlinks to a small pop-up window style glossarymay be a feasible option.

Menu structure

The different sections of the tutorial havebeen designed to be completed in their entirety,and in order. However, a menu structure thatenabled users to independently access sum-mary pages for each section, allowing users to“dip in and out” of the tutorial, could be ofvalue to returning visitors.

Specific audiences

The AIDA Website has been designed to beused freely by patients, relatives, carers, stu-dents, researchers, and health-care profession-als alike. Accordingly, the Website contentaims to cover all bases. The tutorial, which iscurrently primarily aimed at “general” patienteducation, could also be tailored to suit vari-ous different audiences; for example, a specificversion for the education of health-care pro-fessionals and students would conceivably beof value.

An adapted version of the current tutorialmay be of use specifically for pre-conceptioneducation of young women who are consider-ing starting a family. This is a crucial time whenblood glucose control should be optimised andthe patient needs to be fully informed about in-tensive treatment and insulin-dosage adjust-ment. The tutorial may also be adapted specif-ically to be used in diabetes managementskills-based training programmes, such asDAFNE.12

The DAFNE approach to insulin treatment,which originally evolved in Germany, but is now widely adopted in many countries, iscentred on flexible insulin-dosage adjustmentto match carbohydrate intake with a free diet.Initial randomised controlled trial results are promising,12 and further research is inprogress. Of particular interest are the studiesbeing conducted into adapting the DAFNE ma-terial for the education of school-age children.13

It is recognised that this population has specificeducational needs and learning styles, and theinteractive nature of the simulation-aided tu-torial may have added appeal for the youngergeneration.

While it is noted that AIDA is based on anadult model, the simulator can still be used ef-fectively as an educational tool to demonstrate

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the principles of insulin-dosage adjustment toyoung people. An adapted version of the sim-ulation tutorial may also be of value in train-ing DAFNE educators.

Downloadable version

A DOS-based version of AIDA1–4 is availableat the AIDA Website free-of-charge. This hasproved to be a popular resource, with well over190,000 copies of the program having beendownloaded to date.14 It is conceivable that anaccompanying downloadable tutorial couldalso be of interest to both health-care profes-sionals and patients.

Collaboration and increased availability toexternal websites

In order to increase the availability of AIDAand promote intelligent use of the tutorial, col-laboration is actively sought. Webmasters of di-abetes Websites may be interested in makinguse of some of the diabetes/insulin tutorialHTML pages and graphics at their own Web-site. The AIDA developers have created a ver-sion of the tutorial that can operate externallyfrom the AIDA Website. The interactive dia-betes simulations (which require some dedi-cated server programs and set-up) can operateacross the Internet in a separate pop-up/newwindow. A standard HTML template is avail-able from the AIDA Website developers to helpensure that material is in the appropriate for-mat. Further information is available from:www.2aida.org/contact

Examples of third-party use of the tutorialmaterial can be found in operation across theInternet; a case in point is illustrated at: www.mendosa.com/www-2aida-org/tutorial.htm(Fig. 4), and the material has even been trans-lated into other languages. For instance, a Rus-sian language version can be found at: www.diabet.ru/aida2/rus/tutorial.htm (Fig. 5).

Invitation for help

The AIDA Website developers openly ex-press their hope that the tutorial will become adynamic resource and, over time, will expandand grow. Health-care professionals who areinterested in contributing material are invitedto get in contact using the online AIDA contact

form (at: www.2aida.org/contact). For in-stance, assistance with the provision of teach-ing materials related to rapidly acting and verylong-acting insulins, and the use of insulinpumps would be gratefully received. Similarly,readers who would like to help with translat-ing the tutorial into other languages are also in-vited to make contact. All contributions toAIDA and/or the tutorial are fully acknowl-edged at the Website.

Stay informed

To be informed by e-mail as soon as newfree-to-use sections/lessons for the tutorial be-come available at the AIDA Website, visitorsare invited to register for the very low volumeAIDA e-mail announcement list; this can bedone at: www.2aida.org/register, or by send-ing a blank e-mail note to: subscribe@2aida.org

DISCUSSION

This Web-based tutorial endeavours to“teach a little bit about balancing insulin anddiet in diabetes” and modestly purports to “of-fer some information about different insulin-dosage adjustment regimens.” In fact, it al-ready accomplishes far more than this, andwith further development it has the potentialto achieve even more.

In working one’s way through the tutorial, itbecomes evident that one is learning about in-sulin action and blood glucose control in veryrealistic circumstances. The text itself is not dis-similar to other published descriptions of in-sulin action and insulin regimens; however,when it is combined with virtual patient simu-lations of blood glucose response to insulin andcarbohydrate intake, it makes much more sense.

The amount of information given in any onepage is well considered so that the tutorial is com-fortably paced; the content has been carefullysubdivided into manageable sections, whichhelps with the assimilation of what amounts toquite a lot of information. The interaction be-tween the static informational pages and the di-abetes simulator works well, and makes the tu-torial both interesting and enjoyable.

A good working knowledge of insulin actionand a thorough understanding of the interac-

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tions among injected insulin, dietary intake, andresulting blood glucose are essential for anyoneliving with, or treating a patient with, insulin-requiring diabetes. However, insulin dose is notthe “be all and end all” in diabetes manage-ment, and this comes across appropriately inthe tutorial; it is rightly pointed out that carbo-hydrate intake may equally be adjusted in somecases in order to correct inadequacies in bloodglucose control. It is also notably reassuring thatthe dangers of “chasing one’s tail” when cor-recting blood glucose levels are highlighted.

The principles underlying insulin treatmentare not easily learned in a single teaching ses-sion15; however, the application of the interac-tive simulator with this tutorial allows imme-diate experimentation and enables the user tolearn with a more “hands-on” approach.

CONCLUSION

The diabetes/insulin tutorial at the AIDAWebsite at: www.2aida.info is a stimulating andeffective Web-based learning resource with po-tential for further development. It introduces aunique interactive element to the learning expe-rience, which allows the user to explore the con-cepts underlying blood glucose management atan individual pace. This enterprising tutorialdemonstrates an intelligent way of applying theinteractive diabetes simulator in conjunctionwith textual information, and we recommend itto be investigated by anyone with an interest inpatient education resources for diabetes.

ACKNOWLEDGMENT

Special thanks go to Professor GustavoAvitabile (from Naples, Italy) for his kind helpin generating Tutorial HTML pages in a formsuitable for display on the web.

REFERENCES

1. Lehmann ED, Deutsch T: A physiological model ofglucose-insulin interaction in type 1 diabetes mellitus.J Biomed Eng 1992;14:235–242.

2. Lehmann ED, Deutsch T: AIDA2: A Mk. II automatedinsulin dosage advisor. J Biomed Eng 1993;15:201–211.

3. Lehmann ED: Development, evaluation, and usage of

‘AIDA’—an interactive educational diabetes simulator[Ph.D. Thesis]. London: University of London/Imper-ial College of Science, Technology and Medicine, 2004.

4. Lehmann ED: Experience with the Internet release ofAIDA v4—an interactive educational diabetes simu-lator. Diabetes Technol Ther 1999;1:41–54.

5. Lehmann ED: User reviews of AIDA online: a Web-based interactive educational diabetes simulator. Di-abetes Technol Ther 2000;2:329–342.

6. Lehmann ED, DeWolf DK, Novotny CA, Gotwals RRJr, Rohrbach RP, Blanchard SM: Dynamic interactiveeducational diabetes simulations using the WorldWide Web [abstract]. Diabetes Technol Ther 2001;3:A17–A20.

7. Reed K, Lehmann ED: Diabetes website review:www.2aida.org. Diabetes Technol Ther 2005;7:741–754.

8. Hurter P, Travis LB: Introductory Course for Insulin-Dependent Diabetics, 6th ed. Frankfurt: Gerhards, 1991.

9. Lehmann ED, Deutsch T: Compartmental models forglycaemic prediction and decision-support in clinicaldiabetes care: promise and reality. Comput MethodsPrograms Biomed 1998;56:193–204.

10. Lehmann ED, Hermanyi I, Deutsch T: Retrospectivevalidation of a physiological model of glucose-insulininteraction in type 1 diabetes mellitus. Med Eng Phys1994;16:193–202. [Published erratum in Med Eng Phys1994;16:351–352.]

11. Lehmann ED: Simulating glycosylated hemoglobin(HbA1c) levels in diabetes using an interactive edu-cational virtual diabetes patient simulator. DiabetesTechnol Ther 2001;3:517–524.

12. DAFNE Study Group: Training in flexible, intensiveinsulin management to enable dietary freedom inpeople with type 1 diabetes: dose adjustment for nor-mal eating (DAFNE) randomised controlled trial. BMJ2002;325:746–751.

13. Knowles J, Waller H, Eiser C, Heller S, Lewis M, PriceK: Paediatric DAFNE: development of a skills trainingcurriculum for 11–16 year olds with type 1 diabetes [ab-stract P316]. Diabet Med 2005;22(Suppl 2):104–115.

14. Lehmann ED: Development, Evaluation and Usage ofwww.2aida.org. An Interactive Educational DiabetesSimulator. London: AIDA Publications, (in press).

15. Lehmann ED: Computer-assisted diabetes educationand information technology in diabetes care. In: De-Fronzo R, Ferrannini E, Keen H, Zimmet P, eds. In-ternational Textbook of Diabetes Mellitus, 3rd ed.Chichester, UK: Wiley, 2004:1639–1665.

Address reprint requests to:Dr. Eldon D. Lehmann

c/o www.2aida.org Diabetes SimulatorDevelopment Team

P.O. Box 46104London, EC2Y 8WN, UK

E-mail: www@2aida.orgWeb: www.2aida.org/lehmann

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