Apple Monitoring Blood Glucose
mondaynote.com
mondaynote.com
The "CGM" (continuous glucose monitor) has really come into it's own over the last 10 or so years, and I would encourage all diabetics (but especially type 1) to use one. Currently the only 2 real options on the market are:
- http://www.dexcom.com/ - Connects directly to your phone using bluetooth and will send glucose warnings etc as notifications.
- https://www.medtronicdiabetes.com/products/enlite-sensor - Designed to work with Medtronic (who is a market leader) insulin pumps.
Both these options are expensive (even with insurance for many), invasive, and not really tailored towards "casual" glucose monitoring. I think if Apple enters the space with a non-invasive tool it'll be a huge boon for causal glucose monitoring. I also think it could be a more accessible option for people who are interested using a CGM to treat their diabetes but can't/won't use one of the existing options due to cost or inconvenience.
This seems like a win win and I'm excited to see where it goes.
The G4 transmitter has a 2.4 GHz radio and I built an extra device with Wixel and Bluetooth to transfer the data so my Android phone so xDrip+ and my Android watch can display the glucose values real time. It works so great that my A1c levels been going down from over 7% to 5-6%.
If you are in Europe and have a Type 1 Diabetes, you should ask your doctor about your options.
Medtronic just came out with their first closed loop system (https://www.medtronicdiabetes.com/products/minimed-670g-insu...), but OpenAPS has been around for years, and not sure how Medtronic will go about getting the 670 approved in Germany.
670g is a closed loop system, but what it does is it stops giving you the basal insulin when it thinks you are getting a hypoglycemia soon. What it doesn't do is to give you correct amount of insulin automatically when you've been eating carbs or doing exercise to keep your glucose level in the 5.5 mmol/l target. And with the new Fiasp insulin automatic adjustments would be possible.
To be able to build the OpenAPS, you must have an older Medtronic pump which are not covered by German insurance anymore. My Animas doesn't allow to tweak the insulins remotely.
https://en.wikipedia.org/wiki/Diabetic_coma
You definitely don't want anything buggy with medical devices.
1. There is a max rate that it can pump
2. There are alarms that go off if the numbers are above or below your settings (I believe there are also max and mins for those so you can't accidentally set it to a 'fatal' number)
3. The systems seemed 'independent.' The reader did not take for granted that the pump was pumping, but rather continually monitored glucose levels and would still set off an alarm if the numbers weren't within the bounds.
edit: The starter pack costs £159.95, see https://www.freestylelibre.co.uk/libre/products/starter-pack...
I'm having trouble with not feeling hypoglycemias and I'm having them quite often at night. Freestyle Libre by default doesn't automatically measure your glucose levels, but there is a hack with Sony Smartwatch 3, a strap and very custom and hacky android version which enables the NFC reader in Sony and you can get alarms to your phone on low glucose levels. It worked and saved me a couple of nights, but the Libre chips break easily and the system was kind of a drag to use in the end.
In England there are some weirdness with treatment for people with diabetes.
If you use insulin of medication to manage your diabetes you're entitled to free prescriptions. This is free from the time you're diagnosed to your death, and for all medications not just insulin. (But not free dental or optician care)
Prescriptions are low cost in England. Currently they cost:
http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Prescriptionc...
>> The current prescription charge is £8.60 per item (£17.20 per pair of elastic hosiery). A three monthly PPC is £29.10 and will save you money if you need more than three prescribed items in three months. A 12-month certificate is £104.00 and will save you money if you need more than 12 prescribed items in a year.
(I think this is right, but it might have changed) I feel that it's an injustice that glucose monitors and test strips and these new devices are not covered by this medical exemption certificate, and that people with diabetes need to pay for them, even if they don't have to pay the 20% VAT.
England has an independent organisation called NICE that decides on best current practice treatment (with an eye to cost effectiveness). Clinical Commissioning Groups (the local organisations that commission NHS services) need to pay regard to NICE guidance. Here's their standard for type one diabetes: https://www.nice.org.uk/guidance/ng17
Here's their list for blood glucose management: https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendati...
She's been using the FreeStyle Libre (https://www.freestylelibre.co.uk/libre/), which uses NFC and on select markets has an Android app available, but here we still have to use the handheld reader.
https://github.com/NightscoutFoundation/xDrip
Pull requests are welcome too :)
There's an official android app for libre too, i'm not sure if it's available everywhere though.
With xDrip you can input values measured from blood and the software will try to estimate as accurate values as possible, meaning that in the best case you can be quite sure about the reading, but always better to check from blood.
Remember, that calibration should happen only when the levels are steady and you should calibrate from the whole range to trust the readings. Anyways at least 2-3 measurements per day from blood is suggested, even with the more expensive CGM's.
If you want to hack, it is possible to turn the Libre to have automatic alerts. I did it, it's not perfect, but if you have nightly hypos which you don't notice, this can be helpful:
https://github.com/pimpimmi/LibreAlarm/wiki
http://www.freestylesticker.com/product/freestyle-libre-cgm-...
If you're in Europe, I have one modded Sony Smartwatch 3 which I can sell :)
Wow, do you know why this is? The Dexcom G4 is already 5 years old and is absolutely a life-saving system.
The insurance companies are conservative and see the systems as very expensive investments and the technology is something scary in a country which is still very suspicious about Internet and computers in general.
The glucose levels are extracted by a non-invasive technique which transmits low-power radio waves through a section of the human body, such as the area between the thumb and forefinger or the earlobe. These areas have adequate blood supply and are thin enough for waves to pass through the tissue. These signals are then received by a sensor on the opposite side of the GlucoWise device, where the data about the characteristics of the blood within the flesh are collected and analysed.
The other non-invasive technique that has received a lot of press is, of course, Google/Novartis' contact lens. That device measures blood sugar from tears.
Most other blood sugar measurement systems require either blood draws from a pin prick or a sensor attached to your body that measures sugar content in the subcutaneous fluid as a proxy for blood sugar.
I read that this focus is particularly driven by Tim Cook's fascination with the space. It sort of confirms my idea of him as not a very image conscious CEO, especially in contrast with Jobs who was a legend at imbuing Apple with coolness and desirability.
If the idea is to cater to the shifting age if it's fanboys it may be a great play. The young generation moves from obsession with Emojis and Instagram to having diabetes and heart disease pretty quick. Why not cater to the shift when you already have the customer. 3M isn't making glucose testing sexy like only Apple can.
I agree if it's poorly implemented or marketed it won't be adopted, but Apple probably has a shot at getting it right.
There is also the segment that just wants to lose weight, and that can apply at all ages. A continuous glucose monitor is also a great way to monitor keto diets or similar. Keep yourself under a certain glucose level continuously and your body will be forced to use fat sources!
Google, Apple and Samsung have been vie for these feature in 2014.
It is not uncommon to focus on health space when the technology is mature, we can't live and worry about our health.
What is the point if you have the greatest smartphone watch and still lead unhealthy lifestyle?
Hostpitals has been participating in health research because they want to make these accessible for you 24 hours.
If Apple doesn't make decent laptops and desktops then who else can?
This is what bothers be about Tim Cooks priorities in health and celebrities next to his apathy towards computers. (I don't consider the iPad a computer I consider it a device)
“When we were an agrarian nation, all cars were trucks, because that’s what you needed on the farm,” Jobs said at [the] D8 conference in 2010. “But as vehicles started to be used in the urban centers, cars got more popular. Innovations like automatic transmission and power steering and things that you didn’t care about in a truck as much started to become paramount in cars. … PCs are going to be like trucks. They’re still going to be around, they’re still going to have a lot of value, but they’re going to be used by one out of X people.”
Maybe it's time for a new "truck" company that focuses on the needs of the few and Apple can ditch computers and focus on the needs of the many.
And personally, I don't think it's all that weird. I think it fits perfectly with branding, but maybe I'm less aware of it.
On the contrary, going into health will reinforce the brand, not dilute it. Apple has always been an aspirational lifestyle brand. Given the growing scope of computing in our lives - work, social, leisure, health - the lifestyle that Apple sells is only going to get more complete and compelling.
There's also a growing trend of QS and tracking health data points, and increasingly not just among geeks. You can see it in the nutrition space as well, where people are optimizing food, getting bloodwork, etc. These fields are ascendant and glucose tracking matters there too.
1. Regulation: it is very hard to innovate at the pace of the consumer-electronics industry while satisfying FDA regulations.
2. For general purpose applications, signals and measurements are highly noisy and sensors are still deeply in the academic realm, working only in very special use-cases, as opposed to 'in the wild'. It is a different matter for special applications such as Type-I diabetes or other diseases because devices are critically important and patients are willing to tolerate discomfort (of wearing probes, pumps, etc.)
3. In general, predictive power of algorithms tends to be lower for non-genomic health care applications because of variability across individuals, errors in installing devices, rarity of certain types of data for training and validation, etc.
4. Some of the key benefits are hard to grasp for users because of the slow time scales over which things like weight loss occur, and also due to the multi-factorial/multi-component nature of human well-being.
GlucoTrack uses ultrasonic, electromagnetic and thermal technologies to non-invasively measure glucose levels in the blood. GlucoTrack is intended for use by Type 2 and pre-diabetics.
GlucoTrack combines the following technologies:
Ultrasound (speed of sound change within the tissue);
Electromagnetic (conductivity of the tissue);
Thermal (heat capacity of the tissue).
It's not approved by the FDA, but it appears to be selling in Australia, New Zealand, Spain, China, Korea, Italy and some others.
Either the article is very wrong, or Apple is doing something very cute here.
Type 2 diabetics do check their blood glucose -- occasionally. For non-insulin-using diabetics (aka. most type 2s) medical plans typically cover less than one test per day, because the evidence is that testing more frequently doesn't accomplish anything. (Blood glucose testing in T2D basically answers the question "is the treatment working, or do I need to talk to my endocrinologist", while blood glucose testing in T1D is essential for answering the question "how much insulin should I inject right now".)
So the idea of a continuous glucose monitoring system for type 2 diabetics is pretty much nonsense from a medical perspective; sure, they'll get pretty graphs, but those graphs won't provide any medically actionable information. So my first instinct was to think that the article was very wrong.
But maybe Apple is being very cute. The reason we don't have any non-invasive blood glucose tests is that nobody has managed to make them accurate enough to meet FDA requirements for tests to be used for diagnostic and treatment purposes. But if Apple markets this as being for type 2 diabetics... well, they can perfectly reasonably put a sticker on the box saying "for entertainment purposes only", since that's the only thing type 2 diabetics would be using a continuous glucose monitor for anyway! FDA requirements circumvented -- and once Apple gets a large installed used base, they get a huge pile of data which they can use to help them develop a later version which is accurate enough.
It makes total sense to start where they are starting; they'll get teams of data in a very short space of time (from diabetics and non-diabetics alike) and be able to iterate quite quickly from there.
As a non-diabetic, I want this so much. The impact of sugar and insulin on health is finally getting the attention it needs and I think this could be the innovation that makes health trackers actually useful.
totally anecdotal but I test aprox 10 times per day and have reduced an A1C of 8.2 at diagnosis to 5.5 (non diabetic). I'm extremely sceptical that you can optimise your plan sufficiently with a test once per day, it's a akin to having a speedometer on your car that only gives you a speed once during the entire journey.
Some examples: In the morning I go for a cycle, I use the levels to decide what distance to do and also during the ride to ensure I don't hypo (I'll eat some fruit if my levels are getting too close to 70). After lunch I go for a walk, depending on how my level is looking it will either be 3km or 5km. In the evening I generally check my level about 10pm, if it's looking too high then I'll add an additional walk in.
There are many other details where I use my levels to adjust my behaviour, at this point it's all automatic but I couldn't do it without knowing what my level is at any point in time (needless to say I'll be queuing outside the Apple store if they do actually release an Apple Watch with a glucose monitor).
High glucose doesn't have many symptoms unless it is ridiculously high. If you have blurred vision, hot flashes etc, then it's really really high. But there are things you can do before it gets that high. And knowing you are trending in that direction is useful. Going for a long walk can help. Going for an hour or two bike ride can lower your sugar below normal.
On the other extreme, if you just changed your medicine regimen (higher dose or doctor put you on new kind of medicine that works better for you), you are at risk of lowering your glucose too much. Esp. dangerous for medicine taken before going to bed. Recognizing low glucose is much easier (shaking, dizziness) but not when you are sleeping. Being alerted if you are trending below normal and keeping some candy next to you is always wise.
Continuous monitoring helps in all these scenarios.
My T2 father's plan covers 4 a day. He has a pretty lousy insurance plan, too. He hates having to prick his finger four times a day, so he often skips. He also hates all things Apple, but he still asked me what I knew about it.
If the next iPhone allows him to stop pricking his fingers four times a day, he'll buy one the day its released. I doubt he'd be the only one.
As an aside to the article Type II is caused by diverse reasons; not just weight. Weight is deffinately a factor; but there are other genetic and physiological factors that contribute to how well your body uses/produces insulin. The article doesn't help mitigate this by referring to Type II as a "Lifestyle" i.e. Shaming disease.
Diabetics have a enough to deal with then to be rudely told it's their fault and they simply have to 'exercise'. A little compassion goes a long way.
So to answer your question: Probably because if a Type 1 Diabetic uses a non-invasive glucose monitor to determine their insulin dosage, much of the time they will overdose, and possibly fall into a coma or die.
Fact of the matter is that the human body is, chemically and pathologically speaking, fucking bulletproof. Our bodies are just super freaking good at maintaining homeostasis. This means that a lot of tests like blood-glucose, cancer diagnosis, etc that are trying for non-invasive blood testing just have a HUGE parameter space to contend with. Apple's idea may work with calm light-skinned office workers, but will it work with sweating dark-skinned day laborers? African Americans are the population most at risk for DM-II. How about if your blood pressure goes all wonky? What about someone going through a growth spurt? Does it work when you put your arm in motor oil? What about people without arms? Lives aren't 'edge cases'; your device MUST cover all those real people with families and children. I'll believe their device when it passes FDA approval and the clinical data is out there for us all to see and argue over.
Are you talking from a regulatory standpoint? Why couldn't Apple (or anybody) make a device that works on a limited range of skin colors? If you can't help everybody, does that mean you shouldn't help anybody?
Also, I think you underestimate the market size of light skinned office workers with significant disposable income that don't need blood glucose monitoring but want it anyway. I'm one of them.
I wouldn't be surprised if Apple launched multiple devices. The $500-$600 watch would give blood glucose trends or some other derivative information. The $2000-$3000 watch would be the one that gives a medically useful measurement. They could iterate quickly on one and work through the ponderous regulation with the other. Maybe they would even license the technology to Medtronics or some other medical device company and let somebody else deal with the headaches.
Like, yeah, maybe it works in a very limited set of situations, but that's the same as a broken clock that only tells the right time twice a day; you'd never know when the monitoring device is working 'correctly'. It would be a random number generator, effectively, if it was not proofed.
Besides, if you aren't a diabetic, why would you care? The human body is highly variable, from person to person, and even inside of a person after meals. All it would do, if it were accurate 'enough', is say some number that you can't control. Like, you aren't gonna take any insulin shots to mess with it, that would likely kill a normal person. I can't see any actual use for a healthy person. Trying to 'game' that (assumed reliable) number would just put you into a coma; we're supposed to have spikes in the concentration, that's how vertebrates work. Playing 'what-if' games with number would be like Russian Roulette, each experiment may kill you.
https://en.wikipedia.org/wiki/Blood_sugar
http://www.webmd.com/diabetes/daily-control-17/slideshow-blo...
http://www.everydayhealth.com/type-2-diabetes/symptoms/surpr...
Also, I'm not saying that people with dark skin are idiots. I'm saying that the 'optics' of Apple releasing that thing aren't 'good' as a large percentage of their 'customers' that have DM-II are dark-skinned, though not all by any means.
Same goes for blood glucose monitoring. I'd like to see if I can find correlations between my mood, productivity, sleep, fasting, etc... and my blood glucose levels. Like step tracking, the absolute number doesn't matter.
Cook has already said that blood glucose measuring would be useful for people before they have diabetes. That's what makes me think it isn't necessarily a medical device they are building. At least not for version 1.
The last article is one of the things that would be super interesting for me to see. How do blood glucose levels change when I drink a diet soda vs water, for example.
Also, giving people even psuedo-medical diagnoses is just irresponsible; either it works or it does not. You can't tolerate psuedo-random number generators with health in any way. This is why 23andMe has to licence their genetic counselors on what the results mean, as the data can be very easily misunderstood by even very well educated people.
Harvard just released a study on the fitbit, even the best of them were far off on something as simple as calorie counting: https://med.stanford.edu/news/all-news/2017/05/fitness-track...
And if I'm to be almost offensively practical, this is a huge business opportunity. We're all hypochondriacs to some degree, and it's a market that's currently being served by some pretty dodgy outfits, offering magic bullet solutions. And the incumbents are making a ton of money. It's probably not a good idea to give people tools to self diagnose themselves on a daily basis. But it's inevitable, and a logical path for the consumer electronics industry to follow.
My startup enigma.bio is working on low power laser spectroscopy blood analysis techniques inside the tympanic canal for the last 3 years. Seeing interest in the field from large players is exciting.
For example, I am interested in calorie tracking, but the various apps out there mostly seem to cover franchise food. They can't accurately say anything about the sandwich I made in my kitchen.
Don't Theranos us Apple.
I do know I would buy them for my parents immediately once they are shown to work. Would not even pause. Blood sugar is spooky and you are toast if it goes low and no one is around to help
anecdotal section : My mother has been taking insulin since the 80s, she uses a pump currently. The real danger in blood sugar is when levels get low. She has caught her self in the low 40s but if it had happened at night she would be in real trouble. You just simply go to sleep and never wake from it. High numbers while dangerous are sustainable and your conscious throughout.
She has had a few episodes where it went out of control (600+) that took a hospital visit days to get under control with a drip. Same routine, you go in and tell them your level. They don't believe you. They test three times then freak out. You are in heart ward and even then they cannot get it back and turn from blaming your diet to going "We don't know". The point is, even highly regulated/monitored things happen and doctors don't know all the whys.
Disclaimer: I work for Verily, but I know nothing about these projects.
[1] I could point to numerous examples of this (removing APIs used to track individual iOS devices, fighting the government on proposed encryption backdoors, etc), but I think the onus is on you to rather provide evidence to suggest this is something they would do :)
What possible reason could you have to assume that they would sell health data, for which all of the same reasoning applies as well as it being more heavily regulated by the government?
BREAKING NEWS FROM THE FUTURE (Reuters):
Hundreds of thousands Apple users die within hours after IoT glucose measurement + insulin pump device overdoses insulin during WannaDie cyberattack. Apple urges all surviving users to update the system immediately. Surviving users and family members of deceased will get 10 year full Apple subscription and special $20,000 memorial gift card after signing settlement agreement online. update: WaPo reports that CIA has been aware of the vulnerability for 5 years.
Pacemakers and Implantable Cardiac Defibrillators: Software Radio Attacks and Zero-Power Defenses https://spqr.eecs.umich.edu/papers/icd-study.pdf
>Our study analyzes the security and privacy properties of an implantable cardioverter defibrillator (ICD). Introduced to the U.S. market in 2003, this model of ICD includes pacemaker technology and is designed to communicate wirelessly with a nearby external programmer in the 175 kHz frequency range. After partially reverse-engineering the ICD's communications protocol with an oscilloscope and a software radio, we implemented several software radio-based attacks that could compromise patient safety and patient privacy....
However, this also opens up to new dangers, e.g. the easy access to cheap SDR units allows one to try to do serious mischief by jamming / hacking / reprogramming those IoT style units. This should not kill the tech, just something for the users to be aware of.
If anything, here's where the "walled garden", signed and sandboxed, etc nature of App Store makes much sense...
If apple makes an Apple Watch 3 with an optional blood glucose monitoring band, I'd switch back though!
Why not spending the probably huge amount of money in a cure instead of monitoring devices ?
Well, because why kill the Golden Egg Goose ? Millions of people who have to take pills every day are good recurent money. If you cure them, no more cash.
(Well it's the middle of the night, I can't sleep and fill a little bit bitter...)
One more thing. I'm a bit scared with all the private companies collecting personal medical datas. But maybe I've read too much science fiction.
Any app that reads/writes HealthKit data is required to provide a privacy policy before it passes App Store approval.
Additionally, apps can only access that data after a full-screen permissions screen is displayed, and the user manually toggles on the categories of Health data that the app can access.
In my experience, the bar for getting apps that use HealthKit is at least slightly higher than for non-HealthKit apps.
From a non-monetary standpoint, dehumanizing companies is always a bit frustrating. They consist of people, like you and me. Most people aren't sociopaths and the idea that business leaders are entirely sociopathic is worth challenging. I don't think most people would want to withhold a cure for recurring revenue. Charge for it, yes, but not withhold it.
For that to be true the cure would have to be more expensive than management by at least an order of magnitude - assuming monthly refills for management and an annual reporting cycle - but still not so expensive that it became unaffordable.
If it's true, though, it's worth knowing.
As in the other post below, I don't believe magic bullet cures are possible for most diseases.
Following that economic logic further, it's much cheaper and easier to produce a not-very-effective but marketable palliative than it is to aim for a Nobel-winning medical moonshot.
I don't know of any suppressed super-cures, but evidence confirming the limited effectiveness of (e.g.) SSRIs is easy to find and hard to argue with.
Similarly questionable outcomes have been noted in other fields. E.g. novel anticoagulants:
It's economically understandable but humanly sad.
This is pretty shortsighted. Because:
- it's not like you would cure everyone at once anyway
- there are always people who will develop the disease eventually so you can always make money in the long run
- if you are the only effective treatment you can pretty much make the price you want, and collect massive profits that can be invested in the develop of other drugs or solutions.
Never heard of vaccine companies going bankrupt, for example.
But vaccines are an exception in medicine. Serious conditions rarely have magic bullet cures.
E.g. "cancer" isn't one condition, it's a set of loosely related problems. It's very unlikely indeed there will ever be "a cure for cancer", but not at all unlikely that specific cancers will become much more treatable.
That doesn't stop companies promising to develop magic bullet cures - or magic bullet anything - and getting huge interest from investors. (See also Theranos, etc.)
That's also because state put caps as to how much vaccines are supposed to cost, which makes them less profitable than they should be. However if you were to consider the cost of a one-time vaccine versus treating some illness for the rest of your life, it's expected consumers would go for the vaccine unless it's prohibitively expensive.