Digital Health And The Promise Of ‘Game-changing’ Innovation

Digital Health And The Recurrent Promise Of ‘Game-changing’ Innovation.

…..and the prize for the most over-used word in digital health/health-tech this week goes to:

iiiinnnn 3rd place:?Revolutionise!

iiiiiiinnn 2nd place: Empower!

And iiiiinnnn 1st place: lets give it up for…. ‘game-changing’!

Honestly, if I hear (or read) the word ‘game-changing’ one more time to refer, to something that hasn’t even made it to market yet, I think I’m going to cut my hand off at just above my apple watch. But don’t worry everyone, the watch will send bleeps and phone calls to people and in no time at all, my hand will be re-attached.

In today’s newsletter, I am going to cover something which has been plastered over my feed – the new function that is likely to be applied to a future 苹果 watch, that allows real-time non-invasive glucose monitoring. Sounds terrific, doesn’t it? GAME CHANGING even?!

Join me in delving slightly deeper into how it may or may not be useful on the frontline of health and also whether it addresses some of the broader issues not fully resolved with wearables.

The Good (i.e. where I think it can work).

Type 1 Diabetics

Folks with type 1 diabetes have to be obsessed with their blood glucose levels, as not being so can potentially be fatal to them. Due to a complete failure of the pancreas, they need exogenous insulin to regulate their bodies blood sugars. It’s an obvious, HUGE win for this cohort to have instant, real time blood sugar levels without constantly pricking their fingertips. It can help them adjust insulin doses and also alert to more serious illness, such as diabetic ketoacidosis (a very severe and sometimes fatal illness) and severe infection such as sepsis (diabetics are more prone to this).

Both these conditions can present in type 1 diabetics with high glucose levels and feeling generally unwell.

So yeah, for all you ‘game-changers’ out there, I actually agree with you. For type 1 diabetics this has the potential to revolutionise their care AND empower them (see how I got all 3 buzz words in this paragraph?).

The worried well:

Anaemic looking, ultra-healthy diet people, who feel self-monitoring will bring them closer to the elixir of eternal life. They monitor their steps, ensure all their rings are closed and then some, yoga at 3 am and run 10k for breakfast, only eat paleo and keto, when not intermittent fasting, and are fully aware of their macro and micro nutrient mix. This obsessed cohort of millennials (and co), who are middle to high earners and have a high disposable income (i.e. Apples usual target), will buy it and make Apple money in the process.

They will buy it as an addendum to their current health regimen, or because it looks cool or both. Apps like Noom may soon start to change their features to add in ‘ideal’ meals to eat around certain blood sugars/targets etc.

This highly motivated group of early adopters (with money and many other apple products most-likely) will help Apple shares rise even further and they will enjoy this new innovation and test it thoroughly. They are the 'worried-well'. Perfectly healthy people, who take their health seriously, even though the actual health longevity gains for them may not be as stark as other cohorts of people.

By the way, I have no problem with people who look after their health, taking it seriously and taking a ‘bull by the horns’ approach. Kudos (a word I learnt on LinkedIn) to them!

Remote Monitoring

Yeah, the obvious one. Apple watches and other wearable can help with this (yawn). You have seen a million articles on this already. How it fits into work flows and works in reality is usually skipped over (conveniently) in these articles, over the knee-jerk thought of being able to see real time data remotely from a sick person and its obvious ramifications.

It could help in remote monitoring, but as real clinical pathways to manage incoming data are not widely in place yet, I can't see this happening any time soon except for the very sickest people or a narrow subset of people. If it was done on a wider population scale, then we would really need to rethink how medicine was done, including the (controversial) prospect of treating patients as numbers rather than individuals.

The Bad (i.e where people think it may work, but I dont).

Type 2 Diabetes:

The problem is Type 2 diabetics all the way from diet controlled, to those on tablets to those on insulin and even pre-diabetics, (often) have many things in common. Many complex things. These make glucose monitoring in real-time, not really that useful except for a minority. The question then is, whether that minority will take the product up or not. Let me elaborate.

In terms of prevention of Type 2 diabetes, your risk of type 2 diabetes increases if you are: overweight, from a lower socio-economic background, had parents who had the same. The main trigger, alongside some genetic risk and the above, is a diet high in sugar. The only part in the combination of the above pre-disposing factors where blood glucose monitoring may be helpful is in the diet part.

Let's take the above generalised factors and convert it into a patient – how likely is a poor, (probably) poorer educated, overweight, SE Asian man/black man, who’s parents and grandparents were all diabetic, going to give up his high carb diet because the watch he (likely) cannot afford is telling him his blood sugar is too high? You get my point.

Prevention and treatment of type 2 diabetes is multi-factorial and complex. A watch telling this complex cohort to stop them enjoying some extra cake, at the expense of their HBA1C may not be that successful (in my opinion atleast). Type 2 diabetics usually follow a long path of decline and despite medication, many still end up on Insulin as the other modifiable factors involved including socio-economic factors and diet are still sticking points.

Only when real-time glucose monitoring is incorporated as part of a complex (here is where precision medicine comes in) and individualised treatment pathway involving addressing other factors, will it really make a difference. I don't see these issues being addressed in a meaningful way anytime soon.

However, type 2 diabetics who are on insulin may benefit from tighter control of their blood sugars and an apple watch with this functionality may help. It will also save them pricking their fingers like in type 1 diabetes. The question is, will this minority of (usually) older diabetics, have the motivation or reason to spend big bucks on a new gizmo? Their lives dont depend on good control in the same way as type 1's and with engrained factors working against them, will their be appetite for it? Personally, I don't think so -not yet anyway.

App function fatigue:

Once upon a time it was wow – a digital display.

Then it was – wow – a digital display that tells you your footsteps.

Then – wow – now it tells you your heart rate.

Then – wow – the ring closing on activities allows me to track my exercise

Then – wow – now it tells you if you have an irregular heartbeat.

Now – wow – blood pressure AND blood glucose?! Will it cook for me next?

While the novelty is great, my concern is of app/functionality fatigue. A little bit like poster blindness, where all the safety posters in the office are ignored and become part of the background.

Core users (like fitness enthusiasts or Type 1 diabetics) aside, how many people will really (want to) constantly check their blood sugar and make adaptations there-in to lower it? Without guidance on how to use the functionality and for what end-purpose, it may be a redundant and possibly annoying add-on for many (imagine the beeps every time you enjoy a cookie or something). No one wants their watch preaching to them about their diet (do they!?).

Will it become another '10,000 steps' style app. The ones who want it will embrace it, the ones who don't, won't.

The Ugly:

Apple accumulates a massive amount of data. Massive. You can (optionally of course) add your height, weight, gender, blood type, menstrual cycle details, steps, medication, where you run and how long, sleep. Add to that glucose, oxygen levels and blood pressure and they literally know more about you in an instant than your own clinician.

Why is this bad?

It depends how the data is used and what is done with it and who is ultimately responsible for it. There are ALOT of questions that need answering. I list some of these below with some general points too, and I am sure there are many more. Some of these I have made before too.

·????????Who will interpret the data? Currently Apple leaves it to the wearer to act on the information. How will a lay person know what is a ‘good’ blood sugar and what is not? Will this lead to more 'worried well' knocking on the doors of doctors as soon as their blood sugar is a little high?

·????????Could the watch end up encouraging extreme dieting/behaviours around blood sugar control? It is certainly likely to open up new markets and (probably) fads around extreme blood sugar control etc.

·????????Could AI harvest your data without you knowing it and use it to make assumptions about peoples’ health (under the excuse it is anonymised)? Could this be ethnically stratified and lead to it affecting people’s insurance policies or the way they are treated based on theoretical risk based off amalgamated data?

·????????The opposite is also true I suppose. I can see good value in using the data for research – will there be an opt-in/opt out policy for this? Will the research reflect demographics that cant afford an apple watch?

·????????If clinicians are expected to act on the data, how will this fit into clinician workflows? Clinicians cannot realistically real-time monitor all in-coming data. Apple will likely create ‘normal’ parameters vs ‘out of range’ parameters for sugar readings. The problem is, sugar levels and whether they are more tightly controlled or not, is done on a patient by patient basis.

·????????Example: A type 2 patient with a baseline HBA1C of 10, sees his apple watch pinging telling him his sugar is too high and starts to drastically lower his intake to get it into the ‘right range’. The problem is he does it too quickly and essentially has what is hypoglycaemia due to his average baseline readings being high, though in a ‘normal’ population this would not be the case. Who will take responsibility for adverse outcomes as a result?

·????????If it is packaged as a medical device in the UK, the MHRA approval process etc and insurance for errors/clinical risk as a result, depending on where it fits, may render the product price astronomical?

There are many more questions out-standing that apply to many types of wearables to be honest. Just having the data isn't good enough for the patient. It's what is done with it that counts. Who will take responsibility to guide people with this and it's associated risks? Apple? The Doctor? Random health gurus? Private apps? It can become overwhelming for people if Apple don't lead on data interpretation, as the natural urge is to turn to Dr Google or Dr ChatGPT for advice - and we all know the dangers of that.

For me the Jury is out on this new function. It has obvious benefits to certain cohorts of patients, but not as much as people would like (in my opinion), for other cohorts. Game-changing? I'll wait till its released, try it, and then decide.

Rant over. What do you think? Is game-changer used too easily without true thought about the consequences and nuances? Can you see any other risks to this new glucose monitoring watches (and other stuff monitoring wearables)?

I'm always interested in hearing your thoughts, agreements and disagreements!

Junaid.

I advise on digital health solutions. Please dont be shy to follow, connect or message. Happy to set up a chat with like-minded people or companies that would like advisory input on their digital health/tech product offerings.

#digitalhealth #healthtech