
Apple Monitoring Blood Glucose - zdw
https://mondaynote.com/apple-monitoring-blood-glucose-9e6f7bb0b467
======
templaedhel
As a type 1 diabetic I'm super excited to see apple working in this space,
even if they're focusing it on type 2 to start (a logical move, considering
there is something like 30x more type 2 diabetics in the US). I think making
it easier to track glucose levels in real time is the number one thing that
can be done to improve quality of life for _both_ types of diabetics.

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/](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](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.

~~~
acoster
My partner is type 1 diabetic, and CGMs were a game changer for her (they
started rolling out in Switzerland last year).

She's been using the FreeStyle Libre
([https://www.freestylelibre.co.uk/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.

~~~
ng12
> they started rolling out in Switzerland last year

Wow, do you know why this is? The Dexcom G4 is already 5 years old and is
absolutely a life-saving system.

~~~
pimeys
That's because there are so few of us Type 1 diabetics and not enough
political pressure to get the new stuff faster. There are some activist
doctors and nurses that help in Germany, but we also got the G4 for free only
on last November.

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.

------
umeshunni
One of the linked articles has some more technical details on how non-invasive
blood sugar measurement works (for the GlucoWise device currently in
development):

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.

------
aedron
Apple's recent obsession with health monitoring is weird from a branding
standpoint. Losing appeal with young people is the nightmare of any technology
company, becoming known as that gadget for geriatrics is another level of
dejection.

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.

~~~
cs2818
I don't have any data on hand to back this up, but I don't think younger
people are necessarily averse to monitoring their own health. I think personal
health monitoring devices fit well with the devices the younger generation
already uses to help maintain their identity and concept of self.

I agree if it's poorly implemented or marketed it won't be adopted, but Apple
probably has a shot at getting it right.

~~~
dominotw
I agree. I've only seen middle aged office workers wear stuff like Fitbit,
posture correction, sleep tracking type of things. Young people don't have to
worry about 'sitting is new smoking' .

~~~
mahyarm
There is a nerdy segment that loves tracking all of this health data forever
and ever.

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!

------
highd
Research labs have been trying this for years with every spectroscopy known to
man - the signal is just too weak. I don't see any reason to think Apple has
figured something out that labs of optics experts can't do on the benchtop.

~~~
harigov
I think machine learning coupled with increase in sensitivity of the signals
could make a difference.

~~~
sillysaurus3
Why would machine learning be able to overcome a lack of statistical power?

~~~
harigov
Did you miss the part about sensitive sensors? A single sensor may not be
enough to classify accurately but multiple sensors measuring different things
can sometimes work. Such sensor fusion has worked incredibly well for IMU's
and also in self-driving cars.

~~~
lj3
That's how the Glucotrack claims to work. From their site:

 _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.

------
cperciva
_Apple appears to be working on blood glucose monitoring as a way to address
Type 2 Diabetes._

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.

~~~
ollysb
> testing more frequently doesn't accomplish anything

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.

~~~
cperciva
Are you T1 or T2? I was specifically talking about T2s; testing multiple times
a day can be useful to get a sense of daily patterns, but those patterns will
tend to persist from one month to the next so there's no need to test many
times a day every day.

~~~
ollysb
I'm T2. I use the levels to make small adjustments throughout the day.

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).

------
david_brush
As a type II diabetic I would love it if Apple got in the continuous
monitoring field; namely because it will help the field as a whole get better.
It is largely dominated by one company with an invasive method.

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.

------
korethr
This article talks about type 2 diabetes, but I'm wondering why a non-invasive
continuous blood glucose monitor would not be just as useful and desirable for
type 1s as well. A friend of mine has type 1, and more than once, she's
expressed hopeful anticipation for a future combined non-invasive blood
glucose monitor and insulin pump -- effectively an external artificial
pancreas to take over the functionality of her broken natural one.

~~~
charlesism
It would be very desirable, but all of the many companies who have tried to
get accurate results non-invasively have failed. With Apple's resources,
perhaps they'll lick the problem, but I wouldn't bet on it.

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.

~~~
Balgair
A co-worker of mine is doing a similar kinda thing but with circulating tumor
cells, so I have some 3rd hand knowledge of these kinda tests.

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.

~~~
criddell
> your device MUST cover all those real people with families and children

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?

~~~
Balgair
Regardless of the soundness of the logic of your reply, the way that idea
would be seen by darker-skinned communities (especially like the African-
american community in the US that is highly affected by DM-II) would be
something like "Apple made a racist product and wants black people to die".
Additionally, if the device only works on non-sweating, not moving, healthy,
white/asian office workers out of bright sunlight who have not recently eaten
nor have gone more than 5 hours without eating, it's not really something that
helps anyone who would need it.

~~~
criddell
People with darker skin aren't idiots. Current products like Fitbit trackers
already work poorly on dark skinned people, so it's not anything new. I don't
think that community is going to call Apple (or, more generally, physics)
racist.

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.

~~~
Balgair
Wait, why would you want blood-glucose monitoring that is not medically proven
to work or be reliable?

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](https://en.wikipedia.org/wiki/Blood_sugar)

[http://www.webmd.com/diabetes/daily-control-17/slideshow-
blo...](http://www.webmd.com/diabetes/daily-control-17/slideshow-blood-sugar-
swings)

[http://www.everydayhealth.com/type-2-diabetes/symptoms/surpr...](http://www.everydayhealth.com/type-2-diabetes/symptoms/surprising-
causes-of-blood-sugar-swings/#02)

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.

~~~
criddell
Perfect is the enemy of good. My Fitbit counts steps, but it isn't all that
accurate from an absolute standpoint. Still, I find the day-to-day variances
interesting.

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.

~~~
Balgair
The problem is that the number you are getting is useless, there is _no_
relative measure. Yes, maybe for you and for your particular fitbit recently,
you may believe hat it 'works'. But you are very likely an outlier, there is
no reason to believe some device like the glucose one will work for you or
just about anyone else. The tech is essentially vaporware.

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...](https://med.stanford.edu/news/all-news/2017/05/fitness-trackers-
accurately-measure-heart-rate-but-not-calories-burned.html)

------
tomelders
I really can see an ever increasing shelf in Apple stores that stocks medical
monitoring devices, compatible with the Apple Watch and iPhone.

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.

------
oktavist
While a lot of comments revolve around the efficacy of accurately monitoring
for T1/2 diabetes and the past noninvasive trials and tribulations thereof,
consider that the market for such a product is very limited by Apple's measure
(10's of millions for an addressable market, versus billions for
phones/watches). It seems much more interesting if they were chasing a general
metabolic health or pre-diabetic application where the annoyance and lethargy
of the FDA/medical community can be skipped entirely.

------
MeteOzturk
Cross pollination between life sciences and consumer electronics will deliver
amazing opportunities for chronic disease patients. Non-Invasive blood
analysis can deliver new treatment opportunities for diabetes patients. This
is an amazing field to innovate in indeed.

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.

------
Eric_WVGG
Are there any uses for this information for "normals", people with no
particular danger of diabetes?

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.

~~~
dna_polymerase
Well yes. You might not know it but these days there is sugar (in any
variation) in almost all our food. Increased blood sugar levels over long time
lead to diabetes, tracking might help people to understand the risk their
diets might impose.

------
jlebrech
I can imagine wearing bracelets for each metric you want to monitor, it'll be
a sign of health and wealth and be as popular as those snag bands you kids
used to wear in the playground.

~~~
michaelt
You think visible medical equipment is a sign of _good_ health?

~~~
criddell
It depends on the equipment. There's a spectrum from things like oxygen tanks
one on end to fitness trackers on the other end. I think a glucose measuring
Apple watch would be clearly on the fitness tracker end of things.

------
digitalneal
Loyal to Dexcom for the night and day changes their product made to the
quality of life for my mother. But very glad to see Apple putting a foot into
these waters.

------
dwighttk
This is all well and good, but is it accurate?

Don't Theranos us Apple.

~~~
Shivetya
That is key. I don't see how. At first I thought maybe a sweat related method?
Perhaps some odd electronic field trick no on has tried? Unlike heart rate I
doubt a camera and bright light would suffice.

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.

------
crb002
Astro Teller of Google X used to do that sort of thing at BodyMedia. It
wouldn't surprise me if Google also has some projects in the works.

~~~
QuercusMax
Verily (formerly Google X Life Sciences) has several projects they are working
on in this space, including miniaturized CGMs and glucose sensing contact
lenses.

[https://verily.com/projects/](https://verily.com/projects/)

Disclaimer: I work for Verily, but I know nothing about these projects.

------
guiomie
If this device is covered by insurances, this could become a potential cash
cow.

~~~
criddell
Even if it isn't, I think it would still be a cash cow. I've never owned an
Apple watch before, but if they got this working, I'd buy one in a heartbeat
(assuming it's less than $1500). FWIW, I'm not diabetic, I just want the data.

------
justforFranz
I'm sure it's helpful for diabetics, but it won't be long at all before Apple
is selling that data to your health insurer - who will f you.

~~~
ldrndll
Any reason to believe they'd actually do this? Apple are one of the few
companies that seem to genuinely value customer privacy[1]; They make their
money selling your products, not selling your personal information after all.
If this were a Google or Facebook product on the other hand...

[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 :)

------
nabla9
> I'm excited to see where it goes.

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.

~~~
Angostura
Thank goodness, specialist embedded systems are immune from Malware.

~~~
skummetmaelk
I honestly cannot tell if this is sarcasm.

~~~
Angostura
Here you go - /s

------
mtw
I have a Garmin right now. The heart rate monitor gives more reliable
readings, the battery is better etc.

If apple makes an Apple Watch 3 with an optional blood glucose monitoring
band, I'd switch back though!

------
Xoros
I think the term "consumer base" is not heartless but in fact pretty accurate.

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.

~~~
sillysaurus3
I think this idea is pretty odd. If someone had a cure for diabetes, you'd bet
they'd charge an arm and a leg for it. The patents alone would be incredibly
valuable.

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.

~~~
TeMPOraL
Also, withholding cure for a big disease is not necessarily a stable
equilibrium on the market - the first company to release such a cure would mop
the floor with their competitors.

~~~
TheOtherHobbes
This is only true if a one-off sale of the cure is significantly more
profitable than a reliable income stream from products that help manage the
disease without curing 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.

~~~
sillysaurus3
Can someone provide links to examples of companies withholding cures in
exchange for profit? If not, the idea of this is nothing but conspiratorial.

If it's true, though, it's worth knowing.

~~~
TheOtherHobbes
I wasn't being conspiratorial, so much as adding some detail to a market-based
model.

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:

[https://en.wikipedia.org/wiki/Dabigatran](https://en.wikipedia.org/wiki/Dabigatran)

