Saturday, May 31, 2014

How can data serve the diabetes community?

We at Sensotrend tend to promote cooperation between companies quite a lot. As a part of this activity, we're quite active in providing feedback to other startups developing their services. Below you can find an example of this.

The process was triggered by the tweet:
The text below is based on the email discussion that followed, formatted into a blog post.



Hi Alex,



I fully share your vision of combining data from medical devices and wellness trackers, and using that data to improve health and healthcare.



Regarding your questions, here goes:


  1. Tell us a little bit about yourself :).

    Male, age 38, software professional (user experience design, programming, project and product management, sales, consulting) for 16 years, type 1 diabetic for 15 years. A startup entrepreneur for less than a year now.

    Regarding my diabetes, I’m currently using an insulin pump. My HbA1c levels (the ‘official metric’, a rough indicator of my blood glucose levels lately) has been between 6.9 % and 7.3 % (using the old NGSP scale still widely in use, 52 - 56 mmol/mol on the new IFCC scale), so fairly OK.

    My HbA1c used to be worse. Around 4 years ago, I had a kind of a diabetes burnout. I did inject insulin and measured my blood glucose, but I could never really estimate my blood glucose without measuring, nor explain the result after a measurement. The measurements just were anywhere in 3.5 - 22.5 range (again, different scales exist, I’m using mmol/l here, I know mg/dl is used in the U.S.), and there was no visible trend, they were just scattered all over the place, a shotgun pattern. My HbA1c was 9.4 %. It was really frustrating, and overwhelming.

    What helped me out of that burnout was data from a continuous glucose monitor (CGM). It helped me see patterns and trends. Even when it did not always provide clear answers to why something was happening, it gave me better tools to approach those questions myself.
  2. Please describe how an average day in your life looks like? Specifically, please let us know where the medical system plays a role...

    I prick my finger and measure my blood glucose several times per day. Usually when I wake up, immediately before and sometime after each meal, before, during and after any exercise, and before bed time.

    Whenever I eat or drink something containing carbohydrates, I need to think of the effect it has on my blood glucose, and dose insulin accordingly. The same with all physical exercise, and also lack of any exercise. Stress and illnesses also affect glucose levels and insulin consumption.

    Currently, my blood glucose meter is my command center and dashboard for daily operation. It has some intelligence built in, known as a bolus calculator. I have configured it with some parameters: Carb Ratio tells how much each gram of carbohydrates elevates my blood glucose, Insulin Sensitivity tells how much each unit of insulin brings it back down. There are settings for Stress, Illness, two Types of Exercise, and also for Menstrual Cycle, which I’m not using. With all these parameters, the bolus calculator helps me calculate the correct dose of insulin for each situation.

    When I woke up today at 6:49, my glucose was 12.9, a bit high. At 8:17, before breakfast, it was 18.2, so quite high already and rising fast. I need to think why that’s happening. My assumption is that my glucose has been low during the morning hours, causing the liver to release extra glucose to my blood stream, but since I don’t have any measurement data from the night time, I would need a continuous glucose monitor (CGM) to verify that. There may be other factors as well. Sometimes the infusion site (where the pump injects the insulin to my body through a cannula) gets corrupted somehow. Sometimes just pure stress causes my glucose levels to rise. It might also be that the meter reading was off for some reason, but I tend to rely on it being within the 15 % threshold. It’s been really quite usual for my second measurement being higher than the first one, but not by this much. I think about the basal insulin (continuously dosed background insulin) rate during the night hours. If my glucose levels have in fact been too low, it’s an indication that there has been too much basal insulin. However, I did not do any particular exercise the previous day (after sports I need to reduce the basal rate), and as mentioned, usually the trend has been upwards in the morning, rather an indication of too little basal insulin. Then again, it might be that the rising trend only starts when I wake up, as a result of stress, and when asleep the trend is in fact downward. And yet again, we’re just past the 4 day weekend due to Easter holidays. This may have affected the levels of my cortisol hormone. I might have less stress, and therefore the glucose levels have dropped last night, whereas usually the stronger cortisol keeps them up. Who’s to tell? There are several hypotheses, but not enough data.

    I then looked at my meal. Breakfast is usually the easiest of the day, as it tends to be pretty much the same each day. I entered my guesstimate of 50 grams of carbohydrates in my blood glucose meter. It told me to dose 6.3 units of insulin for the carbs, and another 6.5 to bring the high glucose back to the target range. I accepted and pushed OK. The meter communicates with the pump over Bluetooth, and the pump starts to dose the insulin. This is called bolus insulin, one that you dose per event, in addition to the background basal insulin.

    After breakfast, I worked at home for some time, then walked to the office. The walk takes less than 20 minutes and I don’t really count that as exercise, but a pedometer application on my phone keeps track of my steps. When I first started to use the pedometer it took me by surprise that I can walk less than 500 steps on some days when just programming at home, and nearly 20 000 steps on others, when there are several meetings in different places, without really paying attention to it. But it surely has an effect on my glucose levels and insulin consumption, so nowadays I do check the amount of steps some time during the evening.

    At work, I noticed the first symptoms of hypoglycemia, blood glucose dropping too low. I measured for confirmation and got the confirmation from my meter, 3.9 mmol/l. I always carry glucose with me for these situations, and took 6 tablets, enough to restore my glucose. The extra insulin to fix the high glucose at breakfast was probably too aggressive. I’ve created a mental note for myself never to correct a high with more than 5 units with a meal and not more than 2 units when not eating, but somehow managed to ignore that at breakfast. I could adjust the insulin sensitivity parameter in my bolus calculator, but it seems to be working fine with smaller corrections. So I’ll leave it as it is, for now, and try to remember my own rules for bigger corrections. An hour later, before lunch, my meter shows 5.1, a good number.


    My day is filled with wondering and pondering like that. With exercise, it becomes even more complicated. Exercise has been the biggest challenge for me regarding my diabetes treatment. If I don’t do any, my blood glucose values tend to go up, no matter how I try to compensate with additional insulin. However, when I do exercise, I find it hard to adjust my insulin levels accordingly.

    When eating, I need to consider whether I’m going to be active within a few hours after the meal, and in that case lower the amount of bolus insulin. I also should lower the basal insulin up to two hours before beginning to exercise. When exercising, I need to think how long it’s been since I last ate, does the level of exercise match the level I estimated when setting the basal rate. I also need to pay specific attention to my mood and stress. When I go jogging, my glucose levels go down, but when I play soccer, they tend to go up, due to the competitive nature of sports and the related adrenalin. And after the exercise, I need to think about how I should adjust my basal rate for the following hours, the following night, and the next day.

    Lately stress has become a major factor as well. When pitching my startup for a room of investors, I can feel my pulse increasing and a certain nervousness. Nothing that would prevent me from performing, but something clearly affecting my glucose levels (from 5.9 to 18.6 without any extra insulin to compensate the effects of adrenalin).

    You’d think one would eventually get a hang of the required insulin doses for each situation. I’ve had diabetes for almost 15 years now, and I’m still learning. Our soccer season is just starting. The first games are a shock to my body, and it takes time until it adapts, so each game is different. And each new season of soccer has a different impact. My body is not the same it was last year, the winter was poor in Finland and I didn’t ski at all, but I played futsal. All these things play their role in the equation, and it’s not a simple one to solve.

  3. On a regular basis, what data (e.g. blood pressure, activity, etc.) are you most interested in referencing? What do you use it for?

    Most important for me are the blood glucose levels. Are they on or off target, do I need to correct? Also, I need to see the trends, and try to learn from them.

    I monitor my physical activity and exercise quite extensively, to see how it affects my blood glucose and to learn to adjust the insulin doses accordingly.

    When my blood glucose levels are high and won’t come down for some reason, I check my blood for ketones, an indication of possible diabetic ketoasidosis.

    I’ve tracked my blood pressure occasionally. However, the levels seem to be quite static and in a safe range, so I only measure occasionally nowadays, around once every two weeks.

    Regarding urine tests you mentioned, I get checked for microalbuminuria once a year, with a bunch of other lab tests. It is a bit awkward to transfer the sample container to and from home for night time urine collection, but really not a problem I would personally pay any real attention to.

  4. With #2-3 in mind, where are some areas where you feel you could use some help or that someone could improve your daily life?

    I’d appreciate having the possibility to wear a CGM for longer periods of time. Nowadays I can get one from my diabetes clinic for one or two weeks, but I feel that’s hardly enough time to learn anything. There are so many factors involved.

    I’d like to be able to log all nutrition in a more automated way. I’ve seen some attempts in this direction, devices analyzing the blood stream non-invasively and software recognizing the macronutrients from a picture of a meal. I think the need for this kind of measurements is there, but personally don’t trust any of the available solutions enough.

    I’d also like to track my stress levels. I know there are things you can measure, but I don’t currently have the tools. I also don’t know which would be more suitable; heart rate variability, galvanic skin response, or some other metric.

    When analyzing the glucose measurements, whether from a glucometer or a CGM, I’d highly appreciate the possibility to have the results annotated in detail: what kind of exercise was involved (aerobic or non-aerobic, competitive or not), what nutrition, etc., and also the possibility to search and sort the results (show me all the game days from previous soccer season, and also their next days).

    I know the bionic pancreas is being developed for people with type 1 diabetes, but think its commercial deployment is years and years ahead. Still, even now some kind of alerts and advice throughout the day would be welcome.

  5. Given the above-mentioned context, what are the top 3 things you would like to see someone do for you?

    First thing for me would be the diabetes diary with automated data collection from multiple wellness trackers. That’s something I know I can do myself, so that’s what our startup Sensotrend is concentrated on. What would help us are API’s for different services and devices. All of the devices should really transfer their data to cloud services automagically. I know some people think it’s empowering for the patients to enter the data manually to logbooks. No, it isn’t. It’s simply too much of an effort. Too prone for errors, omissions, too. It’s much better to save the efforts for analyzing the data.

    As mentioned, I’d like to be able to track my nutrition easily. I currently have a great incentive to enter my carb estimates to the bolus calculator. But I don’t really track the glycemic index or other macronutrients of my meals, although I would like to have that information present when analyzing my glucose measurement data. Just a great meal logging app with superb assistance would be cool, but all fully automated solutions are very welcome as well.

    Another thing I can think of is the measurement of stress. I’d like to be able to track that without any effort, and be able to concentrate on matters that cause the stress. I’d also like to quantify it better than just based on how I feel.

    Finally, data alone does not give you answers. For me, seeing trends from CGM allowed me to see some patterns, as opposed to the shotgun chart of fingertip measurements. But I needed to find the ways of stabilizing that rollercoaster. So it is super important to get high quality instructions and assistance.

    The current healthcare system gets me from bad condition to OK, but how about when I want to go from OK to great? I understand the resources of the skilled doctors are best spent in bringing as many people as possible to the OK level. On the other hand, when I’m OK, and still have the drive to learn more and keep improving, I don’t think I’d be requiring so much handholding. Just high quality resources I could study on my own. Resources I can trust. I find it rather hard to find those.

    Even better than reading material would be services that analyze the data I’ve tracked, find patterns there, and provide explanations and suggestions. That’s where I hope to lead Sensotrend someday, and really hope we won’t be there alone. We’re a long way from there, though. Plenty of research is required before that. And plenty of data. We’re hoping to advance step by step, first just visualizing the data from different sources in a single user interface optimized for diabetes treatment, then perhaps sharing that information with peers and healthcare professionals, and gradually introducing algorithms making data analysis easier for people, before ultimately letting algorithms propose changes to treatment parameters.


  6. Anything else related to this area that you think someone should be solving or that you would like to see?

    I’d like to see healthcare services increasingly adopting the data from wellness trackers and other devices the patients use themselves. I’m already seeing a lot of that and think that’s a clear trend. It could still be accelerated, though.

    I’d like to see the big healthcare IT giants open up their interfaces for third parties to introduce services on their platforms, but kind of understand why that’s taking some time to happen.

    I’ve heard some doctors have mixed feelings regarding information provided by the patients. All of the healthcare professionals that have participated in treating my diabetes appreciate the data that reflects the real life of the person with diabetes. They do prefer the glucometer log over a pen and paper logbook, though. So I’ve never really seen that trust issue, but have heard it exists in some other fields of medicine.


I’m happy to elaborate on any of the answers. I’d also be happy if I would have been able to write them in a shorter format, but this is the shortest I could do this time. So apologies for the length, I hope you find the information valuable, though. :)

Sunday, May 18, 2014

Diabetes Thought For the Day

The topic of the last day of Diabetes Blog Week is My Favorite Things, meaning what has moved me the most during the week.

This was the first time ever I attended the Diabetes Blog Week. One important thing for me was that the week pushed me to write and get my thoughts out. Too many times in the past I've drafted something but never quite finished with the writing. It really helps to have a schedule. I didn't manage to post on Saturday, but don't feel too bad about it.

What's a lot more important is that the through the Diabetes Blog Week I found dozens of new interesting diabetes blogs, and gained an incredible amount of new diabetes wisdom. However, during the week I only managed to read a few percentages of the total blog posts listed. I really want to create a habit of reading more of these blog posts.

What's key when creating a habit, provided motivation is there already? We need to make it simpler to take that action. So, to make it as easy as possible to read new blog posts, I decided to create a simple web page that takes me to a new blog each time I visit it. It would not be that complicated to navigate to the Diabetes Blog Week pages, select a topic, and a new blog from there. However, I didn't believe I'd be able to make that sequence of actions into habit, and wanted to make it even simpler.

Originally, I considered a service that would take me through the blog posts one by one, in the order they were entered in Diabetes Blog Week, topic by topic. Then I thought it could be more fun if there be some randomness in the process. So instead, the service I created now randomly selects one of the posts entered so far. I've bookmarked that page, and just now made it my home page, so whenever I'm going online, I'll always have new diabetes reading available. You can do that too. The address is:

http://www.sensotrend.com/ThoughtForTheDay/


It only took an hour to set this up. Honestly, writing this blog post took more effort. Here again, I think the main point was to keep it simple. In the future, I might include filters to search posts about certain tags or topics. I also may add posts from previous blog weeks, or add a user interface for bloggers to add their content to the service manually. Or anything any of you may think of, that would add value to the service. But first, let's see if this raises any interest.

Many thanks everyone for the amazing week! And a special thank you to Karen for organizing it all!



http://www.bittersweetdiabetes.com/2014/05/diabetes-blog-week.html

Friday, May 16, 2014

Diabetes Life Hacks

Today's Diabetes Blog Week topic is Life Hacks, everything about the tips and tricks that help people with diabetes in the day-to-day management of their condition. We restrict the advice to non-medical ones.

In Finland, the Quantified Self and Biohacking movements are working closely together. Biohacking includes all the modifications you can make to your habits and behavior, nutrition and exercise, mental models and ways of thinking. Quantified Self, with the mantra "Knowledge Through Numbers" helps validate the results, taking a more scientific approach. With many kinds of measurements you can see whether a change you made really had an impact or are you just telling yourself it had.

I have some simple metrics I follow. For instance, I create a mental note whenever I floss. When I realize it's been a week since the last time, I know I'm also not paying enough attention to the treatment of my diabetes, and it's time to let go of some of the pressuring factors and concentrate more on diabetes. Diabetes treatment must always have that priority. Otherwise I'll just get into a state where I'm no good doing anything else.

My biggest challenge with diabetes has been with understanding the effects different types of exercise have on my glucose levels. I've started to understand some of the biological mechanisms, but still need to track myself in order to apply that knowledge to my own treatment. For almost a year now, I've carried a pedometer in my pocket. Actually several ones nowadays. I've got two applications in my phone, Moves and Wellmo. Both of them track my every step, just by running on the background, without requiring any interaction or manual logging. That's great, and I've learned that it really makes a difference if I take 200 or 20 000 steps per day.

The best hack with increasing my step count was to install a tracker also to my wife's phone. The week that followed was the first time ever I recorded 10 000 steps every single day.

Moves works great as a diary too. Sometimes when analyzing the data from my continuous glucose monitoring sessions I have hard time remembering what was it that I did a week ago that may have caused a certain change in my glucose levels. In addition to my steps, Moves keeps a log of where I've been, and a glimpse on a certain day always helps me remember what I was doing. Moves is also quite clever in automatically separating between walking, running, and cycling. Again, fully automatically, just running on the background.

Wellmo is a more comprehensive wellness solution. It allows me to track changes in my weight, my blood pressure, alcohol consumption, and a lot of other metrics. If I'd be a true gadget freek, I'd get the weight scale and blood pressure meter from Withings, so they'd be transfered to Wellmo's service automatically. As I only track my weight once a week and blood pressure even less often, it's not a big thing for me to enter those measurements manually. And Wellmo does a good job in reminding to enter those values. I also manually enter all exercise and sport I do.

All this logging is very different from tracking blood glucose results. I never manage to enter my glucose values to a logbook, as there's often so much other things going on at the same time: I need to measure, think of what that measurement means, is it higher or lower than I expected and if so, what could  have caused that, guess the carbohydrates in the meal and the glycemic index, taking into account a couple of previous times I've had a similar meal and remembering how well I estimated then, enter the carb estimate to the bolus calculator, think about other affecting factors (stress, exercise I've done and perhaps will do after the meal), check the amount of insulin the bolus calculator proposes and estimate it's sanity, etc. Taking out a logbook and entering the values there as well, does not really fit into the scenario, with my limited capacity.

So that's what I'm currently hacking together with Sensotrend. Getting the data from where it already exists. Blood glucose values and carb estimates from my meter, insulin values from my insulin pump, basic activity from pedometer apps, exercise from apps designed to track exercise, and so on. To make tracking all  that information so much easier.




Again, this is a part of a series of posts part of the Diabetes Blog Week.

Thursday, May 15, 2014

The Exciting State of Diabetes Technology in 2014

My post of yesterday dealt with the #DBlogWeek theme of What Brings Me Down. Today, let's take a look at what brings me back up and running again.

One of my early posts got a comment linking to Scott Hanselman's blog post The Sad State Of Diabetes Technology In 2012. Both that post and the discussion in the comments thread express the frustration all people with diabetes sometimes share. We'd just like a break from constantly monitoring ourselves, guesstimating carbohydrates, injecting insulin, etc. And we know many of the problems we're experiencing can be solved with technology. And we're frustrated when we don't have that technology, only a promise of it.

I personally, at least on a good day, find it much better to appreciate every small step that is taking us in the better direction. I know we're not there yet, and it will take us decades to get to where diabetes no longer produces a slightest burden, but all the progress I'm seeing genuinely aims at making life with diabetes easier and improving the treatment results.

In my previous posts, I've presented some of the Finnish diabetes startup companies. Today, let's take a global view.


Connectivity

One of the main issues presented in Scott's post was interoperability between devices, and open, standardized interfaces. While a lot of work is still needed on this front, a lot of progress has already been made. Companies like Diasend integrate with nearly all glucose meters out there, and are able to get the data out of them to their service, so that people with diabetes can remotely communicate their measurements with healthcare professionals, and the healthcare professionals only need to learn one user interface to inspect those results. Mendor have done a lot of the same work integrating glucometers to their Balance software. And Sinovo similarly for their SiDiary, also enabling people to feed their results to Microsoft's HealthVault platform, a Personal Health Record system where those measurements can be linked to all other relevant data, like nutrition and exercise, obtained from other apps and devices.

The above solutions mainly rely on people with diabetes using the readers shipped with their glucose meters, to upload the results. That process involves fetching the device, connecting it to a computer, starting the upload program and using it. While not a huge task, still something that people won't make a part of their daily routine.

There are a few attempts to make this process simpler. Biomedtrics, Diabeto, and Glooko all provide solutions not involving the computer in the process. Modz have a SIM card in their meter, sending each measurement to the cloud fully automagically. This week, I'm getting a Fora meter that communicates measurement results to my smartphone, and the phone then transmits the results to a cloud service, again with no manual interaction required from me. I really like the way things are evolving.


Towards the Bionic Pancreas

I'm also thrilled to read the experiences people are reporting from the Bionic Pancreas experiments. People with type 1 diabetes finally getting that break, not having to worry about glucose levels, carbs, and injections, just living their lives.

There's so much going on on this front, including the whole We Are Not Waiting movement, starting again from getting the measurement data out of continuous glucose monitoring devices in real time (see Hacking Type 1), but already involving development of advanced algorithms and Do It Yourself Pancreas Systems.
Just today, Femma announced they're about to start testing their own algorithms for an artificial pancreas system.

Photo from http://www.hackingtype1.com/2014/03/08/awareness/

A lot of all this is of course just pipe dreams. I realize this, and I'm still encouraged by each new attempt. They all tell me I'm not alone, people share the same frustrations and are active in trying to solve them the best they can.

I'm also excited of each small concrete step forward, like finally getting a meter that transmits it's results to a cloud service automatically.

Small steps, but important ones!




This is my post for the Diabetes Blog Week, under topic Mantras and More, what gets us through a tough day.

Wednesday, May 14, 2014

Easy Answers

Throughout my life, I've been underweight. I've come to notice that most of dietary advice just implicitly assumes that all people always just want to lose weight. I'm sure this has triggered in me an allergy towards easy answers suitable for everyone.

I've learned this with diabetes as well. When we're taught the basics of the condition and the treatment, it's of course good to stick to the basics. But oversimplifying diabetes can lead to frustration and a burnout. It did for me.

You're told you can calculate your carb ratio and insulin sensitivity by just measuring your blood glucose just before and two hours after your meal, and that's relatively simple. And you do that, even eating a same pre-packaged meal each time, that even has the nutrition values printed on the packaging -  and you still keep getting different results each time. It just makes you feel discouraged, stupid, and disappointed.

The same with diabetes and physical exercise. As a general rule of thumb, physical exercise enhances the effects of insulin and lowers blood glucose. I notice this quite clearly when running, for instance. But with football it's a totally different game. My glucose tends to rise quite dramatically, and I need more insulin during games, not less. Part of that is due to type of exercise, also running sprints and intervals is different from running a long distance with an even pace. Another part is the competitive nature of the sport, and the adrenalin that produces. Just knowing physical exercise generally lowers blood glucose is not what I need as a diabetic. I really need to understand more of the complexity of the matter.

Lately, as a startup entrepreneur, I've done my fair share of public speaking. It has interesting effects on blood glucose as well. The adrenaline just pumps my glucose levels up. I've seen many people in diabetes online communities testifying similar results.
So there is a plethora of things affecting our blood glucose levels. Thinking you can easily calculate the effects of a meal with two measurements ignores these other factors. At the very least, you need to know to take many measurements, and estimate the averages. Much better would be to understand as much as possible of the other factors, and take those into account when estimating the effects of one variable.

Sticking to the simple answers has not been helpful for me. I would greatly appreciate healthcare system in general moving from that old broadcast model (one message for all) to more personalized information and advice. I've seen that change take place in media, and believe that with the current availability of wellness trackers and medical devices, the technology makes this transition possible also in healthcare.




This is my third post for the Diabetes Blog Week. The theme for today is What Brings Me Down. For me, that has been the easy, over-simplified answers.