A Case for Wearables

Wearables have been getting a lot of bad reputation due to studies revealing that people abandon them after 6 months. I’d like to defend them, and offer a different view.

I hit that critical 6 months mark with my Polar Loop in July. I suddenly noticed I just wasn’t wearing it anymore. Also, I started to get annoyed with having to charge the band every few days. Something had clearly happened in our relationship.

Wearables provide information

I originally started tracking my daily activity with the Moves app, over a year ago. I had heard a lot about the 10 000 daily steps required to stay fit, but I had no idea how many I was taking myself.

With the Moves app, it took me a few months to learn what it takes to reach that goal. My daily walking commute gets me half way through, and my other activities vary so that I sometimes pass the 10 000 mark, often times not. What was really important for me to learn, however, was how much variation there is. Some days I just stay at home, programming. On those days, I may take less than 200 steps. On other days, I may have several meetings taking place at different locations, and I may take over 15 000 steps without really noticing being involved in any physical activity.

Wearables do help people with chronic conditions

The main reason for me to track my daily activity is not to get fit. I have type 1 diabetes, which means my body no longer produces the insulin hormone, rather I must inject it myself. I really must pay attention to that variation in my baseline activity, as it directly affects my blood glucose levels and therefore also my insulin needs, both during that day and over the following night.

Moves app already helped me get some of that understanding, and the Polar Loop added more details. I’m able to track my heart rate at the gym as well as during football games and practices, and learn the effects different levels of exercise have on my blood sugar levels.

Wearables do facilitate behaviour change

I never expected an app or device to motivate me to exercise more. For me, it has always been more about learning the effects. Still, tracking my daily steps changed my perspective.

Before, my engineer brain optimized my walking routes for efficiency, for the least amount of steps. Once I started tracking my steps and had that magical number 10 000 in my head, I suddenly started to optimize the routes so that I could get to that goal or exceed it. I ended up selecting routes that would actually increase my step count, instead of getting somewhere in the fastest way. I feel that change in perspective is permanent, even if I end up abandoning my wearable device.

Wearables get abandoned for a reason

So, my precious wearable had taught me to better manage my chronic condition and helped me be more active, and I was still about to abandon it after that 6 months mark. Had it failed me in some way? I would say, quite the contrary! My wristband has provided me with a wealth of information, and I’m immensely grateful for that. It’s just that after 6 months I’m not learning that much anymore.

Now, I still wear my Polar Loop almost daily. Partly because it’s a nice visual aid when I explain what our startup Sensotrend does, combining information from medical devices (I point to my glucose meter or insulin pump) with data from activity trackers and other wellness apps (I point to my wrist band). But also because I really want to take the data I gather to the next level, make it more actionable.

For instance, I’m currently implementing an app on my phone that reminds me to set my insulin delivery overnight to a lower level if my daily count has exceeded 15 000 steps, or increase the rate in case I’ve recorded less than 5 000. This kind of personalized and actionable notifications are the direction I’m hoping many wellness apps will evolve in.

Human touch enhances the effect of wearables

Finally, let’s not forget the importance of some human interaction. For instance, my wife followed my tracking with interest for a long time, but only started tracking her own steps after I installed a pedometer app to her phone. Installing an app seems trivial for me, but she never got to do it herself. Now she’s way beyond her 6 months mark, and still tracks her steps daily.

Doing things together certainly also helps with the behavior change. The first time ever I myself recorded 10 000 steps on 7 consecutive days were the days immediately after I had installed the tracker to my wife’s phone.

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This post was originally published in the HealthSPA blog.

Using Accu-Chek Smart Pix on Mac

The official system requirements for Accu-Chek Smart Pix software don't list OSX as supported, but you can use the reader and the software on Mac, quite easily.

The official system requirements indicate only Windows is supported.

This is how I do it:

First, I install the reader to the USB port on your Mac. I get a notification of an error, but I just ignore it.

The light on the device flashes and then starts blinking, indicating the device is already open for reading your meter or pump.

First a flash

Then blinking

I then open the SMART_PIX device and launch the START.HTML file.

And there it is, Smart Pix software on my standard Safari browser.

The software is immediately ready to read a device, so I just put my meter in data transfer mode and set it in front of the receiver.

Once the transfer is complete, I get a notification...

... and can then access the information from my meter.

The same works with the pump. I click Read Device, set the pump to data transfer mode and put it in front of the receiver.

After the transfer is complete, I can see also the pump data in Smart Pix.

As I explained in the previous post, all the data from before the change from daylight saving time to standard time is unaccessible to Smart Pix, so here I only see a short period of data.

I can then examine the data with all the views and graphs Smart Pix has to offer, and also generate the report.

If I want, I can 'print' the report and save it as a PDF file to be sent to my healthcare team to look at.

So, works for me!

On my Windows machine I use a different version of Smart Pix that actually preserves all my data in an internal database, and therefore allows me to view data from an even longer period of time. But apart from that, the software works pretty well for me also on my Mac.

Please feel free to let me know in the comments if your Mac behaves differently.

Update: Please note the response from Accu-Chek. The software has not been certified to work with Mac, so you're using it on your own risk!

@mrinnetmaki TY for the mention pls note the SmartPix is not approved/cleared in the manner you've described in your blog.
— Accu-Chek US (@accuchek_us) October 29, 2014

Device data and Daylight Saving Time

Last year I lost a few months worth of data from my insulin pump, due to poor software.

When I downloaded the data to my computer on November 3rd, I could only see it back to October 27. When examining the raw data, the data available at the cutoff point was:

<BASAL Dt="2013-10-27" Tm="10:24" cbrf="0.75" profile="3" remark="time / date set (time shift back)" />

There was no data going back from that time. The previous time I had downloaded the data from my pump was at the end of August, so I ended up losing two months worth of data.

That data contained all the information of my temporary basal settings, and was really important for me. As I'm figuring out the correct basal dosing related to my exercise, I want to take a look back every now and then to see which rates have worked best during exercise and after it.

I really wanted to save the data from all the football matches from one season, where I had used different settings for different games and practices, to be able to analyze the results and also share it with my healthcare team and other people with diabetes. Now I could not do it anymore.

I explained my problem to the pump support team and they confirmed this is a flaw in their software. The pump actually preserves all the data, but the software used to read it gets confused when there are overlapping entries or gaps in the records. And this happens each time you change the time on the pump, whether due to daylight saving time or traveling to another time zone. They also explained that this is a well known problem and they are working on getting it fixed. As for now, there is no fix available.

So if you're using the Accu-Chek insulin pump and care about your data, make sure to download the data before changing the time on the device!

Our path to Slush 2013

There are just a few days left to register your startup to Slush, in case you're interested in the early bird price. Note the comment!

Post by Slush.

And then there's the registration form.

When we filled the form a year ago, we really didn't have much clue on what to write there. We did the best we could, submitted the form, and waited. And waited.

Then, just two weeks before the event, we got an email announcing that our company was not among the 100 companies selected for the pitching competition. They recommended that we concentrate our efforts on networking during the event.

We were devastated. It felt that mail destroyed everything we had been working for over the past months. We were very disappointed with the application process, that was just a black box. Had we known what kind of info they expect in each of the form fields, we could surely had filled it out better. The world seemed to be a very unfair place for a moment.

But after a day or two, we got a new mail, saying we had been selected to be present on the Health Track and we'll get a demo booth for one day. So instead of pitching for one minute for a random audience, we'd have the chance to present our service to many people interested in healthcare services, without time limits - and we got the stand for free! Things were looking very bright again.

A week before the event we got yet another email. We were offered 5 minutes stage time to launch our service on stage as part of the Health Track program. This was just superb. So much better than the pitching competition would have been for us. Of course, there was only a week left and we had all of that week already scheduled for other preparations. But we just had to take this opportunity as well.

So we quickly created a launch campaign and the presentation. We couldn't get everything done in time, so we were probably one of the only companies with a booth but without a rollup (we used a screen instead). Free tip for you, startups, get your rollup ready in time. You're going to need it.


During the event, there were some last minute changes again and a bit of hassle, but that feeling of creative chaos is just part of what makes Slush so great, I guess. Our booth was busy the whole day and the launch was received with a lot of love and plenty of registered users.

In the end, there was one more nice surprise, when Slush featured us in their blog. We ended up getting so many good things. For us, this still is perhaps the most striking experience of what it means to be an entrepreneur. We lived through the initial disappointment and through every new positive turn so fully and with so much emotion. And it taught us that even in desperate times there are amazing things ahead.

This year, we still don't know exactly what to write on the registration form. But we do know there will be ups and downs on our path to Slush and beyond. And we'll most likely be devastated and depressed at some point again. But this time we'll face all obstacles with a new kind of confidence.

Our Learnings from Startup Sauna

Startup Sauna just published their schedule for Local Events, and are welcoming applications for the 2014 autumn batch. To help you make up your mind on whether to apply, we decided to share some of our experiences from the spring batch.

We had a hard time deciding on whether to even apply. When we did and managed to get in, we still weren't sure whether that's the right move.

For us, the main question was timing. We had graduated from the Protomo startup incubator some time earlier and had our business model and financials together in some form. But we weren't really fully satisfied with them and thought we could improve.

On the other hand, our product required development as well, and we knew Startup Sauna wouldn't help us much with that. We were also in a process of including a new member into an important technical role in our team, and being present in two places at the same time would not really be possible. Concentrating on product development seemed to us to be more important.

When making the decision, we thought it would be awesome to concentrate on business development for just five weeks really intensively, so that we'd get all of that figured out and our materials ready for a long time ahead. After the accelerator period we would really be able to concentrate fully on product development. If there was a pitch event somewhere we could just attend and deliver our fine-tuned pitch, and when a potential investor would ask for some material, we'd have all those in stellar condition and could just send them.

We talked with some teams from previous Startup Sauna batches, asking what they had gotten out of the program. Everyone spoke highly of the spirit within the accelerator and praised the amount of contacts you get, but some also warned us that the time spent with coaches may not be enough to really develop the business of the company.

In the end, we decided to take the opportunity. We had gotten so much out of Slush, and it was organized by the same people.

The program consisted of lectures by experienced startup entrepreneurs and professionals in the field, pitching training, and one-on-one sessions with investors and coaches. The lectures were of high quality, but not that different from the ones from our incubator. Same with the training. The one-on-one sessions lasted typically 20 minutes, which is certainly not enough for any coaching, but is really good for getting to know a bit of each other and see whether it would make sense to meet again separately from the accelerator program. In our incubator, we typically got a longer time with the coaches, from an hour to two. These are clearly different approaches, Startup Sauna way being much closer to matchmaking than coaching.

Our company is located in Tampere and Startup Sauna resides in Espoo. We decided not to move to Espoo for the five week period, rather commute by train (around two hours in one direction, but almost all of that is efficient working time) and stay overnight occasionally at friends or family members who live in the capital area. This way we were still able to meet as a team in Tampere every once in a while.

Our hopes were high, but the biggest ones did not materialize. Our pitch surely improved during the program, but that was never one of our main problem areas. We also got a lot of contacts that could help us forward at some point. But we can't really say our business plan and investor materials improved that much during our stay at the accelerator. And the five weeks certainly had a negative impact on our product development and also damaged the team. We ended up losing the potential hire.

So if you're considering applying to the autumn batch, there are a few things to consider. Don't expect too much development to happen over the accelerator period. The thing our batch spent most time developing was the pitch, so if you think yours is in a bad shape, this might be a good opportunity. Of course you need to find a way to get in with your poor pitch, which may not be easy.

I would also suggest you make it extra clear to yourself what it is that you're expecting to get and communicate that clearly during the application process. Tell the coaches what it is you want to achieve and push them to help you make that happen. For our batch, there was no real per-company curriculum, rather the program was pretty much the same for all of us. And it was hard to get one-on-one time from the head coaches. After all, there were 17 teams, and even the head coaches seemed to be present less than two days per week. And a significant amount of that time was reserved for scheduled activities. So again, perhaps 20 minutes of one-on-one time weekly. You really need to think how to use that time to communicate what you think makes sense for your company.

Finally, these are just experiences of one team. Also remember that the Startup Sauna is different each time. I'm sure they have analyzed the feedback from the teams in our batch, and made many changes for their autumn batch.

The Evolution of a Pitch

In this post, we'll take a look at how our investor pitch has evolved over the past year.

As securing financing is perhaps the most important task of any startup, and as the pitch deck is perhaps the most crucial tool in that process, you'd think that's the one thing startups do really well. But it turns out that in addition to the pitch deck, there's so much other stuff that a startup needs to be involved in, that one never gets enough time to get the pitch perfected. So some of our pitch decks below are just plain horrible, whereas others we feel are OK, meaning good enough to deliver the message. But there's no pitch we're even nearly 100% happy with.



Our first ever public presentation was at FiBAN Pirkanmaa Pitching Competition, after having worked as a team for less than two months. Despite the appearance of the slide set, we ended up on second place out of 12 teams and companies.



For Slush, prepared a deck for sit-down meetings with investors, and another one for the product launch (above). You can also see the video of the launch presentation. It annoys me quite a bit that we use the term HIE on one slide, where the correct term had been PHR, a Personal Health Record. Nevertheless, the presentation was received with a lot of love from the audience, perhaps partly because I almost cried at the end. It was just such a big moment for me. I've met people who tell me six months later they still remember me and the company from that pitch. That just reminds me of the fact that it's never about the slides.



Seed Forum had quite strict guidelines for the 6 minute pitch in their event. That's good in the sense that there's less pondering about what to tell. On the other hand, there's no universal pitch format that would suit each and every startup.

We've given some very informal presentations as well. For instance, the presentation on startup's point of view in a seminar discussing the current state of diabetes treatment (in Finnish, see also the video recording). It really feels strange to keep a presentation for 20 or 30 minutes, after getting used to shaving off seconds from an investor pitch to make it fit to the allotted time.



Our latest investor pitch is the 3 minute one from Startup Sauna demo day. I'm still not loving it. I don't think I'll ever be really happy with the pitch. There's always things you can do to enhance the visuals, the story is never straight enough. I feel we also need to cram in all the drama and death and such, whereas I'd much rather talk of my own problems that are closer to irritation and annoyance towards devices and apps that require me to copy information manually from one place to another, measurement by measurement. That's what we're really solving right now. But for a big stage, you need bigger drama, and we'll try to roll with that.

The First Year of Sensotrend

It's hard to believe a full year has passed since the first post in this blog.

To recap Sensotrend's first year shortly, I'd say we've gotten plenty of praise and publicity, and learned a tremendous amount about startup business and financing. On the other hand, a year ago I certainly imagined our product to have been launched by now. There has hardly ever been a better time to be a technology startup entrepreneur in Finland, but it still feels incredibly hard to get a company off the ground.

From the start, our worst scenario was that we'd spend all our resources into developing a product and then exhaust when the time came to bring it to the market. We've heard time and time again that this is the most common case for startups, especially so in Finland where engineering has traditionally been the strongest part of any technology company.

So we decided to concentrate our early efforts into communicating our idea to the public. That way, even if we would not succeed, more people would have learned about the need, and the next company implementing the same idea would have better chances of success. In the end, what really drives me personally is the need for a solution. I need the product that combines my data from all the different apps and devices much more than I need to be the one implementing it.

In our incubator we also learned that startups that start by implementing a product almost always fail because their product ends up not meeting the needs of the real users. Rather, the product must be developed together with the end users, constantly validating the assumptions of the engineers implementing the product.

So we have been 'out of the building', as they say in the Lean Startup scene. And we've certainly been out a lot, discussing our product with people with diabetes, doctors, nurses, partner companies and investors. A lot more than we've been inside the building, implementing the service.

Right now I feel we need to get back into the building for a while. We need to take all that we have learned and validated so far, and start working towards a MVP (minimum viable product, another Lean Startup buzzword) that we can give to end users, to take our learning to the next level.

Focusing on product development means saying no to a lot of offered publicity and most likely also to some opportunities to secure more funding. We'll still do our best to get a message out every now and then in this blog or through our Twitter or Facebook accounts.

But our main priority right now is to get a product out for initial test users. We've got a bunch of alpha and beta users recruited, and we'll involve them in every step of the development of the product. If you're a person with diabetes, eager to test cutting edge technology and not afraid to see it break to pieces momentarily, you can still get involved. Just send us an email at info@sensotrend.com.

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:

How can data serve the #diabetes community? @Scanadu wants to know, contact Alex@Scanadu.com to learn how you can help. #S4PM #ourD
— quantifiedself (@quantifiedself) April 16, 2014

The text below is based on the email discussion that followed, formatted into a blog post.

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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. :)

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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:

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!

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

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.

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

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!

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

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.

Self-tracking in real time: here's what live video interviews do to me. #MedX pic.twitter.com/EO91e303Ik
— Kim / Diabetes (@txtngmypancreas) January 29, 2014

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.

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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.

Finnish Diabetes Startups, Combined

There are two important diabetes device manufacturers in Finland. Mendor's Discreet glucose meter offers everything you need to measure your blood glucose in a single package. It makes measuring blood glucose really fast, and also discreet. Modz have a glucose meter that sends the measurement results directly to the cloud service and routes it to a cell phone in another location if requested, so parents of children with diabetes can monitor the treatment of their children, for instance. It's also highly motivational, and they have their Moodz characters - and also Angry Birds themes!

You can get the Modz meter with the Angry Birds look!

Of course, both of the device manufacturers also develop their own software solutions to analyze the measurement results. But there are limits to how many things a startup company can really focus on.

There are other companies concentrating on software and services. Both MyHealthWay and Quattrofolia are warming up the WellMate concept developed in Nokia in early 1990's. Both are building their offerings as turn-key standalone solutions, and targeting other chronic illnesses as well. Quattrofolia are being bold enough to even start their own clinic.

Then there is the brand new Femma5. They don't even have a website up yet, but they have a grand vision for algorithms for artificial pancreas systems.

Working Together

What does this all mean for Sensotrend? I personally really appreciate the work Mendor has put into product development, and also for integrating other blood glucose meters into their Balance software. We've worked together with them to get the data flowing between Balance and Taltioni, and like to continue cooperating even further. Currently their Balance software only analyzes blood glucose measurements. We're trying to help them see that that information does not really include everything you need to know to manage your treatment parameters. Factors like nutrition, exercise, and insulin dosages need to be factored in.

Modz complements Sensotrend's offering beautifully. We get a lot of wishes for our solution to be real time, allowing parents to check on their kids while they are away. Most currently available glucose meters don't offer that kind of automatic real-time sharing of measurement results, and Modz certainly fulfills a real need there. With them, we're discussing combining our efforts in service development. We seem to share a common vision.

I like the way MyHealthWay manages the communication between people with diabetes and their healthcare professionals. And their mobile apps look quite nice, I'd like to use them as part of Sensotrend's service, for manual data entry when that is needed. They haven't yet warmed to my proposals of cooperation. They also don't see the value of automated data import, rather feel it is important that people with diabetes interact with their app as often as possible, claiming it empowers the patient. I myself tend to disagree with that sentiment. For me, data entry needs to be as automated and easy as possible. I want to be empowered by data just being there for me to analyze it when I want to, not having to manually copy each entry from a device to another.

I edited the above based on Jarl's comment "Our roadmaps cover the automatic input part as well but the point here is to start off with the manual input to activate the user and become empowered in his/her care process and see beyond the figures and data in order to see the big picture." Please see the full comment in comments section.

Quattrofolia have interesting studies and knowledge around HbA1c values, how those can be calculated from measurement results and how that benefits people with diabetes. For me, some of that thinking seems kind of twisted. I mainly appreciate HbA1c as an easy and cheap metric available when there are no reliable glucose measurements. But when there are measurements available, they offer much more information, and HbA1c should just be used as a verification method to spot possible systematic errors. What I really like about Quattrofolia, though, are their plans for the evolution of their service, into a kind of a Diabetes University, providing high quality guidance for people with diabetes.

Finally, I hope the data gathered with Sensotrend's own solution will ultimately help Femma5 in their development work. At some point, they need to know how different kinds of exercise affect different people, and in general how differently we all react to all the factors affecting blood glucose values.

Just combining the products and services of all these Finnish diabetes startups into a single offering would be a big step towards that often discussed Dream Device. If we can agree to work together to get the basics in place, we'll get to take the next steps much sooner!

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This is my second entry to the Diabetes Blog Week. The selected theme for today was poetry, but with everything going on with our Startup Sauna program, end user interviews, and closing the financing round I wasn't able to connect with the poet within, and decided  to play the wildcard 'Diabetes Dream Device' instead, and continue with yesterday's theme.

Stronger Together

Many things have changed since we started building our service, but our vision of doing this in cooperation with other companies is still strong.

Last week, a bunch of Finnish startups met with Microsoft's Healthvault representatives. The discussion was about creating a combined service offering for diabetes, involving services from each of the companies. There are many great health and wellness startups in Finland. Platforms like Healthvault and Taltioni are one possible glue that may join their areas of expertise into a great combined offering for healthcare.

Sensotrend's solution for diabetes treatment depends on data from other services. Of course, we need the data from blood glucose meters and continuous glucose monitors. We have integrated our solution with the devices from Medtronics, Accu-Chek, and Dexcom, but that integration always comes with a cost. Mendor have already integrated their Balance software with dozens of glucose meters from different vendors. We're working with them to get that data flowing between Balance and Taltioni.

Just the glucose readings are not enough for us. We want to visualize the measurements together with all the factors affecting them. Insulin doses, nutrition, physical exercise, stress, weight changes, etc... Modz, another device manufacturer shares our sentiment, and we're discussing how we could work together in creating such services and visualizations.

Of course, we also need data from many other sources. There are plenty of activity and wellness trackers available, and quite a few Finnish companies (Beddit, Fjuul, Moves, Myontec, Omegawave, Polar, PulseOn, RecoApp, Runteq, Sensorfit, Sports Tracker, Suunto, Vigofere,  Wellmo, ...). We want our end users to be able to select the tools and apps that best suit their individual lifestyles and needs.

W2E helps us by bringing all that data to platforms like Taltioni and Healthvault. They build the integrations to many trackers, and standardize the data to a common format.

In addition to tracking physical activity, sleep, and stress, we're still missing a key ingredient, nutrition. We can get the carbohydrate estimates from the bolus calculator integrated in insulin pumps and glucose meters. People with diabetes have a high motivation to enter their estimates to these tools, as the bolus calculator makes it easier to estimate the correct dose of insulin. But not all people with diabetes have an insulin pump system with a smart bolus calculator. For them, we need to offer other tools to enter that data.

For many people, it makes sense to track more parameters than just the amount of carbohydrates. Glycemic index indicates how fast the carbohydrates are absorbed from the meal after eating, an important metric. You should always take this into account when analyzing post meal measurements. You may also need to inject your insulin dose differently if the glycemic index of your meal is low, meaning not all of the carbohydrates are released into blood stream immediately after eating. In addition to carbohydrates, it is also important for people with diabetes to understand their overall energy consumption and to track other macronutrients: fat, protein, and alcohol.

As with exercise, we'd like to see several meal logging apps being available for people with diabetes using our service. Some apps may concentrate just on storing pictures of meals, some can help searching for nutrition information from databases, and some may educate users about different meal choices. We're in discussions with MealLogger and SeeHowYouEat, and there are still many we need to get in touch with.

The business models

Many times the discussions with app providers and device manufacturers lead to ownership of the data and of the customer relationship. We're quite happy with the solution where the full set of data only resides in the original service provider's database. There probably is no suitable slot for every piece of information in Taltioni or Healthvault anyway. For a sports tracking application, we may just store the sport, duration, and maximum or average heart rates to Taltioni. However, with that information we also want to store a link to the origin of that data, so the end users may check the full range of heart rate variations, the running course, speed, and other information in case they need more detail.

Even in this case, the personal health record platforms still have a critical role in managing trust relationships between services. It is absolutely best for the end user if they can administer all their data sharing in one place. On Taltioni or Healthvault, they can indicate which services are allowed to read which pieces of their information, and revoke that permission at any time they feel like it. It gets too messy and complicated to manage all this in different services, case by case.

Finally, we're happy to share a fair piece of income with all parties. We plan to pay the platform fee to the personal health record platforms, and another for companies that integrate and aggregate data from multiple sources so we only ever need to care for one integration, the one to the central system. We're hoping that will be an incentive for all players to participate in the ecosystem.

Because there's no way we can do all of that ourselves. And there's no way any other company can.

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This post is my first entry to the Diabetes Blog Week. Today's theme is Change the World.

Startup Sauna - five weeks of adventure ahead

We are very happy and proud to let you know that we are among the 18 teams who were chosen for Startup Sauna batch of this spring. Startup Sauna is a leading European startup accelerator and also the organizer of the marvelous Slush conference.

We are looking forward to hard work and tough coaching that will improve our business potential. We are also expecting to get loads of new contacts and have a great experience during the next five weeks.