Forget just staying in shape. Activity trackers, heart rate monitors, and other wearable fitness devices are about to change medicine and health care as we know it. By Jill Duffy
What if you could buy an over-the-counter genome testing kit, just as you can buy a pregnancy test today, then take it home and know within a matter of minutes whether you’re at risk for cardiac arrest? What if, as a result of taking that test, your doctor prescribed a regimen of diet, exercise, and stress reduction, monitored by your Internet-connected refrigerator, sensor-laden workout clothes, and an fMRI headband that dimmed the lights when it noticed increased brain activity associated with stress? What if you could upload a copy of your brain to a hard drive so that doctors could reinstall your memories if a disease or accident wiped them out?
Today’s fitness trackers, those $99 smart pedometers everyone’s wearing on their wrists and belt loops, are the forefathers of a much more advanced health and wellness system. The ways we use them and the things we learn from them are directly influencing how we will think about health 10, 15, and even 50 years from now.
I’ve been testing health and fitness trackers for almost four years. I’ve worn all the ones you’ve heard of (the Fitbits, the Nike+ FuelBand), as well as many you probably haven’t, including a finger sensor that measures heart rate variability and a calf compression sleeve that monitors lactic acid buildup during runs and bicycle rides. Although I’m lucky to be in good shape now (genetics are on my side), I’m also thinking ahead. What if I’m diagnosed with an illness, or worse, something goes wrong with my health that isn’t easy to pinpoint? I have four years’ worth of objective data I can bring to specialists to validate my prior health conditions. All these logs create a detailed snapshot of life from my 30s. And even better, what if researchers could look at what I and other patients did ten years ago and use it to predict how our bodies will respond to different treatments in the present?
Our bodies are complex systems. Long-term habits and trends certainly do play a significant role in determining our health outcomes. We’re on a clear path to discovering exactly how different aspects of daily life, such as how much we walk and what we eat, affect our future, particularly in relation to medical intervention. And it’s all starting with pedometers.
WALK A DIFFERENT WALK
Think of the Fitbit Charge, Jawbone UP, Basis Peak, and other wearable trackers currently on the market as just the first generation of these kinds of devices. Dr. Priyanka Agarwal, assistant clinical professor at the University of California at San Francisco Division of Hospital Medicine, Center for Digital Health Innovation, imagines the next iterations incrementally measuring more important aspects of our lives and offering more personalized recommendations.
“The second generation [of fitness trackers] is going to be tracking more vital signs and basic biometrics,” Agarwal says. This second wave is already coming, with several devices reading heart rate all day long. “The third generation,” according to Agarwal, “is going to maybe have parameters around your cardiac output or your breathing or your lung function. In the fourth generation, there could be sensors that are measuring chemicals in our urine that people are using on a daily basis to try and predict, or to try and look for, markers of illness or disease that are not even biometric-measurable, but are really more biochemical.”
Fitness trackers are part of the larger self-quantification movement. Self-quantification is the act of collecting quantifiable information about one’s self, which can include a huge range of data points: steps walked per day, calories consumed, resting heart rate, active heart rate, total hours slept each night, time spent using Facebook, and much more. It’s born of the same self-tracking that athletes and dieters have done for years, logging miles run, rating soreness after a run, and adding up their nutritional intake.
I’ve certainly put myself through the paces. It’s remarkable how much I know about my body after testing health and fitness technologies personally. For example, I know from wearing the Basis Peak and Fitbit Surge that my resting heart rate is typically between 54 and 60bpm, and that it dropped a little when I started training for a half marathon. I know that on average I walk about 15,000 steps per day. From an online tool called InsideTracker that plots blood test results over time, I know the daily dose of 2,000IUs of vitamin D I started taking back in August (with my doctor’s approval, of course) is going into my blood stream. I get a good amount of cardio exercise each week, and the Ithlete heart rate variability reader confirms that I’m in athletic shape but not a professional athlete. The last time I used a gadget called Skulpt Aim to measure the muscle quality and fat percentage of all my major muscle groups, I learned that my left bicep has a long way to go to catch up with my right.
With modern consumer electronics giving us more information about ourselves and our bodies, two things drastically change. First, it’s easier to collect information passively with devices that blend into daily life. Rather than write down every food you eat with a paper and pencil, you can now scan a bar code from a box of cereal and have an app like MyFitnessPal automatically log all the nutritional value of one serving. Second, the data is simply better. Advances in software and user interfaces make it easier than ever to look for patterns and correlations between your actions and lifestyle, and your health—although it’s still no piece of cake and often requires the help of a doctor, friend, or coach, according to Dr. Paul Abramson, a San Francisco–based private practice doctor who works with patients willing to partake in a little self-quantification.
THE DIY ATTITUDE
Self-quantification also makes is possible for patients to act more like consumers and take control of their own data. It’s fitting in this do-it-yourself age. With self-collected data, people can figure out for themselves in a very personalized way what changes to make to their behavior or environment to bring out positive changes in health.
“The general trend here, and I think a really healthy one, is that we’re moving medical decisions and medical knowledge into the consumer space,” says Dr. Joseph Roberson, chief medical officer for VitalConnect. VitalConnect develops new technologies to address challenges in health care. “You’re responsible for your health, not the physician,” Roberson adds. “The physician’s job is that of the consultant. It’s to give you advice.”
A clear example of how consumers are taking matters into their own hands is in sleep analysis. By tracking sleep patterns and correlating them with, say, diet, self-quantifiers are able to see how consuming certain foods and drinks (caffeinated or alcoholic beverages in particular) negatively affect their sleep quality. You don’t need a medical degree to look at a chart showing bedtime, total sleep time, and sleep quality, compare it with a chart of your coffee intake, and draw a few hypotheses. And you certainly don’t need much more than a little motivation to start experimenting, say by tracking how your sleep quality changes when you quit drinking coffee and soda after 5 p.m.
As someone who has slept well her entire life, I thought I wouldn’t learn much from tracking my sleep. And I thought coffee has never had a strong effect on me; I once fell asleep in a movie theater with a freshly empty cappuccino cup in my hand. But after about ten days wearing a Jawbone UP24 wristband and using a companion mobile app called UP Coffee to look for correlations between caffeine consumption and sleep, I discovered that I slept around 40 minutes less following days when I drank three or more caffeinated beverages. Normally I have only two. Forty minutes doesn’t sound like a lot, but research shows that sleep deprivation can be cumulative, meaning getting less than 7 hours of sleep as little as four days in a row can take a serious toll on our neurobehavioral functions.
Of course, you’d want to consult a physician or sleep specialist if you experiment with sleep analysis and don’t see any improvements. But even then, you’d arrive at the sleep center having already ruled out several possible causes of your poor sleep, and have pages upon pages of historical data to boot.
Thinking into the future, though, your refrigerator may be able to help you carry out an experiment like this one by reminding you not to drink caffeine at night, or maybe by locking down the beverage drawer on days following a particularly bad night’s sleep. In a fully connected world, your refrigerator would automatically know to take these actions because it would be communicating with your smart mattress and other sensors.
BLEEDING EDGE: THE CURRENT STATE OF TRACKERS
We aren’t quite to the point where trackers can talk to connected home devices to make real, personalized changes in our environment to keep us well. But we’re close. And real-world examples show that the state of self-health-tracking today is still amazingly advanced.
For instance, take a patient with congestive heart failure. Her doctor might ask her to step onto a Wi-Fi–connected bathroom scale (such as the Withings Smart Body Analyzer) every morning. Her weight is transmitted over a secure network to her health care provider. If a sudden change in weight is detected, the doctor receives a notification. And if the doctor thinks the change may be an indicator of another serious medical problem, such as fluid buildup in the lungs, she’ll call her patient and tell her to come in immediately. CareMore, a health company owned by insurance and health services provider WellPoint, has already built this exact monitoring and alert system, and it’s helped save patients through early detection and treatment of serious medical problems.
Or consider a diabetes patient. Roberson’s company VitalConnect makes a device called HealthPatch, which is an adhesive bandage with sensors that monitor a patient’s vital signs, movement, and several other metrics, all without having to hook up the patient to a bunch of machines. Roberson’s 80-year old mother is diabetic, and when she’s at home wears the patch, which can detect the difference between sitting and standing. When she stands, her heart rate should go up a little. If her heart rate jumps too much, that’s a sign she’s probably dehydrated, Roberson explains. “We can set an alarm to show that she needs to be drinking more. We also have the ability to set an alert if she falls, for example, so that it can notify a health care provider or a family member or a neighbor—anyone you choose.”
It’s not just diabetic senior citizens who benefit from these smart devices. With professional sports players, it’s not so much a matter of keeping them well, but keeping them at their optimal fitness level. A number of devices on the market today make recommendations about when the athlete has recovered enough from a previous workout to begin the next one. Some smart devices can track the performance of individual muscles. Others get even more specific than that, like that calf-compression sleeve that measures lactic acid buildup and gives a cyclist real-time, objective feedback about when to exert himself and when to back off. Many people have heard about the helmet sensors that alert a coach when a football player has been hit in the head too hard. Considering the amount of money in professional sports, increasing someone’s performance output by even 5 percent could have huge incentives.
The market for wearable fitness trackers started peaking around late 2012, and just in this past year, dozens of new products hit the market. Often, fitness device makers announce new products before they’re truly available and sell a limited number of beta versions to early adopters. Those people are often software developers or other experts in fields related to the device (such as health sciences), and they tinker with the working prototypes and provide feedback while the manufacturers are still working out hardware kinks. The result is an industry that’s advancing quickly with excellent input from many different points of view.
WHAT’S WRONG WITH GENERATION ONE?
Smart pedometers with the typical nine-axis sensor (a three-axis accelerometer, gyroscope, and magnetometer) for tracking steps walked, quality of sleep based on motion data, and little else, are already passé among the tech-savvy. If a tracker doesn’t also have an optical heart rate monitor that can read your pulse through your skin, why bother with one?
“Every year the market is flooded with more and more sophisticated wearables and applications,” says Riaan Conradie, CEO and cofounder of HealthQ Technologies, a company that’s building more advanced systems for tracking health. “People are hungry to understand their bodies better. However, wearables, due to their noninvasive nature, are limited in what they can measure.”
Conradie believes we need to shift away from focusing on wearable devices and instead gravitate toward an approach where we view the body itself as the sensor, and use computers to create models of the systems inside our bodies. “Sensors by themselves will always over-promise and under-deliver,” he says. “We need to have a mathematical model to truly understand what we’re seeing.
“With the modeling approach, one can delve deeper into metrics that are not measurable with wearables,” Conradie continues. “This enables one to, for instance, model the blood glucose dynamics, and then use more available noninvasive wearable inputs to provide information for the mentioned models. By following this approach, a very wide variety of metrics and information pertaining to medical problems such as diabetes, obesity, and heart disease opens up.”
Another problem with the current generation of wearables is that they are meant to collect a lot of information over a long period of time, but about a third of people who buy an activity tracker abandon it within the first six months, according to a white paper by Endeavour Partners based on research from 2014. If people won’t wear the devices, they do no good.
Better are the slew of products released between October 2014 and early 2015. The newest trackers collect more data points and do so more invisibly. Take, for instance, the just-released Apple Watch. It’s not only a smartwatch that puts text messages and other iPhone onto your wrist, but it’s also a comprehensive fitness tracker with a handful of applications designed specifically to collect medical data for research, if you opt in to the program. (The “opt-in” clause is crucial for people concerned with privacy surrounding their health data—a topic beyond the scope of this article.)
Or consider the much more futuristic products by a company called Athos. Instead of designing a bracelet or clip-on tracker, Athos makes sports performance apparel—shirts, shorts, and capris—with sensors embedded in them. The clothing measures a variety of data about your heart, lungs, and muscles as you work out, and sends this information to a small attached “core” that then transmits it to your smartphone, so you can see in real time how your body is performing.
To combat device fatigue, another interesting health and wellness device, called Mother by Sen.se, is actually a mini connected home kit, with sensors that are reprogrammable so that you can change what they track if you grow tired of it. For example, you can assign one of the four trackers included with the kit to be your activity monitor, and when you’ve lost interest in counting your steps, you can reassign it to monitor your medication to make sure you take it on time.
Another product on the 2015 roadmap that sold out all its pre-orders when it was announced is a tracker called Sproutling. It’s an ankle cuff designed for infants that collects a comprehensive amount of data about your baby, and it pairs with a mobile app to make predictions based on what it knows about your child. The cuff reads heart rate, skin temperature, motion, and position, which means it can figure out when your baby is sleeping or awake, and predict how many minutes you have before your baby wakes up from a nap.
The switch from the first generation of trackers to the second isn’t just about collecting more data or having more data streams, but what that additional data can help us predict, whether about how much “me time” you have left before your kid wakes up or if you’re at risk for type 2 diabetes.
E-HEALTH CARE, SHARING, AND BIG DATA
Health and fitness trackers collect data. Software and apps help patients draw conclusions about their data. But health care providers, everyone from nurses
to physical therapists, still play the role of consultant, giving advice on how to act on that data.
Technology has made it easier and more efficient to connect the two parties (the patient and the “consultant”), and the data collected by fitness and health trackers gives health care providers insight into what is happening with our bodies all the time, not just when we’re in a doctor’s office. Suddenly, we can safely eliminate minor problems, such as white coat hypertension and even the stress of driving to a physician’s office. The health care provider can access the bigger picture of the patient’s whole data from anywhere, without the two even needing to be face-to-face.
Virtual doctor’s visits are real and are happening today. HealthTap, for example, is a mobile app that lets anyone ask medical questions of a professional, certified doctor. PingMD, another mobile app, goes one step further to connect you to your personal physician, where you can exchange messages and even pictures in a private, secure, HIPAA- and HITECHcompliant platform. And those are just mobile apps.
“In 10 minutes or less, you can be face-to-face [virtually] with a board-certified doctor, 24 hours a day, seven days a week, 365 days a year—right now that’s in 44 states plus Washington D.C.,” says John Jesser, speaking of a telehealth service called LiveHealth Online. Jesser is vice president of provider engagement and cost of care at WellPoint, which owns LiveHealth Online. The service wants to make it as easy for a patient to upload information to LiveHealth Online as it was to collect in the first place with a fitness tracker or other health technology. “All that information will only make the conversation with the health care professional richer,” Jesser adds.
Gathering all this information in the cloud has two interesting but opposite outcomes. The first has to do with big data, and second is in regards to having more personalized medicine.
Big data, in a nutshell, means collecting huge amounts of information about users, far more than any controlled medical study could. Users these days often consent en masse every time they check that “I agree” box on an end user license agreement for a new app. The app provider typically anonymizes the information, but can still see some interesting trends, such as differences in behavior or data in men versus women, or women over a certain age, or men who have self-identified as having a sedentary lifestyle. This data is self-reported and difficult to check for accuracy, but it’s collected at a scale the likes of which no medical research center has ever been able to do before. Data analysts might be able to draw new inferences from these huge data sets as a result.
“We’ve been trying to move in the United States from reactive to preventive care for a long time,” says Roberson. “When you can measure people’s health decisions, on a global basis, that lowers their tendency to develop cardiovascular disease, then that’s really valuable.”
The flip side is that all this technology—from the e-delivery platforms to the health trackers to the other tools that self-quantifiers use—lets individuals get much more personalized medical advice. Say a medical study finds that, of 100 people with the same condition, 80 percent of them respond to a particular treatment. What if you’re in the 20 percent as a nonresponder? The technology we have now and will have in the near future makes it easier to first identify that you are a nonresponder and then figure out what would be a better course of treatment specifically for you. “The general trend here, and I think a really healthy one,” Roberson says, “is that we’re moving medical decisions and medical knowledge into the consumer space.”
Jessica Richman is CEO and cofounder of uBiome, a mail-away microbiome sequencing service. “We’re involved in a number of research studies on heart disease and autism, and the microbiome is pretty much related to everything. [Microbiomes] are leading indicators of what’s going on with us,” says Richman. Personalized medicine, both reactive and preventive, is only possible with the increasing availability of services like uBiome that give a highly detailed and highly personalized analysis of the body.
Equally important to the changing face of health care is the availability of virtual doctor’s appointments. Teleconferencing and swapping messages via a mobile app lets patients know when they don’t need to drive to the physician’s office or hospital, and that lowers costs. Physicians end up treating patients who require immediate care faster, and patients who don’t need intervention at all get better preventive care at the same time, within the comfort of their homes. That’s a radical change, and surely hits home to any new parent with a “better safe than sorry” attitude for bringing their kid to the ER for every bump, rash, and fever. It’s already possible to snap a photo of a rash, upload it securely to your doctor, and receive back a secure message saying, “It doesn’t seem to be a problem. Keep an eye on it for a day, and call if you notice any changes.”
Getting health data online has another benefit: community, or social sharing.
“New technologies are particularly powerful in creating new communities,” says Dr. Amaël Arguel, a postdoctoral fellow at Centre for Health Informatics of the Australian Institute of Health Innovation studying e-health care. “People who face similar problems can virtually meet each other to share their experience and to get some support,” Arguel says. “Social influence is well known for being an efficient factor for influencing behavioral change and decision making.”
THE PAST AND THE FUTURE
LifeQ’s Conradie imagines that the high-tech future of health care is imminent. “I speculate that in the next ten years, we will have implantable sensors for various data streams,” he says. “In the next 20 years, we will be able to simulate most thought processes, and with companies like ours, we would be able to understand how our environment affects our body and mind. In the next 50 years—sheesh! This will be dangerous to speculate, but the world will be hyperconnected and problems that are system-wide [such as social and economic] will be solved virtually, automatically, as they arise, through intricate systemic feedback and feedforward loops.”
Arguel, on the other hand, looks to the future with some skepticism—not because the technology isn’t possible, but because some people might not want to use it. “Adoption of new technologies is not only related to the availability of the technology itself, but also depends of users’ attitude toward it,” she says. Case in point: Twenty-five years ago, who wasn’t excited about the prospect of video phone calls? Yet who would have imagined that the communication technology that so many people prefer today, text messaging, is actually much closer to the telegram? Video conferencing services, such as Skype and GoToMeeting, are readily available with extremely low barriers of entry, but we tend to use them only in certain situations. The future didn’t quite turn out as many people expected.
I believe that the first generation of fitness trackers is precisely what is preparing us for a truly high-tech future. The more people are comfortable wearing devices that measure their gait, heart rate, respiration, or sweat, the more easily we’ll slip into a world where fMRI headbands and glucosemonitoring contact lenses—which are currently in development by Google[x]— don’t seem all that scary. What about a sensor embedded on the crown of your dental work? How about smart devices tucked inside the uterus, perhaps attached to an IUD that’s already there? We’re becoming accustomed to the medical devices that will change our health care and the data collection that they perform by way of $99 consumer gadgets.