Misplaced excitement

Misplaced excitement

As we have been reporting Apple’s once secret now public effort to dive into the deep end of the diabetes pool is creating quite the stir. Now to be fair the company itself hasn’t revealed exactly what they are working or what their strategy is. The main speculation is that the company is develop a non-invasive glucose monitor of some sort. Speculation which got a major boost when it was reported that Apple CEO Tim Cook was wearing a prototype of this way cool whiz bang toy.

Given that the annual ADA confab is only a few weeks away we’re sure this will be a major topic of conversation. Even though the company has not articulated a diabetes strategy that hasn’t stopped the speculation. Now this does not surprise Diabetic Investor as this is Apple a company known for way cool whiz bang. A company which has gobs of money and has a loyal almost fanatical following. Everyone just assumes that Apple will succeed where everyone has failed. That at long last the Holy Grail of diabetes devices will be discovered.

Although we remain skeptical that Apple will be successful, that they have found the secret sauce let’s just for grins and giggles assume they have. Will this discovery of the Holy Grail of diabetes devices change anything? Given that this quest has been going on since before Diabetic Investor began publishing, that’s more than 20 years, let’s review why everyone is so excited.

The theory has always been that the reason patients don’t monitor their glucose levels regularly is the “pain” associated with performing a glucose test. That if this “pain” was taken away and levels could be measured non-invasively patient outcomes would improve.

We on the other hand have never believed this to true. Our contention has always been that for most patients these numbers are meaningless. That the reason they do not monitor their levels regularly is these numbers have no value. That the information is not patient relevant nor it is patient actionable. This is not just true for the millions of patients who do not use insulin but also to fair amount of insulin using patients whose insulin dosing regimen has been dumbed down by their physician.

Yes, we know its redundant but there is a reason insulin pump patients monitoring their levels the most frequently followed by patients following multiple daily injection (MDI) therapy. Once you move beyond these patients who intensively manage their diabetes average testing frequency drops off dramatically. Although the reasons should be obvious allow us to provide a peek into the life of a patient who does not intensively manage their diabetes, a patient who does not use insulin or if they do they are taking insulin along with their pills.

Unlike intensively managed patients their dosing regimen does not change no matter what their levels are. These patients take the same amount of metformin, Januvia, Jardiance and Lantus no matter what their levels are. It does not matter if their level is 100, 200 or 500 they take the same pills at the same time every day. If they care about any number at all its HbA1c mainly because this is the number their physician talks about all the time.

Many seem to believe that this will change once a non-invasive glucose monitor arrives. That these non-intensively managed patients suddenly will value this information. That because there is no “pain” associated with testing that these numbers mean something. That this information suddenly becomes patient relevant and patient actionable. We disagree here’s why;

Now it goes without saying that this way cool whiz bang toy will come with an app that is just as a cool. Yes, this app will not just collect the data, analyze it and send it to the patient’s physician but it will also send the patient messages designed to help them better manage their diabetes. It will give them the how to, the diabetes instruction manual so to speak.

Let’s assume for a moment that the patient is receptive to these messages and wants to make a change, what then? Well they can change what they eat or whether they exercise or not but the one thing they cannot change if their therapy regimen. This requires an intervention with their physician who may or may not agree with the recommendations made by the way cool app. But what the heck let’s say everyone is agreement that yes, a change in therapy is needed, are we happy yet? Not by a long shot.

Besides getting the patient and physician to agree whatever change is made needs to be approved and paid for by the patient’s insurance provider.

Take a moment and think about this in a real-world setting. Here you have a patient that is not intensively managed, a patient who has a disease they don’t want. A disease they don’t understand. A disease that to manage well requires work, lots of work. This patient does not feel any physical discomfort and honestly “feels” just fine. Yet their new toy is telling them they aren’t fine. That they must change.

Now let’s say after all this guilt the patient becomes a good patient and does everything they are being told to do, what is their reward? Will they “feel” any better? Will their life become easier? Will they save money? Will the disease they have which they didn’t want in the first place and never have understood go away? Will their health insurance premiums go down? Will they pay less out of pocket for their meds?

What tangible benefits will the patient personally experience? Keep in mind that better outcomes are NOT a tangible benefit to these patients. They cannot see or feel a better HbA1c. No one will come up to them and say; “OMG your A1C looks great”.

Just in case anyone doubts this consider the following. Years ago, a study done at the University of Chicago concluded that patients would SACRAFICE YEARS OFF THEIR LIVES RATHER THAN DO ALL THINGS THEY WERE SUPPOSED TO DO WHEN IT CAME TO MANAGING THEIR DIABETES. Stop for a moment and reread that last sentence.

Our connection has always been even if you combine the how to with the want to this isn’t enough. That it will not in most cases provide the drive, the desire to keep doing what these patients are being told to do. That without some sort of tangible reward that these patients will lose the drive, the desire.

Perhaps the best way to think about this is to think of patient on a weight loss program. The patient does all the heavy lifting and loses the weight. Even better they get positive reinforcement when their friends, family members and co-workers tell them how great they look. What happens? More often than not they gain the weight back.

Think now how a non-intensively patient must feel. A patient who is NOT receiving constant positive reinforcement. A patient who is NOT reaping any TANGIBLE rewards for all the hard work they have been putting forth. They aren’t saving money. They aren’t “feeling” better. Yet their work load has increased. Diabetes is no longer part of their lives, it has become their life. They are not living with diabetes, they are now living for diabetes.

This is why we could care less whether Apple discovers the Holy Grail. This is just another damn toy and this isn’t about toys. But that won’t stop the excitement as the truth is everyone is fascinated by way cool whiz bang toys especially when they come from the Apple orchard.

As Momma Kliff used to say; “There are times when excitement is warranted, but far too often people get excited for the wrong reasons. They become blinded by the hype, the promise of a better tomorrow when they can’t see the realities of today.” To us this whole Apple pie thing is just lots of misplaced excitement. Yeah it will get tons of attention but other than create more copy it won’t make a damn bit of difference.