I am a founder and researcher at https://replica.health and co-creator of https://metabo-net.org. This is super exciting and cant wait to see what we can learn once large datasets of overlapping ketones + glucose + insulin data become available.
One point I discussed with other researchers at ADA this year: in theory automated insulin delivery does not stand to benefit much from ketone sensors, since diabetic ketoacidosis will almost always be preceded by high blood glucose, which we already measure using the cgm. It will be interesting to see what this ketone data is actually used for.
We came up with the idea of having a place where nerds could come together to hang out and learn from each other and we decided to call the concept "Hacker Dojo". I had a sign laser engraved in 2002 at a state fair to memorialize the idea but we didn't actually get to open a Hacker Dojo until 2009.
There's a conference room in it called Kaminsky.
Dan was not a very good roommate but man, his brain worked in weird and wonderful ways, and it was inspiring how he could just rabbit-hole on stuff other people didn't find interesting until he MADE it interesting and found things nobody else had.
I wasn't sure how specific to be in my comment, but I'm glad the people who knew him know who it is. Speaks a lot of the man. I'm also 100% ready to believe he was not a good roommate by the condition of his car ;)
Automated glucose control will be the next frontier in so many areas of healthcare. I'm still skeptical that anyone will be able to noninvasively and accurately sense blood sugar, but I'm glad people (especially kids with T1) will have one more tool to help them. I hope they can figure out the reimbursement side to get it into the most hands possible!
If the large studies are to be believed, you could save hundreds of thousands of lives and many billions in excess expenditure, because stable blood glucose shortens length of stay. People with diabetes alone account for 60% of hospital expenditure, so improving their care improves the system in a big way.
>People with diabetes alone account for 60% of hospital expenditure
That number seemed too large to be true, and I think you might be conflating some numbers...
The NIH study about Economic Costs of Diabetes in the US in 2022 [1] states:
>For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes.
So, 25% of health care (not hospital) dollars in the US are apportioned to people with diabetes, and in 61% of those cases, the cause is directly attributable to diabetes itself.
Similarly, an NHS study [2] revealed that 60% of overall diabetes spend goes towards diabetes-related complications.
Finally, this presentation [3] states that: "hospital stays involving patients with diabetes contributed almost $83 billion or 23% of the total hospitalization costs in the United States," and, of course, not all of those were directly diabetes-related.
Obviously that is still a staggering amount of money spent on diabetes every year, and represents a huge burden on our healthcare system. But 60% for all hospital expenditure just doesn't track from my cursory Google-ing here.
Blood glucose levels affect lots of health functions. Diabetes represents an extreme end of the spectrum where the body's ability to regulate these fluctuations fails, but just because your body can get your levels in control eventually doesn't mean you won't suffer from the negative effects of it needing to do so.
Maintaining consistent glucose levels improves mental health, weight management, sleep quality, muscle recovery, systemic inflammation, cardiovascular health, and may even slow aging. There isn't much clinical data at the moment on how to use blood glucose measurements to control glucose levels outside of people with diabetes (there are lots of things that impact it besides just sugar intake), but there are definitely major theoretical benefits if it can be worked out.
Also, just reducing the incidence of diabetes would be no small accomplishment. About 3.5% of global disability adjusted life-years (DALYs) are due to diabetes. As of 2021 it was the 7th largest contributor of global DALYs.
sample of 1, but yeah changing my diet (very low sugar, more veggies) did alter my health visibly and rapidly. to the point that if I eat something too sweet too fast i have a very mild headache soon after, my system readjusted to not seek levels i grew up with
if sugar gives you a headache, this may be related to a gastrointestinal issue (e.g. gluten sensitivity, dietary histamine sensitivity, small intestinal bacterial overgrowth possibly causing its own sensitivities...) The specifics of the cause in your case are between you and your doctor, but i'd like more people to know, especially since these sorts of problems disproportionately affect people with autism and ADHD, long a core Hacker News demographic, and most of us have trouble paying attention to everything our body is feeling in exquisite detail.
other signs of digestive problems in this area may include:
- a pattern of early-afternoon fatigue and brain fog (this is mediated by histamine, which in turn can be caused by a food allergy, a non-allergy food sensitivity, bacteria in the stomach that don't belong there, or the like)
- feeling generally flushed and hot after eating food (more histamine!)
- waking up in the middle of the night, ~4am, especially if you're feeling too hot (also a sign of excess histamine)
- often having an upset stomach, and lots of stomach acid
- increased sensitivity to heat or exercise (mast cell degranulation because your body is already on edge)
- generalized hard-to-place fatigue, brain fog, depression (the whole histamine-response pathway is shot through with various neurotransmitters)
- serious nasal congestion contributing to sleep apnea, and extreme fatigue
now, this is going to be different from person to person, but your doctor's not going to know anything's wrong if you don't tell them!
(and if something like this is the case, it's also the sort of condition that might sometimes has an instant miracle cure, because if you stop releasing the feel-bad neurotransmitters every time you eat, then you suddenly stop feeling terrible!! go figure.)
> it's also the sort of condition that might sometimes has an instant miracle cure
I assume that by this you mean figuring out some kind of dietary restriction?
I also struggle with a lot of those things (also ADHD) plus other inflammation-related issues (ezcema), and noticed a very specific pattern of fatigue during the day that improves at night. It's hard to tell what might be effective or not since keeping stability in my routine is a struggle, but I've mostly came up empty on explanations/solutions so far.
What happens is you lose carb tolerance if you don't take them regularly.
I had really high carb tolerance but doing keto for many years has plummeted it and I'm very sensitive now (can still train it). Another example doing keto for many years you also have lower alcohol tolerance.
Recall that GLP-1s were originally designed as next-generation long acting insulin modulators; they're a form of passive control. The CGM gives you data to act on, or at the very least observe. I find, from my experience wearing them as a person without diabetes, they give really interesting insights into my own life by giving numbers to stressful moments, which can be good insight to have. That's called stress induced hyperglycemia. Everyone has a unique and continuously evolving glucose system, so YMMV.
I am confident that blood glucose has a lot to do with mood regulation as well.
Having been diagnosed with bipolar since 1997, when I began mainlining insulin last year I immediately took notice of how calm and docile I became. I have anger issues and taking insulin turned me into a lamb. I also immediately began sleeping peacefully and restfully, which had been elusive for a decade.
I currently take a calcium channel blocker for hypertension, and Metformin for the glucose, and I monitor with Stelo. But I would give anything for that calming effect of fast-acting insulin.
Cardiac surgery, burn units, ICU, neuro come to mind. All have been studied to show mortality and complications improvements with AGC, but unfortunately the commercial technology has not materialized yet.
Drug interference (with the sensor chemistry) and perfusion (which the sensor needs to function) are two major problems that a hospital presents that are not present in ambulatory (outside the hospital) use. Also the FDA has not approved any systems yet; the software is actually quite difficult to get right.
I’m willing to bet we can see longevity improvements from better blood sugar control. Not 100% certain but extremely likely, this would include potential heart attack and dementia reduction…
IMO blood sugar is too simple and focused on because of ease of measurement. Someone can have rollercoaster blood sugar and be far more metabolically healthier than someone with low and steady blood sugar. Continious insulin and cortisol monitors are far more interesting IMO
That's not a fair representation of what happened. That study was going for _aggressive_ control - beyond what any normal person would do. They were combining multiple drugs to force blood sugar down rapidly, including right after meals (when it _should_ be going up).
Paying more attention to your blood sugar and acting reasonably to keep it in check isn't giving anyone heart attacks.
From the AI
> The concern was not that lower glucose is inherently bad. Rather, pushing blood sugar down rapidly and very tightly—especially with insulin and multiple glucose-lowering drugs—caused more episodes of hypoglycemia, weight gain, and treatment complexity. Severe low blood sugar can trigger abnormal heart rhythms and other cardiovascular stress. The intensive-treatment arm was stopped early after about 3.5 years because it had a higher death rate, although the exact mechanism was not definitively established.
I'll be showing my bias here, but you're probably referring to NICE-SUGAR, which I think suffered mainly from having a pretty uninspired control algorithm. We built and simulated it and several other clinical protocols and it had the widest spread of performance, but it lost a ton of points to hypoglycemia performance, which is where you get into increasing mortality. The NICE-SUGAR protocol [1] has no notion of weight based dosing, and even has some completely missed edge cases. There have been similar studies in Japan with a better algorithm and they showed the expected benefits.
Ketones have some dieting and weight loss applications, so I guess you could do better real time tracking of how you're digesting carbs and when it's okay to eat? maybe
They are specifically relevant to trying to enter a fasted state.
The presence or absence of ketones in your blood can tell you whether or not (say) that coffee you just drank took you out of the fasted state (that you were in for not eating overnight).
Whether or not you are in a fasted state matters not just for weight loss, but also for things like longevity (when you are in a fasted state your body cleans up dead cells that contribute to things like cancer, whereas in a non-fasted state it leaves them lying around).
Preventive medicine is a bit one. If your fitness watch could measure blood glucose, I think it would be a ton more impactful in terms of health outcomes.
Can you be specific about what your bloodwork results showed and what special insights your CGM gave you and what behavioural changes it led to?
My anecdotal experience from doctor colleagues giving CGM to patients is that it does 3/5ths of fuck all to everyone except those with actual insulin dependent diabetes (T1 or T2) because when you get down to it the insights aren’t that great and most people actually aren’t that invested in shifting the dial on their health that much. But I’m fascinated by examples to the contrary
Seeing just how much rice can impact your blood sugar is eye opening. Sticking to a "half the normal amount" of rice when eating Indian/Asian food can help a lot with blood sugar. And keeping blood sugar in check _seems_ to have a fair amount of researching backing up the idea that it's healthier and makes you feel better
For sure it's going to depend on the person, but I bet a lot of the hacker news crowd here appreciates observability and metrics.
In software we're wiring up stuff with prometheus and making grafana dashboards and changing code and configuration based on what we see happening. CGMs in a way give you insight into one aspect of your body and diet.
I've been trying Lingo, and it's been super-interesting to see in almost realtime how your body reacts to different foods. Sure you read all the time about "watch your carbs..." or "don't eat so much sugar", but it's hard to know how seriously to take that advice.
It's a whole different thing though when you eat one thing for a snack and see a big spike in a graph on your phone, and eat a different thing the next day and see hardly any change at all. It makes it much easier to rationalize your food choices.
My story is: I had a really bad crash after eating a chocolate, which never happened before. That prompted the bloodwork, which shown that A1c was not where it's supposed to be.
I bought CGM myself, without any doctor's input. Didn't know they exist before reading some selfhelp book which my wife found.
Echoing another poster, it's eye opening how some of the foods you'd never think of, are spiking glucose levels.
Overall, after both me and my wife adjusted diet, much better energy through the day, no crashes.
Also rare genetic issues like GSDs and FAODs may benefit immensely from dual glucose and ketone metering. Next we need potassium and magnesium meters and that will benefit the people with rare renal wasting syndromes like Gitelman and Bartters
Metabolic psychiatry is rising, though very slowly. You do "epilepsy keto diet", and may work in bipolar/schizophrenia (need GKI 1-2, it's not keto for weight loss). But you don't need the continuous monitor, normal ketone monitor is fine, because the food list is very narrow.
The continuous monitor should help until you get the hang of the diet, it's a bit hard to maintain, but if it works, worth it.
"management" is the key word. Early diagnosis might help a lot not just with T1 but also T2.
Early diagnosis would save a lot of pain and suffering... and money.
I worked with an older T1 and apparently a bit less than half of kids diagnosed with T1 are diagnosed unconscious during a DKA event in the ER. "Treatment" cost, or at least requested revenue LOL, is at least $30K for an ER visit like that, and it also costs at least some months (years?) off their expected lifespan.
Figure about 0.5% of the population in the USA is T1, you read stuff like "about two million T1 diabetics" in the USA. So early T1 diagnosis would save the country overall about $30B just in DKA treatment alone at time of initial diagnosis.
If you could screen an entire population for less than $30B total lifetime cost, it would be financially rational to prescreen for T1 rather than waiting for ambulances to present incredibly sick kids. And potentially profitable.
Prescreening the entire population for metabolic disorders is quite plausible as a "tech startup idea" as the alternative is waiting for them to arrive in an ambulance while extremely sick/nearly dead. Lets say it could be done for $10B, leaving $10B for startup profit (charge insurance companies $20B which is not bad....) and $10B in lowered health care costs for the country in general, not to mention less suffering in the population. A win-win scenario.
IF blood sugar related disorders could be pre-screened for less than $10B total cost. A solid "maybe"? Plausibly a startup doing blood sugar prescreening would be a "multibillion dollar company" although not a trillion dollar unicorn. Still a good idea.
Metabolism, and the endocrine system in general, is very responsive to physical activity. Even in athletes, glucose can have significant ups and downs when it gets intense.
It would be interesting to see this technology branch out into monitoring hormones, minerals, vitamins, etc. For all of human history, the closest we've had to realtime monitoring is just our mood. It would be life changing for anyone to have this feedback.
Invasive CGMs (Continuous Glucose Monitor) and minimally invasive CGMs exist. It's the non-invasive CGMs which are being worked on because managing an implant or having something always poking through you is a big annoyance+risk compared to wearing a watch, ring, or patch.
The problems for these non-invasive options so far is they either too easily fail to work, are bulky/expensive, give very ballpark accuracies, or some combination thereof.
The biggest problem is that they are racist. Optical blood sugar sensing devices were developed a decade ago. They were pretty accurate for pale white people, ballpark for most skin tones and don’t work at all for Black people. Good luck bringing that to market. Apple threw out the whole product and restarted with infrared.
just got the https://www.stelo.com/ device. Doesn't hurt at all to install under your arm. The applicator just does this big SNAP! when you press the button and the filament goes under your skin but it's painless and no blood, it's not a needle at all.
Ketones are only going to be present if you are exceptionally bad (very high carb diet) or exceptionally good (very low carb diet) at managing your blood sugar. It's not going to be terribly useful for your average diabetic who has fairly good control over their blood sugars.
A measure which acts as a high and a low pass filter on a band of less risk which can be monitored by other means, or subject to improvements on measurements and narrow the central zone?
> your average diabetic who has fairly good control over their blood sugars
I think it's huge for diabetics. It's a mental toll for them. They hate having to constantly prick themselves to take readings. It's awkward, inconvenient and you have to do it multiple times to be sure you got a good reading. And worse of all, it's possible to forget to take a reading when you need to.
I don't understand. All of the diabetics I know personally (one type 1 and two type 2 diabetics) use continuous glucose monitors and have for some time, so they rarely need to prick their fingers anymore. Ketone levels can be checked with a urine test.
There's some difference in the readings of a CGM due to sampling different things (blood with finger sticks vs intercelluar fluid for a CGM) and taking a bunch of vitamin C (pills or in food) can throw the readings off. But I think one or two sticks a day to calibrate the CGM and in situations where readings seem off should be sufficient.
Which makes me think the market for these is diet-focused folk. Get the FDA to clear it on medical grounds for a specific usecase then sell it more broadly.
This already happens with CGMs. The bulk of the sales is with people who want them for lifestyle monitoring even though they're only medically cleared for diabetes use.
It would be beyond stupid for a healthy "diet focused" person to want to use this. They're not at risk for ketoacidosis, and there is zero evidence that continually measuring ketones would be useful in any sense. That's different from the purported use of CGMs, which is to monitor for glucose spikes in response to specific foods (and even then, the evidence that monitoring glucose spikes in healthy people has any benefits is really thin).
If someone really wanted to measure their ketone levels there are simple urine tests that do it - there is no need to measure it continuously for healthy people. And if they want to see if they're in ketosis it's pretty easy to determine - if they're on an ultra low carb diet and their breath smells like shit, it's a good sign they're in ketosis.
The difference is that these only measure blood sugar, while the new system also measures ketones, of keto diet fame, which are leading indicators of a really dangerous situation called diabetic ketoacidosis. It's treatable with a hospitalized IV insulin drip, but can be avoided if you have some advance notice.
My mom had T1D onset in her 50s. (It's usually thought of as a children's disease.)
She figured it out because she recognized the symptoms of ketoacidosis. That sent her to the hospital, which has thankfully allowed her to outlive her pancreas.
Diabetic ketoacidosis only happens in T1D, or when you have something extremely wrong going on metabolically (like failing organs, etc).
Normally it should never happen. It happens at ketones like ~10+ mmol, and it's ~impossible to go more than ~6 for a healthy human even eating 100% fat and fasting for a week+ and doing marathons or whatever all at the same time.
The keto diet, can actually help in T1D, by keeping blood sugar more stable overall, but you still need insulin, just less.
It can happen in people with uncontrolled T2D as well. My cofounder is a pediatric ICU doctor who has treated hundreds of DKA patients.
Also there wasn't really a relationship of the keto diet to the rest of my post, just using it to contextualize a technical term with one that might be more familiar.
> It can happen in people with uncontrolled T2D as well. My cofounder is a pediatric ICU doctor who has treated hundreds of DKA patients.
Yes, but you have to work really hard for many years to achieve this!
While on T1D it happens by default if you don't inject insulin.
> while the new system also measures ketones, of keto diet fame, which are leading indicators of a really dangerous situation called diabetic ketoacidosis
It was being said like ketones are bad, because they are known for this scenario, but should be noted that it only happens in these few scenarios, like in uncontrolled diabetes or organ failure or smth.
In most other cases they should be good. But won't happen randomly unless you're explicitly doing keto.
Ketones don't come from nowhere, they come from your body breaking muscles down in a last ditch effort to control sugars after they are dangerously elevated for extended periods of time, I'm talking 500+ over weeks. It's sort of like adding a "your car has been completely out of gas for one week" monitor to your "gas tank level" monitor.
Um, no ? Ketones come from fat burning, not muscle.
In T1D with no insulin, muscle break down from gluconesis will increase blood sugar in the blood even more. The absence of insulin also makes ketone production unrestricted, so you end up in ketoacidosis.
Muscle is used when you don't have fat, or when you eat completely nothing (burn both fat & muscle).
Like I've gained ~10KG of muscle while on keto diet. Blood sugar at 70-100 depending on scenario. Usually on the lower end.
These are the same CGM technologies (Dexcom = Stelo and Lingo = Libre), just aimed at the over the counter "health and fitness" market.
This is not verified info, but I would assume these are either A) the exact same device, just with different marketing B) "binned" production runs that did not meet the accuracy threshold for clinical/prescribed use, but are otherwise "good enough" for someone looking to healthmaxx.
I think they are the same with some software differences. I believe that the sampling rates and tolerances are different. For example, dexcom displays 5 minute samples while the stelo shows 15 minute averages (it internally gets a new sample every 5 minutes like the dexcom). I think the official accuracy is a bit lower for the Stelo as well, although in practice it's probably close to the dexcom.
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Looked into the OTC ones and it does seem they’re binned versions. The failure rate appears to be higher too, which is more acceptable in a non life threatening device.
It also probably gives the companies really valuable data.
What a remarkable legacy. I hope this technology helps prevent others from being lost to DKA. May Dan’s memory live on through the people he inspired and the communities he helped create.
Does anyone know if something like this is required to be approved by the FDA? Like if someone were to make one for the hobbyist/weight loss market, would that even be legal?
It depends on intended use. If it is to diagnose, cure, treat, or prevent a medical condition then it is a medical device that may need approval. If it's not intended for anything medical, it doesn't need FDA approval. For example, clinical thermometers are class II medical devices, lab thermometers aren't medical devices at all. If the device were genuinely only marketed for general wellness, it would be exempt.
Amateur cyclists already wear CGMs, and as a type 1 myself, they see mine and start asking all about CGMs. It must be so boring for them to worry about fluctuations between 85 and 120.
There has been talk, but as one who hangs around those circles I've not heard of anyone actually doing it. But I'm sure someone is. At the same time, what I'm reading is that CGM won't give a non-diabetic any actionable information.
a regulated blood sugar level aids massively in cellular repair, inflammation reduction, and immune response. These are well studied and established. I could absolutely see a top athlete using AID in the future as part of a recovery routine, but I can also understand reluctance to adopt anything new or weird.
A few years back, there were a number of startups that essentially resold prescriptions of the ABT/DXCM CGM and provided personalized meal/exercise-response analytics on top. Seems like traction has been tough going, though. Dialing back from "anyone with potential metabolic issues" -- what's a realistic market? Something like high-level athletes and/or bio-hacker enthusiasts are the only folks who seem to care. On the low end, the OTC options are eating away as well.. they are less accurate, but probably solve the use case better for a pre-diabetic "once-a-year/occasional" wear use case.
Talking to ultramarathoners and cyclists, I think lactate is a biomarker that is tracked (POC blood samples) and would be more immediately useful for training/performance. AID might be construed as a form of doping, IMO.
Lactate actually comes for free with blood glucose when you measure it with a chemical sensor, it's just not something that's usually asked for. I definitely think it would be considered a form of doping to use it in competition, but I think recovery is where it would make more impact anyways. You also wouldn't want to use it before a race, as you'd run the risk of reduced pancreatic function.
AGC will find its main application in surgical and inpatient uses, eg in cardiac, neuro, burn, ICU, and people with diabetes in any hospital setting.
There doesn't seem to be a continuous lactate sensor on the market. Lactic acid production and/or clearance are definitely useful data w.r.t. exercise (many training regimens talk about lactate thresholds) and also useful in in-patient settings.
No disagreement about AGC in the hospital -- there is a lot of lab/titration work in current clinical workflows for monitoring patient glucose levels.
Lactate's available in the internal engineering data of these sensors, just not something that anyone has wanted to spend the time or money to qualify with the FDA. It essentially comes "for free" due to the chemical reaction the sensor uses.
I think you are misinformed: the electrochemical reaction used by continuous glucose sensors relies on a glucose-specific enzyme and it doesn't have anything to do with lactate. Lactic acid strips use a completely separate enzyme/reaction.
Hat tip to you and sibling comment about continouous lactate sensors (seem like they are microneedle/patch based?). Quick review shows minimal clinical evidence, but maybe that's sufficient for the consumer wearable market.
I've had the fortune to work with several CGM OEMs behind the scenes as part of our work developing an artificial pancreas, they all have a secret lactate signal!
There doesn't seem to be a continuous lactate sensor on the market.
They exist, a simple search will turn up a variety (how well they work is a different question). But see my sibling comment, they're banned from cycling competition.
I am aware of the "eating wins races" strategy for endurance sports.
Glucose and ketone monitoring seems a natural, more precise extension of that strategy. Isn't the point of carb-cramming to get more glucose into your blood stream, where your muscles can convert that into forward motion?
Yes. But you don't need to monitor glucose levels to do this. Because it's well known you can productively use as much as you could manage to consume (without vomiting). So all the device will ever tell you (if you're in the middle of significant endurance event) is that you need to raise your blood sugar. It'd be no more actionable than a writing 'your blood sugar is low' on your hand with a sharpie.
Monitoring glucose and ketones can help you develop metabolic flexibility and let you grok how easily your body cuts over to ketones. Knowing your personal realtime glucose and ketone levels helps you understand just how much carbs will kick you out of ketosis or keep you in it. Glucose monitoring will help you avoid large crashes that can lead to low energy. Among other things!
My understanding is that essentially all high-level endurance athletes are just maximizing their simple sugar intake at all times (during exercise) and knowing blood glucose/ketone levels wouldn't change anything about that intake, nor would it have any impact on crashes.
I thought this was going to be a non-invasive sugar-level device, but it looks like in fact the innovation here is that a popular CGM line can now do ketones?
non-invasive continuous blood sugar measurement is mired in patents and technical challenges. Turns out it's really difficult to disambiguate the absorption lines of glucose from other similarly shaped molecules when you're also dealing with untangling skin conductivity, transmissivity, sweat, inflammation etc.
I also think there's no financial incentive from incumbents to develop something like this. Why would abbott develop something that works "forever" if they can milk people buying new sensors every 10~14 days.
There is a major IP holder in the space who is asserting their ownership, so even if they could solve the technical challenges, they might not be able to come to market.
As someone who has to deal with type 1 diabetes every day, this is marketing nonsense. No one needs ketones in the sensor - we need high-quality sensors, and Abbott's are only mediocre at best. They are not as bad as Dexcom, which is appalling, but they are still far from the superior quality of Medtronic/MiniMed which measure glucose exceptionally well.
Ketones are rare. They can kill you, but before that happens, your blood sugar usually rises enough for you to realise you may have ketones and start using test strips to measure them. Instead of this marketing gimmick, Abbott should have focused on improving the quality of their glucose sensors which is far more important.
I tend to agree that making the sugar measurements more robust is worth more than measuring the ketones at all. However, low sugar and high ketones can happen. And just getting notified when ketones pick up can be worth something too. The additional measurement is not useless seen from my perspective.
As an example: I was on a study that gave T1D patients Dapagliflozin (Farxiga). During the study, while on a long hike, I was hovering at low sugar and consequently insulin supply was mostly cut off for an extended period. As I started to to feel unwell, I measured ketones. I was briefed as preparation for the study to measure ketones when something seems wrong. Otherwise I wouldn't have thought of measuring ketones. Might not even have carried the kit.
On that occasion, the ketones were way above 1 mmol/l: a very high value. Protocol would have required me to call the study doctor due to the high level. Since it was a Sunday, I spared her, shot some insulin, ate a sandwich, and continued my hike. I could do that because I was not alone on that hike. I knew that if my situation deteriorated, somebody would be around to call rescue.
At the study debriefing I mentioned the incident and they said that adding to the effect of the Dapa, I was probably dehydrated, which led to the rare situation of both low sugar and high ketones.
All in all I think that if the sensor makers exhaust possible improvements for the glucose, it can make sense to add the ketone measurement as a safeguard. Having high sugar can have many reasons, and it often takes me a while to get to measuring ketones. Getting the signal of rising ketones, I would react faster a few times a year in situations where my insulin supply is broken.
There are and have been continuous glucose monitors available for some time, and you can even get one if you don't have diabetes - I'm wearing the Lingo one right now.
All this device adds is a simultaneous ketone check, which is really only relevant to diabetics and not as much of a benefit because ketone levels are often checked with a urine test.
You should understand the difference between taking a single drop of blood and trying to run a battery of tests on it, and sticking a probe into your extra cellular matrix to continuously monitor changes. It’s small, but it’s having a constant shifting flow of fluid at all times so it’s getting far more than one drop.
Looked after my son who has T1D for now 5 years, checked keytones maybe 20 times.
Compared to blood glucose which we check look at every 5 minutes.
Maybe this is more for Type 2 or other diabetes, or for people prone to DKA.
Or it is for people with a working pancreas who think looking at their blood sugars (and now keytones) tells them something like soothsayers reading tea leaves
A CGM that has ketone levels is quite literally pointless. If you have a CGM in the first place you would know if your sugars were high enough for long enough to get DKA.
Mate they won't understand. People generally are exceptionally ignorant about type 1 diabetes and also eager to fall for marketing gimmicks like this one. They have no idea what type 1 diabetes is.
For anyone who doesn't get it: glucose is checked every five minutes because it changes very often, jumping or falling dangerously. It's a nightmare. Checking glucose is 1000 times more important than ketones which are almost never a problem. If you get accurate glucose readings you are highly unlikely to ever experience ketoacidosis in the first place. Before ketones become a problem, glucose has to stay high for hours. Abbott is pulling this marketing trick instead of improving the quality of their sensors. Libre 2 is absolute crap. Libre 3 is somewhat okay and sometimes even mediocre - which is still a pretty bad situation. Bad glucose sensor is a nightmare and it can kill a person or a child much likely than ketoacidosis. It will actually lead to ketoacidosis by showing incorrect glucose readings. Now I wonder whether they added a ketone sensor as a failsafe for their low quality glucose sensors.
No one asked them to add a ketone sensor as an add-on to their glucose sensor, except maybe their marketing department. People want higher quality glucose sensors that fail less often and are more accurate. Glucose sensors, not ketones!
Understanding why children's pancreases stop delivering insulin in the first place, which remains one of the big medical mysteries, would be a huge breakthrough for preventative medicine.
I am a founder and researcher at https://replica.health and co-creator of https://metabo-net.org. This is super exciting and cant wait to see what we can learn once large datasets of overlapping ketones + glucose + insulin data become available.
One point I discussed with other researchers at ADA this year: in theory automated insulin delivery does not stand to benefit much from ketone sensors, since diabetic ketoacidosis will almost always be preceded by high blood glucose, which we already measure using the cgm. It will be interesting to see what this ketone data is actually used for.
A friend died of diabetic ketoacidosis. He loved technology and seeing people succeed. Thinking of him with this news. Miss you Dan.
Grateful we're moving forward on so many fronts in the world.
He was my roommate in 2001 in San Jose.
We came up with the idea of having a place where nerds could come together to hang out and learn from each other and we decided to call the concept "Hacker Dojo". I had a sign laser engraved in 2002 at a state fair to memorialize the idea but we didn't actually get to open a Hacker Dojo until 2009.
There's a conference room in it called Kaminsky.
Dan was not a very good roommate but man, his brain worked in weird and wonderful ways, and it was inspiring how he could just rabbit-hole on stuff other people didn't find interesting until he MADE it interesting and found things nobody else had.
I miss him too. What a gift he was to the world.
Dan was a spectacular brain, and made contributions that still echo today.
He is one of two friends to have passed from DKA. Miss you, Zach. RIP.
Miss pwning with you.
侍
I wasn't sure how specific to be in my comment, but I'm glad the people who knew him know who it is. Speaks a lot of the man. I'm also 100% ready to believe he was not a good roommate by the condition of his car ;)
Cheers to Dan.
Thank you for sharing his memory with us.
Out of curiosity, Type I or Type II diabetes, if you (or others) are aware?
Automated glucose control will be the next frontier in so many areas of healthcare. I'm still skeptical that anyone will be able to noninvasively and accurately sense blood sugar, but I'm glad people (especially kids with T1) will have one more tool to help them. I hope they can figure out the reimbursement side to get it into the most hands possible!
Automated glucose control is already available via wearable insulin pumps combined with CGMs in a 'closed loop' system.
None have been approved for hospital use as of yet, which is the next frontier.
Why is hospital use so important?
If the large studies are to be believed, you could save hundreds of thousands of lives and many billions in excess expenditure, because stable blood glucose shortens length of stay. People with diabetes alone account for 60% of hospital expenditure, so improving their care improves the system in a big way.
>People with diabetes alone account for 60% of hospital expenditure
That number seemed too large to be true, and I think you might be conflating some numbers...
The NIH study about Economic Costs of Diabetes in the US in 2022 [1] states:
>For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes.
So, 25% of health care (not hospital) dollars in the US are apportioned to people with diabetes, and in 61% of those cases, the cause is directly attributable to diabetes itself.
Similarly, an NHS study [2] revealed that 60% of overall diabetes spend goes towards diabetes-related complications.
Finally, this presentation [3] states that: "hospital stays involving patients with diabetes contributed almost $83 billion or 23% of the total hospitalization costs in the United States," and, of course, not all of those were directly diabetes-related.
Obviously that is still a staggering amount of money spent on diabetes every year, and represents a huge burden on our healthcare system. But 60% for all hospital expenditure just doesn't track from my cursory Google-ing here.
[1] https://pubmed.ncbi.nlm.nih.gov/37909353/
[2] https://www.diabetes.org.uk/about-us/news-and-views/cost-com...
[3] https://www.bu.edu/csmet/2020/08/04/healthcare-data-analytic...
Wild numbers. I already thought GLPs were huge but this makes me think it’s even larger.
oof, that's what I get for commenting late! I was thinking of that 23% number.
In fairness, that’s still massive.
> Automated glucose control will be the next frontier in so many areas of healthcare.
What areas do you have in mind outside of diabetes management?
Blood glucose levels affect lots of health functions. Diabetes represents an extreme end of the spectrum where the body's ability to regulate these fluctuations fails, but just because your body can get your levels in control eventually doesn't mean you won't suffer from the negative effects of it needing to do so.
Maintaining consistent glucose levels improves mental health, weight management, sleep quality, muscle recovery, systemic inflammation, cardiovascular health, and may even slow aging. There isn't much clinical data at the moment on how to use blood glucose measurements to control glucose levels outside of people with diabetes (there are lots of things that impact it besides just sugar intake), but there are definitely major theoretical benefits if it can be worked out.
Also, just reducing the incidence of diabetes would be no small accomplishment. About 3.5% of global disability adjusted life-years (DALYs) are due to diabetes. As of 2021 it was the 7th largest contributor of global DALYs.
sample of 1, but yeah changing my diet (very low sugar, more veggies) did alter my health visibly and rapidly. to the point that if I eat something too sweet too fast i have a very mild headache soon after, my system readjusted to not seek levels i grew up with
fwiw...
if sugar gives you a headache, this may be related to a gastrointestinal issue (e.g. gluten sensitivity, dietary histamine sensitivity, small intestinal bacterial overgrowth possibly causing its own sensitivities...) The specifics of the cause in your case are between you and your doctor, but i'd like more people to know, especially since these sorts of problems disproportionately affect people with autism and ADHD, long a core Hacker News demographic, and most of us have trouble paying attention to everything our body is feeling in exquisite detail.
other signs of digestive problems in this area may include:
- a pattern of early-afternoon fatigue and brain fog (this is mediated by histamine, which in turn can be caused by a food allergy, a non-allergy food sensitivity, bacteria in the stomach that don't belong there, or the like)
- feeling generally flushed and hot after eating food (more histamine!)
- waking up in the middle of the night, ~4am, especially if you're feeling too hot (also a sign of excess histamine)
- often having an upset stomach, and lots of stomach acid
- increased sensitivity to heat or exercise (mast cell degranulation because your body is already on edge)
- generalized hard-to-place fatigue, brain fog, depression (the whole histamine-response pathway is shot through with various neurotransmitters)
- serious nasal congestion contributing to sleep apnea, and extreme fatigue
now, this is going to be different from person to person, but your doctor's not going to know anything's wrong if you don't tell them!
(and if something like this is the case, it's also the sort of condition that might sometimes has an instant miracle cure, because if you stop releasing the feel-bad neurotransmitters every time you eat, then you suddenly stop feeling terrible!! go figure.)
> it's also the sort of condition that might sometimes has an instant miracle cure
I assume that by this you mean figuring out some kind of dietary restriction?
I also struggle with a lot of those things (also ADHD) plus other inflammation-related issues (ezcema), and noticed a very specific pattern of fatigue during the day that improves at night. It's hard to tell what might be effective or not since keeping stability in my routine is a struggle, but I've mostly came up empty on explanations/solutions so far.
Woah. I have ADHD and most of these symptoms.
What happens is you lose carb tolerance if you don't take them regularly.
I had really high carb tolerance but doing keto for many years has plummeted it and I'm very sensitive now (can still train it). Another example doing keto for many years you also have lower alcohol tolerance.
Do you think CGM + alerting is a good solution for this compared with just, like, low-dose GLP-1s?
Recall that GLP-1s were originally designed as next-generation long acting insulin modulators; they're a form of passive control. The CGM gives you data to act on, or at the very least observe. I find, from my experience wearing them as a person without diabetes, they give really interesting insights into my own life by giving numbers to stressful moments, which can be good insight to have. That's called stress induced hyperglycemia. Everyone has a unique and continuously evolving glucose system, so YMMV.
I am confident that blood glucose has a lot to do with mood regulation as well.
Having been diagnosed with bipolar since 1997, when I began mainlining insulin last year I immediately took notice of how calm and docile I became. I have anger issues and taking insulin turned me into a lamb. I also immediately began sleeping peacefully and restfully, which had been elusive for a decade.
I currently take a calcium channel blocker for hypertension, and Metformin for the glucose, and I monitor with Stelo. But I would give anything for that calming effect of fast-acting insulin.
Cardiac surgery, burn units, ICU, neuro come to mind. All have been studied to show mortality and complications improvements with AGC, but unfortunately the commercial technology has not materialized yet.
Why is a hospital setting so different that AGC can not be used? Or is the temporary use of such not yet approved?
Drug interference (with the sensor chemistry) and perfusion (which the sensor needs to function) are two major problems that a hospital presents that are not present in ambulatory (outside the hospital) use. Also the FDA has not approved any systems yet; the software is actually quite difficult to get right.
I’m willing to bet we can see longevity improvements from better blood sugar control. Not 100% certain but extremely likely, this would include potential heart attack and dementia reduction…
IMO blood sugar is too simple and focused on because of ease of measurement. Someone can have rollercoaster blood sugar and be far more metabolically healthier than someone with low and steady blood sugar. Continious insulin and cortisol monitors are far more interesting IMO
This has been tested actually. A clinical trial looking at tight blood sugar regulation was aborted after it resulted in multiple cardiac events.
That's not a fair representation of what happened. That study was going for _aggressive_ control - beyond what any normal person would do. They were combining multiple drugs to force blood sugar down rapidly, including right after meals (when it _should_ be going up).
Paying more attention to your blood sugar and acting reasonably to keep it in check isn't giving anyone heart attacks.
From the AI
> The concern was not that lower glucose is inherently bad. Rather, pushing blood sugar down rapidly and very tightly—especially with insulin and multiple glucose-lowering drugs—caused more episodes of hypoglycemia, weight gain, and treatment complexity. Severe low blood sugar can trigger abnormal heart rhythms and other cardiovascular stress. The intensive-treatment arm was stopped early after about 3.5 years because it had a higher death rate, although the exact mechanism was not definitively established.
I'll be showing my bias here, but you're probably referring to NICE-SUGAR, which I think suffered mainly from having a pretty uninspired control algorithm. We built and simulated it and several other clinical protocols and it had the widest spread of performance, but it lost a ton of points to hypoglycemia performance, which is where you get into increasing mortality. The NICE-SUGAR protocol [1] has no notion of weight based dosing, and even has some completely missed edge cases. There have been similar studies in Japan with a better algorithm and they showed the expected benefits.
[1] - https://www.glycemiccontrol.net/NICE/StudyDesign/NiceALGORIT...
Interesting! Found this overview: https://emcrit.org/pulmcrit/tight-glycemic-control/
Nonsense, you can fast or live in ketosis for years without any adverse consequences.
Ketones have some dieting and weight loss applications, so I guess you could do better real time tracking of how you're digesting carbs and when it's okay to eat? maybe
They are specifically relevant to trying to enter a fasted state.
The presence or absence of ketones in your blood can tell you whether or not (say) that coffee you just drank took you out of the fasted state (that you were in for not eating overnight).
Whether or not you are in a fasted state matters not just for weight loss, but also for things like longevity (when you are in a fasted state your body cleans up dead cells that contribute to things like cancer, whereas in a non-fasted state it leaves them lying around).
whether or not (say) that coffee you just drank took you out of the fasted state
A cup of coffee has zero carbohydrates, trace lipids, and about half a gram of protein. That's not going to pull anyone out of a fasting state.
Now, if you're talking about a cup of flavoured milk, that's a different question...
I think I drink coffee but I really drink lattes…
Adding any amount of milk to a coffee adds carbs. And a large number of people add _some_ amount of milk.
[delayed]
Preventive medicine is a bit one. If your fitness watch could measure blood glucose, I think it would be a ton more impactful in terms of health outcomes.
In what way? Nondiabetic folks self regular glucose just fine on their own.
[delayed]
That's what I thought too, until I got my last bloodwork results and started wearing one of the OTC continuous glucose monitors.
That device helped a lot to switch diet habits.
Can you be specific about what your bloodwork results showed and what special insights your CGM gave you and what behavioural changes it led to?
My anecdotal experience from doctor colleagues giving CGM to patients is that it does 3/5ths of fuck all to everyone except those with actual insulin dependent diabetes (T1 or T2) because when you get down to it the insights aren’t that great and most people actually aren’t that invested in shifting the dial on their health that much. But I’m fascinated by examples to the contrary
Seeing just how much rice can impact your blood sugar is eye opening. Sticking to a "half the normal amount" of rice when eating Indian/Asian food can help a lot with blood sugar. And keeping blood sugar in check _seems_ to have a fair amount of researching backing up the idea that it's healthier and makes you feel better
Sure it impacts it. But what does that matter? Your body is very efficient as self regulating
> Your body is very efficient as self regulating
Yet the mind of most people is terrible at that, we love to overeat our body regulations.
For sure it's going to depend on the person, but I bet a lot of the hacker news crowd here appreciates observability and metrics.
In software we're wiring up stuff with prometheus and making grafana dashboards and changing code and configuration based on what we see happening. CGMs in a way give you insight into one aspect of your body and diet.
I've been trying Lingo, and it's been super-interesting to see in almost realtime how your body reacts to different foods. Sure you read all the time about "watch your carbs..." or "don't eat so much sugar", but it's hard to know how seriously to take that advice.
It's a whole different thing though when you eat one thing for a snack and see a big spike in a graph on your phone, and eat a different thing the next day and see hardly any change at all. It makes it much easier to rationalize your food choices.
I did it for a month and learned what kinds of things led to spikes and what did not and it wasn’t always obvious without the monitor.
My story is: I had a really bad crash after eating a chocolate, which never happened before. That prompted the bloodwork, which shown that A1c was not where it's supposed to be.
I bought CGM myself, without any doctor's input. Didn't know they exist before reading some selfhelp book which my wife found.
Echoing another poster, it's eye opening how some of the foods you'd never think of, are spiking glucose levels.
Overall, after both me and my wife adjusted diet, much better energy through the day, no crashes.
In the same way a step counter encourages people to walk more, a glucose monitor on your watch could discourage you from eating that extra donut
Does a step counter do that? All studies I've seen say they don't cause people to adapt their behavior
This study says otherwise: https://med.stanford.edu/news/all-news/2007/11/pedometers-he...
Even if it doesn’t increase steps on average, it will absolutely still work with someone who’s self-motivated and not just looking for a quick fix.
Also rare genetic issues like GSDs and FAODs may benefit immensely from dual glucose and ketone metering. Next we need potassium and magnesium meters and that will benefit the people with rare renal wasting syndromes like Gitelman and Bartters
Metabolic psychiatry is rising, though very slowly. You do "epilepsy keto diet", and may work in bipolar/schizophrenia (need GKI 1-2, it's not keto for weight loss). But you don't need the continuous monitor, normal ketone monitor is fine, because the food list is very narrow.
The continuous monitor should help until you get the hang of the diet, it's a bit hard to maintain, but if it works, worth it.
"management" is the key word. Early diagnosis might help a lot not just with T1 but also T2.
Early diagnosis would save a lot of pain and suffering... and money.
I worked with an older T1 and apparently a bit less than half of kids diagnosed with T1 are diagnosed unconscious during a DKA event in the ER. "Treatment" cost, or at least requested revenue LOL, is at least $30K for an ER visit like that, and it also costs at least some months (years?) off their expected lifespan.
Figure about 0.5% of the population in the USA is T1, you read stuff like "about two million T1 diabetics" in the USA. So early T1 diagnosis would save the country overall about $30B just in DKA treatment alone at time of initial diagnosis.
If you could screen an entire population for less than $30B total lifetime cost, it would be financially rational to prescreen for T1 rather than waiting for ambulances to present incredibly sick kids. And potentially profitable.
Prescreening the entire population for metabolic disorders is quite plausible as a "tech startup idea" as the alternative is waiting for them to arrive in an ambulance while extremely sick/nearly dead. Lets say it could be done for $10B, leaving $10B for startup profit (charge insurance companies $20B which is not bad....) and $10B in lowered health care costs for the country in general, not to mention less suffering in the population. A win-win scenario.
IF blood sugar related disorders could be pre-screened for less than $10B total cost. A solid "maybe"? Plausibly a startup doing blood sugar prescreening would be a "multibillion dollar company" although not a trillion dollar unicorn. Still a good idea.
Metabolism, and the endocrine system in general, is very responsive to physical activity. Even in athletes, glucose can have significant ups and downs when it gets intense.
It would be interesting to see this technology branch out into monitoring hormones, minerals, vitamins, etc. For all of human history, the closest we've had to realtime monitoring is just our mood. It would be life changing for anyone to have this feedback.
I wonder if there are any legs in an internal sensor that pushes out its reading every x? That seems pretty plausible.
Invasive CGMs (Continuous Glucose Monitor) and minimally invasive CGMs exist. It's the non-invasive CGMs which are being worked on because managing an implant or having something always poking through you is a big annoyance+risk compared to wearing a watch, ring, or patch.
The problems for these non-invasive options so far is they either too easily fail to work, are bulky/expensive, give very ballpark accuracies, or some combination thereof.
A good read on this topic is The Pursuit of Noninvasive Glucose: 'Hunting the Deceitful Turkey'.
seems to be: https://nolanhergert.github.io/notes_old/0media/physics/noni...
That’s the one
The biggest problem is that they are racist. Optical blood sugar sensing devices were developed a decade ago. They were pretty accurate for pale white people, ballpark for most skin tones and don’t work at all for Black people. Good luck bringing that to market. Apple threw out the whole product and restarted with infrared.
There are 6 month implantable CGMs, they're just quite expensive.
You got me thinking about possible hollow spots INSIDE my leg to put a sensor :P
Internal as in swimming in the bloodstream?
just got the https://www.stelo.com/ device. Doesn't hurt at all to install under your arm. The applicator just does this big SNAP! when you press the button and the filament goes under your skin but it's painless and no blood, it's not a needle at all.
Ketones are only going to be present if you are exceptionally bad (very high carb diet) or exceptionally good (very low carb diet) at managing your blood sugar. It's not going to be terribly useful for your average diabetic who has fairly good control over their blood sugars.
A measure which acts as a high and a low pass filter on a band of less risk which can be monitored by other means, or subject to improvements on measurements and narrow the central zone?
Sounds bloody useful to me.
> your average diabetic who has fairly good control over their blood sugars
I think it's huge for diabetics. It's a mental toll for them. They hate having to constantly prick themselves to take readings. It's awkward, inconvenient and you have to do it multiple times to be sure you got a good reading. And worse of all, it's possible to forget to take a reading when you need to.
I don't understand. All of the diabetics I know personally (one type 1 and two type 2 diabetics) use continuous glucose monitors and have for some time, so they rarely need to prick their fingers anymore. Ketone levels can be checked with a urine test.
There's some difference in the readings of a CGM due to sampling different things (blood with finger sticks vs intercelluar fluid for a CGM) and taking a bunch of vitamin C (pills or in food) can throw the readings off. But I think one or two sticks a day to calibrate the CGM and in situations where readings seem off should be sufficient.
Well I'm a T1D and I'm not generally worried about DKA because I wear a CGM and keep my blood glucose below 140 mg/dL
Which makes me think the market for these is diet-focused folk. Get the FDA to clear it on medical grounds for a specific usecase then sell it more broadly.
This already happens with CGMs. The bulk of the sales is with people who want them for lifestyle monitoring even though they're only medically cleared for diabetes use.
It would be beyond stupid for a healthy "diet focused" person to want to use this. They're not at risk for ketoacidosis, and there is zero evidence that continually measuring ketones would be useful in any sense. That's different from the purported use of CGMs, which is to monitor for glucose spikes in response to specific foods (and even then, the evidence that monitoring glucose spikes in healthy people has any benefits is really thin).
If someone really wanted to measure their ketone levels there are simple urine tests that do it - there is no need to measure it continuously for healthy people. And if they want to see if they're in ketosis it's pretty easy to determine - if they're on an ultra low carb diet and their breath smells like shit, it's a good sign they're in ketosis.
“Wearable” seems misleading. It looks like this is inserted into the arm like a cgm? Or am I looking at the wrong product?
Yes.
What about all the other wearable sensors like
https://www.stelo.com
https://www.hellolingo.com
The difference is that these only measure blood sugar, while the new system also measures ketones, of keto diet fame, which are leading indicators of a really dangerous situation called diabetic ketoacidosis. It's treatable with a hospitalized IV insulin drip, but can be avoided if you have some advance notice.
My mom had T1D onset in her 50s. (It's usually thought of as a children's disease.)
She figured it out because she recognized the symptoms of ketoacidosis. That sent her to the hospital, which has thankfully allowed her to outlive her pancreas.
Diabetic ketoacidosis only happens in T1D, or when you have something extremely wrong going on metabolically (like failing organs, etc).
Normally it should never happen. It happens at ketones like ~10+ mmol, and it's ~impossible to go more than ~6 for a healthy human even eating 100% fat and fasting for a week+ and doing marathons or whatever all at the same time.
The keto diet, can actually help in T1D, by keeping blood sugar more stable overall, but you still need insulin, just less.
It can happen in people with uncontrolled T2D as well. My cofounder is a pediatric ICU doctor who has treated hundreds of DKA patients.
Also there wasn't really a relationship of the keto diet to the rest of my post, just using it to contextualize a technical term with one that might be more familiar.
> It can happen in people with uncontrolled T2D as well. My cofounder is a pediatric ICU doctor who has treated hundreds of DKA patients.
Yes, but you have to work really hard for many years to achieve this!
While on T1D it happens by default if you don't inject insulin.
> while the new system also measures ketones, of keto diet fame, which are leading indicators of a really dangerous situation called diabetic ketoacidosis
It was being said like ketones are bad, because they are known for this scenario, but should be noted that it only happens in these few scenarios, like in uncontrolled diabetes or organ failure or smth.
In most other cases they should be good. But won't happen randomly unless you're explicitly doing keto.
Ah yes, I see what you mean! Ketones are not inherently bad, just the accumulation of them w.r.t having diabetes. Should have made that more clear.
Those ‘only’ measure glucose levels. As the article says, this is the first approved device that monitors both ketone and glucose levels.
Ketones don't come from nowhere, they come from your body breaking muscles down in a last ditch effort to control sugars after they are dangerously elevated for extended periods of time, I'm talking 500+ over weeks. It's sort of like adding a "your car has been completely out of gas for one week" monitor to your "gas tank level" monitor.
Um, no ? Ketones come from fat burning, not muscle.
In T1D with no insulin, muscle break down from gluconesis will increase blood sugar in the blood even more. The absence of insulin also makes ketone production unrestricted, so you end up in ketoacidosis.
Muscle is used when you don't have fat, or when you eat completely nothing (burn both fat & muscle).
Like I've gained ~10KG of muscle while on keto diet. Blood sugar at 70-100 depending on scenario. Usually on the lower end.
These are the same CGM technologies (Dexcom = Stelo and Lingo = Libre), just aimed at the over the counter "health and fitness" market.
This is not verified info, but I would assume these are either A) the exact same device, just with different marketing B) "binned" production runs that did not meet the accuracy threshold for clinical/prescribed use, but are otherwise "good enough" for someone looking to healthmaxx.
I think they are the same with some software differences. I believe that the sampling rates and tolerances are different. For example, dexcom displays 5 minute samples while the stelo shows 15 minute averages (it internally gets a new sample every 5 minutes like the dexcom). I think the official accuracy is a bit lower for the Stelo as well, although in practice it's probably close to the dexcom.
I can all but guarantee you they are the same device. IDK if they are even binned differently. The software is the main difference.
The "real" device gives you what it measures as your real highs and lows while the OTC devices won't report high highs or low lows.
I have a Stelo (I was curious and diabetes runs in my family) while my wife has the Dexcom.
I t Looked into the OTC ones and it does seem they’re binned versions. The failure rate appears to be higher too, which is more acceptable in a non life threatening device.
It also probably gives the companies really valuable data.
You can read the Stelo out into XDrip with some settings adjustments, last I checked, so it is just some “light” software tweaks between sensors.
https://navid200.github.io/xDrip/docs/Dexcom/G7.html
No FDA authorization I guess
Nope that was two years ago.
https://www.fda.gov/news-events/press-announcements/fda-clea...
What a remarkable legacy. I hope this technology helps prevent others from being lost to DKA. May Dan’s memory live on through the people he inspired and the communities he helped create.
Does anyone know if something like this is required to be approved by the FDA? Like if someone were to make one for the hobbyist/weight loss market, would that even be legal?
It depends on intended use. If it is to diagnose, cure, treat, or prevent a medical condition then it is a medical device that may need approval. If it's not intended for anything medical, it doesn't need FDA approval. For example, clinical thermometers are class II medical devices, lab thermometers aren't medical devices at all. If the device were genuinely only marketed for general wellness, it would be exempt.
Basically yes, take a look at the not for human consumption drug, sorry medicine market.
Was analogs in the 2010s, Obama had to pass the analog act low… now it’s back with peptides and glp 1 which aren’t scheduled but..
Yeah I guess make enough money and then lobby for the benefit of your audience base or for future proscuation
I have to imagine Apple was pushing for similar functionality but probably got distracted over the last few years due to the lawsuits.
Apple would want to make something non-invasive. I don’t think this is non-invasive. It looks a lot like the existing CGMs, but it does more.
How long has the tech existed to do this?
so weird this is at the top. I just wrote an article yesterday about zuck and the masterclass that the meta ray-ban glasses are.
Wearables ain't going anywhere but up.
Is it trustable?
bet marathoners and ultra runners will start using this to improve performance
(don't have a problem with that, but it's predictable)
too bad it's not "wearable" like a watch but that might be coming eventually too since Garmin has a patent on it
* https://the5krunner.com/2026/02/06/garmin-non-invasive-blood...
(btw Fenix 9 launched today but it's same hardware as Fenix 8 and no glucose feature)
Amateur cyclists already wear CGMs, and as a type 1 myself, they see mine and start asking all about CGMs. It must be so boring for them to worry about fluctuations between 85 and 120.
I don’t think amateur cyclists will have much to gain from this other than satisfying their curiosity.
Before buying one, just know that fit cyclists will appear glucose intolerant on a CGM. See Fig. 1 at https://pmc.ncbi.nlm.nih.gov/articles/PMC10933193/
There has been talk, but as one who hangs around those circles I've not heard of anyone actually doing it. But I'm sure someone is. At the same time, what I'm reading is that CGM won't give a non-diabetic any actionable information.
a regulated blood sugar level aids massively in cellular repair, inflammation reduction, and immune response. These are well studied and established. I could absolutely see a top athlete using AID in the future as part of a recovery routine, but I can also understand reluctance to adopt anything new or weird.
A few years back, there were a number of startups that essentially resold prescriptions of the ABT/DXCM CGM and provided personalized meal/exercise-response analytics on top. Seems like traction has been tough going, though. Dialing back from "anyone with potential metabolic issues" -- what's a realistic market? Something like high-level athletes and/or bio-hacker enthusiasts are the only folks who seem to care. On the low end, the OTC options are eating away as well.. they are less accurate, but probably solve the use case better for a pre-diabetic "once-a-year/occasional" wear use case.
Talking to ultramarathoners and cyclists, I think lactate is a biomarker that is tracked (POC blood samples) and would be more immediately useful for training/performance. AID might be construed as a form of doping, IMO.
Lactate actually comes for free with blood glucose when you measure it with a chemical sensor, it's just not something that's usually asked for. I definitely think it would be considered a form of doping to use it in competition, but I think recovery is where it would make more impact anyways. You also wouldn't want to use it before a race, as you'd run the risk of reduced pancreatic function.
AGC will find its main application in surgical and inpatient uses, eg in cardiac, neuro, burn, ICU, and people with diabetes in any hospital setting.
I definitely think it would be considered a form of doping to use it in competition
Already banned:
https://www.bikeradar.com/news/uci-bans-supersapiens
There doesn't seem to be a continuous lactate sensor on the market. Lactic acid production and/or clearance are definitely useful data w.r.t. exercise (many training regimens talk about lactate thresholds) and also useful in in-patient settings.
No disagreement about AGC in the hospital -- there is a lot of lab/titration work in current clinical workflows for monitoring patient glucose levels.
Lactate's available in the internal engineering data of these sensors, just not something that anyone has wanted to spend the time or money to qualify with the FDA. It essentially comes "for free" due to the chemical reaction the sensor uses.
I think you are misinformed: the electrochemical reaction used by continuous glucose sensors relies on a glucose-specific enzyme and it doesn't have anything to do with lactate. Lactic acid strips use a completely separate enzyme/reaction.
Hat tip to you and sibling comment about continouous lactate sensors (seem like they are microneedle/patch based?). Quick review shows minimal clinical evidence, but maybe that's sufficient for the consumer wearable market.
I've had the fortune to work with several CGM OEMs behind the scenes as part of our work developing an artificial pancreas, they all have a secret lactate signal!
There doesn't seem to be a continuous lactate sensor on the market.
They exist, a simple search will turn up a variety (how well they work is a different question). But see my sibling comment, they're banned from cycling competition.
I am curious how this will help. During training? During the actual race, the strategy is to eat a much as you can without puking.
I am aware of the "eating wins races" strategy for endurance sports.
Glucose and ketone monitoring seems a natural, more precise extension of that strategy. Isn't the point of carb-cramming to get more glucose into your blood stream, where your muscles can convert that into forward motion?
Yes. But you don't need to monitor glucose levels to do this. Because it's well known you can productively use as much as you could manage to consume (without vomiting). So all the device will ever tell you (if you're in the middle of significant endurance event) is that you need to raise your blood sugar. It'd be no more actionable than a writing 'your blood sugar is low' on your hand with a sharpie.
> to improve performance
How? Like, what is the mechanism where this is useful?
Monitoring glucose and ketones can help you develop metabolic flexibility and let you grok how easily your body cuts over to ketones. Knowing your personal realtime glucose and ketone levels helps you understand just how much carbs will kick you out of ketosis or keep you in it. Glucose monitoring will help you avoid large crashes that can lead to low energy. Among other things!
More on metabolic flexibility: https://www.levels.com/blog/what-is-metabolic-flexibility-an...
My understanding is that essentially all high-level endurance athletes are just maximizing their simple sugar intake at all times (during exercise) and knowing blood glucose/ketone levels wouldn't change anything about that intake, nor would it have any impact on crashes.
All high level endurance athletes are on high carb diets all the time and are never anywhere near ketosis (unless something has gone very wrong)
I thought this was going to be a non-invasive sugar-level device, but it looks like in fact the innovation here is that a popular CGM line can now do ketones?
non-invasive continuous blood sugar measurement is mired in patents and technical challenges. Turns out it's really difficult to disambiguate the absorption lines of glucose from other similarly shaped molecules when you're also dealing with untangling skin conductivity, transmissivity, sweat, inflammation etc.
I also think there's no financial incentive from incumbents to develop something like this. Why would abbott develop something that works "forever" if they can milk people buying new sensors every 10~14 days.
For abbott, no. But what about for Garmin, Apple, Samsung, or Google?
Diabetics would snap up a smart watch which does accurate glucose monitoring in a heartbeat.
There is a major IP holder in the space who is asserting their ownership, so even if they could solve the technical challenges, they might not be able to come to market.
> There is a major IP holder in the space who is asserting their ownership,
Is it a secret? Why not name them?
As a T1 diabetic, can confirm.
Seems to be the case, yeah
Reminds me of this warning: https://youtu.be/S6Jiei4Wup4 (Youtube Short from the Drey Dossier)
science is awesome
As someone who has to deal with type 1 diabetes every day, this is marketing nonsense. No one needs ketones in the sensor - we need high-quality sensors, and Abbott's are only mediocre at best. They are not as bad as Dexcom, which is appalling, but they are still far from the superior quality of Medtronic/MiniMed which measure glucose exceptionally well.
Ketones are rare. They can kill you, but before that happens, your blood sugar usually rises enough for you to realise you may have ketones and start using test strips to measure them. Instead of this marketing gimmick, Abbott should have focused on improving the quality of their glucose sensors which is far more important.
I tend to agree that making the sugar measurements more robust is worth more than measuring the ketones at all. However, low sugar and high ketones can happen. And just getting notified when ketones pick up can be worth something too. The additional measurement is not useless seen from my perspective.
As an example: I was on a study that gave T1D patients Dapagliflozin (Farxiga). During the study, while on a long hike, I was hovering at low sugar and consequently insulin supply was mostly cut off for an extended period. As I started to to feel unwell, I measured ketones. I was briefed as preparation for the study to measure ketones when something seems wrong. Otherwise I wouldn't have thought of measuring ketones. Might not even have carried the kit.
On that occasion, the ketones were way above 1 mmol/l: a very high value. Protocol would have required me to call the study doctor due to the high level. Since it was a Sunday, I spared her, shot some insulin, ate a sandwich, and continued my hike. I could do that because I was not alone on that hike. I knew that if my situation deteriorated, somebody would be around to call rescue.
At the study debriefing I mentioned the incident and they said that adding to the effect of the Dapa, I was probably dehydrated, which led to the rare situation of both low sugar and high ketones.
All in all I think that if the sensor makers exhaust possible improvements for the glucose, it can make sense to add the ketone measurement as a safeguard. Having high sugar can have many reasons, and it often takes me a while to get to measuring ketones. Getting the signal of rising ketones, I would react faster a few times a year in situations where my insulin supply is broken.
What's so bad about Dexcom and Freestyle compared to Medtronic CGMs?
Finally. I really dont want to buy yet another watch device unless it provides blood sugar detection.
There are and have been continuous glucose monitors available for some time, and you can even get one if you don't have diabetes - I'm wearing the Lingo one right now.
All this device adds is a simultaneous ketone check, which is really only relevant to diabetics and not as much of a benefit because ketone levels are often checked with a urine test.
So she was merely ahead of her time.
The use case was never the problem. The problem was that it did not work.
You should understand the difference between taking a single drop of blood and trying to run a battery of tests on it, and sticking a probe into your extra cellular matrix to continuously monitor changes. It’s small, but it’s having a constant shifting flow of fluid at all times so it’s getting far more than one drop.
Who?
Theranos lady.
Huh, makes 0 sense to me, blood tests w/o much blood isn’t same as glucose checking, we’ve been able to do that w/o much blood for…a long long time.
That silly patch idea?
Looked after my son who has T1D for now 5 years, checked keytones maybe 20 times. Compared to blood glucose which we check look at every 5 minutes.
Maybe this is more for Type 2 or other diabetes, or for people prone to DKA. Or it is for people with a working pancreas who think looking at their blood sugars (and now keytones) tells them something like soothsayers reading tea leaves
Considering that DKA accounts for 160k hospital admissions a year, your lived experience translates poorly to such a flippant dismissal.
[0] https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.htm...
I agree, but there are a lot of factors going on to contribute to that number.
For example, about 20% of that number is because someone is finding out for the first time they have T1D [1].
Insulin costs and monitoring costs are also going to be a pretty big contributing factor. CGMs and finger sticks aren't cheap.
IDK how often it happens that ketoacidosis happens when glucose appears to be fine, I assume it's pretty rare.
[1] https://www.sciencedirect.com/science/article/pii/S016882272...
A CGM that has ketone levels is quite literally pointless. If you have a CGM in the first place you would know if your sugars were high enough for long enough to get DKA.
DKA is what killed the legendary Dan Kaminsky.
Mate they won't understand. People generally are exceptionally ignorant about type 1 diabetes and also eager to fall for marketing gimmicks like this one. They have no idea what type 1 diabetes is.
For anyone who doesn't get it: glucose is checked every five minutes because it changes very often, jumping or falling dangerously. It's a nightmare. Checking glucose is 1000 times more important than ketones which are almost never a problem. If you get accurate glucose readings you are highly unlikely to ever experience ketoacidosis in the first place. Before ketones become a problem, glucose has to stay high for hours. Abbott is pulling this marketing trick instead of improving the quality of their sensors. Libre 2 is absolute crap. Libre 3 is somewhat okay and sometimes even mediocre - which is still a pretty bad situation. Bad glucose sensor is a nightmare and it can kill a person or a child much likely than ketoacidosis. It will actually lead to ketoacidosis by showing incorrect glucose readings. Now I wonder whether they added a ketone sensor as a failsafe for their low quality glucose sensors.
No one asked them to add a ketone sensor as an add-on to their glucose sensor, except maybe their marketing department. People want higher quality glucose sensors that fail less often and are more accurate. Glucose sensors, not ketones!
Understanding why children's pancreases stop delivering insulin in the first place, which remains one of the big medical mysteries, would be a huge breakthrough for preventative medicine.