Apple just announced a major upgrade for Dexcom and Apple Watch

“An exciting nugget of information for Dexcom users was hidden among more eye-catching announcements during yesterday’s Keynote Address at Apple’s WWDC (Worldwide Developers Conference) in San Jose. Near the end of his preview of the upcoming watchOS 4 software update for Apple Watch, Kevin Lynch (VP of Technology at Apple) briefly showed a slide that included Dexcom’s CGM watchface. He stated (19:45 into the keynote address):

“We are also now supporting native core bluetooth on the watch, which is going to enable experiences for apps that work with small devices around you. So for example, continuous glucose monitoring directly from Dexcom’s sensor… to your watch.”

Similarly, Apple provided an information page which again specifically referenced continuous glucose monitoring as a beneficiary of the Watch’s upcoming software update (free for all Apple Watch owners, scheduled for this Fall).

What this means: iPhone no longer required!

As we predicted about 18 months ago when watchOS 2 was announced, the upcoming Watch OS4 software update will finally allow the Apple Watch to display CGM data without an iPhone nearby. Going for a run? You can leave your iPhone at home. Going on a flight? You can leave your iPhone in airplane mode.

Keep in mind that owning an Apple Watch still requires owning an iPhone, so Android users can’t just go buy an Apple Watch for use with their Dexcom CGM. (Android support for Dexcom should be here any day now, though). But this new feature does allow users to be separated from their iPhone for periods of time without losing access to their CGM data.

This also (likely) means faster CGM data on Apple Watch

Although not explicitly stated, I predict that watchOS 4 will allow CGM data to be refreshed faster on the Apple Watch since it will be pulling data directly from the Dexcom transmitter. The way it currently works requires data to be sent from Dexcom -> iPhone -> Watch, so removing the middle man should make for faster synchronization.

All that being said, Dexcom owners with Apple Watches can look forward to a better CGM experience with the free watchOS 4 software update scheduled for this fall.

What could Apple’s “super secret” diabetes project be?

News broke earlier today from CNBC’s Christina Farr that Apple, Inc. has a small team of engineers working on creating sensors that can “non-invasively and continuously monitor blood sugar levels to better treat diabetes”. The project is allegedly far enough along in development that Apple is investigating possible regulatory pathways and performing feasibility trials at clinical sites in the Bay Area.

The article suggests that the project is a wearable sensor (either inside or worn in conjunction with a future version of the Apple Watch) that can track blood sugar non-invasively with optical sensors, similar to how the current Apple Watch can monitor heart rate. Such a non-invasive continuous glucose monitor would undoubtedly be a “holy grail” for diabetes, but can Apple succeed where so many other companies have so far failed to deliver?

Just for fun, let’s brainstorm potential possibilities for what this secret Apple Project could be. We’ll sort them by order of plausibility.

Most Likely Possibility: Health-focused Apple Watch “Pro” with an Invasive Glucose Monitor Partner

 

One question underlying this whole scenario is whether or not Apple really wants to be a medical device company. As Tim Cook himself pointed out to The Telegraph in November, 2015: “We don’t want to put the watch through the Food and Drug Administration (FDA) process. I wouldn’t mind putting something adjacent to the watch through it, but not the watch, because it would hold us back from innovating too much, the cycles are too long. But you can begin to envision other things that might be adjacent to it — maybe an app, maybe something else.”

Interestingly enough, he does mention the possible for an Apple-made companion device or software to the Apple Watch that might be a health device.

 

That being said, systems that closely resemble non-invasive continuous glucose monitors exist or are on the horizon. The Abbott Freestyle Libre Flash is approved in Europe for continuous glucose monitoring in diabetes, and does not require any calibration with a glucose meter.  (A short-term version called the Abbott Libre Professional is FDA-approved in the USA).

 

Similarly, Verily (part of Google) has partnered with DexCom to work toward a penny-sized continuous glucose monitor that would be usable for both Type 1 and Type 2 Diabetes and not require calibrations.

 

Also, implantable CGM should be here soon (Senseonics is currently filing for FDA approval), which is inserted under the skin and worn for 90+ days.
The common thread with all these devices is that they are invasive and all require some sort of display/reader to receive the readings.

Apple could potentially create an FDA-approved Healthcare-focused (as opposed to just fitness) Apple Watch “Pro” that is more robust and can communicate reliably with such sensors. If the wireless connection and stability of the device were medical-grade, removing extra middle-man devices would be a huge boon to patients. Users of such a “Pro” Watch might sacrifice some other features (small size?) or not get a model updated every year, but it would be reliable enough for medical use. (Such a health-stable PRO Watch would be quite useful for Artificial Pancreas projects too).

Most Interesting Possibility: Consumer-grade Optical (or Microneedle) Glucose Monitoring for Everyday Use

Combining my theory that Apple does not want to become a medical device company and the fact that accurate non-invasive glucose monitoring is a feat of titanic proportions, perhaps their top-secret glucose monitoring project is not for medical use at all.

As society becomes more health-conscious and sensor-driven, it’s only a matter of time before the general population starts monitoring glucose. In the diet and nutrition communities, sugar and carbohydrates have become the enemy, and some athletes (without Type 1 Diabetes) actually use invasive continuous glucose monitors while training to optimize their diet and exercise regimens.

Companies like Sano have been working toward non-invasive CGM for everyday use, and Apple has acquired companies (eg C8 Medisensors) working on various forms of non-invasive CGM. Some of these companies utilize optical sensors, and others use an array of microneedles to sample interstitial fluid.

With consumer-grade CGM, people could observe rough trends about their blood sugar. They’d be able to see first-hand how quickly certain foods (eg. cereal, white rice) can spike blood sugars, and how avoiding carbs can keep blood sugars relatively flat. Furthermore, widely prevalent sugar monitoring might not be accurate enough to dose insulin or diagnose diabetes, but it could help raise awareness and promote screening for Pre-Diabetes.

As an endocrinologist without diabetes, I’ve had the opportunity to wear CGM’s in the past, and they have been very enlightening. If I had the choice, I’d wear quite often.

Moonshot Possibility: Medical-grade Non-Invasive Glucose Monitoring for Diabetes

Now this is clearly what the original source is suggesting, but I also find it the least likely. The article itself recognizes the immensity of this challenge:

“Accurately detecting glucose levels has been such a challenge that one of the top experts in the space, John L. Smith, described it as ‘the most difficult technical challenge I have encountered in my career.’ The space is littered with failures, as Smith points out, but that hasn’t stopped companies from continuing to attempt to crack this elusive opportunity.”

Much like Verily’s partnership to measure glucose levels via a smart contact lens, a non-invasive continuous glucose monitor from Apple would be mind-blowing. However, the diabetes community is well-aware of other longshots that have promised much, but never delivered. (Exhibit A: the GlucoWatch).

In addition to the technical challenges, I’m also not sure what Apple’s end-game with such a medical device would be. Would they try to carve out their own niche in the diabetes glucose monitoring space, taking on Dexcom and Medtronic? Would they license their technology to these companies? Would they try to market directly to consumers?

All that being said, I am extremely excited that Apple is focusing their efforts and resources on glucose monitoring and diabetes. I can’t wait!

Medicare announces coverage criteria for Dexcom G5, but blocks use of smartphones?

Coming sooner than expected, Medicare recently clarified coverage criteria for the Dexcom G5, paving the way for Medicare to reimburse for people with both Type 1 and Type 2 Diabetes requiring intensive insulin dosing to use the Dexcom G5 mobile.

Dexcom and the diabetes community heralded the exciting news, as the lack of CGM coverage for Medicare patients had previously been a glaring oversight. Dr. Steven Edelman, founder of TCOYD, often joked about this, saying, “Good news! According to Medicare, Type 1 diabetes is cured when you turn 65!”

Despite the good feelings all around, a closer look at the Medicare document includes some concerning language that might forbid users to take advantage of one of the most useful features of the Dexcom G5: the ability to view sugars on your smartphone or smartwatch.

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Our Guide to Diabetes Apps for iPhone and Android

The App Store is crowded with diabetes apps for both iPhone and Android, but how do you know which ones to choose? That’s why we tested them out and created a list of our favorites.

 

MyFitnessPal (iPhone, Android) – For Tracking Nutrition/Carbohydrates

Count carbs with MyFitnessPalMyFitnessPal (Free) is the most popular health app of all time, and for good reason! It has the largest searchable food database, with over 5 million different items, from home-made recipes to fast-food chains and restaurants.

But it’s also one of the best diabetes apps available. Users can track their nutrition for the purpose of weight-loss and/or counting carbohydrates. It’s like carrying a Calorie King guide in your pocket, but it’s searchable and constantly updated.

To simplify the hassle of logging food, MyFitnessPal can even use your smartphone’s camera to scan barcodes and instantly record nutrition information!

 

MySugr (iPhone, Android) – For Monitoring Diabetes

mysugrBuilt by a team of people with diabetes, MySugr (Freemium) is an adorable app that helps users log their sugars, carbohydrates, and medications. This app features statistics and graphs, including an estimated hemoglobin A1c that updates as you record your sugars.

Like all the other diabetes apps in this article, MySugr includes support for Apple Health, meaning that glucose data can be imported automatically from newer wireless glucose meters like the Accu-chek Connect.

For $2.99 each month, Pro Mode adds reminders to check your blood sugar and the option to generate PDF and excel reports for your doctor’s visits.

 

Diabetes Kit (iPhone, Apple Watch) – For Monitoring Diabetes

DiabetesKit for iPhoneSimilar to MySugr, the creator of Diabetes Kit (Freemium for iPhone) built the app on his own to help keep track of all his various numbers such as sugars, medications.

The unique aspects of Diabetes Kit are its companion Apple Watch app and its number-driven user interface, with multiple useful graphs and dashboards to help learn from your data. Unfortunately, unlike the other diabetes apps listed here, Diabetes Kit does not include a feature to estimate A1c.

Also similar to MySugr, $9.99 a year unlocks Pro Mode, which includes reminders and the option to generate PDF reports.

 

Sugar Streak (iPhone, Apple Watch) – For Motivation to Check Sugars

Sugar Streak for iPhoneSugar Streak (Free) is great for people who have a hard time remembering to check their blood sugar. During setup, users pledge to check their sugar anywhere from once to four times each day.

By recording their sugars and fulfilling their pledge each day, users build a sugar streak! As their streak gets longer without being broken, they earn points more quickly, and the points can be redeemed towards small prizes like gift cards.

Meanwhile, the app creates a glucose logbook with real-time statistics like estimated A1c, and can generate reports to assist with future doctor’s visits. Unlike the previous two diabetes apps, Sugar Streak does not track activity/nutrition/medications.

Disclosure: I am the creator of Sugar Streak.

Conclusion

These are just a few of our favorite apps for managing the various aspects of diabetes. While using a diabetes smartphone app might not be for everyone, we think many of our readers will enjoy at least one of our suggestions.   The quality of diabetes apps have a come a long way from just a few years ago, and they should only continue to improve!

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How to use watchSugar to view Dexcom on Apple Watch home screen

Released in October 2015, Apple Watch OS 2 introduced the ability to view third party app information as “complications” on the home screen watch face. While users with Continuous Glucose Monitor (CGM) users were salivating at the idea of viewing their Dexcom G4 and G5 information by simply glancing at their Apple Watch, FDA hurdles have delayed Dexcom’s officially introducing these features for Apple Watch.

Thankfully, indie app developer (and Type 1 PWD) Adam Wolf has come to the rescue and released watchSugar for iPhone and Apple Watch, which adds a complication to view blood sugar and trend information from your CGM directly on the watch face. From some preliminary testing, it works exactly as promised!

What it Does

Before watchSugar, there was no simple solution for viewing Dexcom CGM data directly on the watch face, in the same way you would view the weather forecast or stock information.

Apple Watch Complication for Dexcom CGM

With watchSugar, there are two complications (large and small) that are viewable in most of the Apple Watch faces. The larger complication also shows the timestamp for when the glucose was sampled, which is quite important.

How to Install watchSugar Apple Watch Complication:

  1. [Steps 1-4 are to be performed on the iPhoneInstall watchSugar via the App Storedownload watchSugar App Store
  2. Make sure the companion Apple Watch app is installed by opening the Watch app, tapping on watchSugar, and making sure “Show App on Apple Watch” is toggled on.watchSugar Watch App
  3. Launch the watchSugar app and log in using your Dexcom Share/Follow credentialswatchSugar Login
  4. You should see a confirmation screen as pictured above on the right.
  5. [Steps 5-9 are to be performed on the Apple WatchForce touch on ANY watch face (by pressing firmly in the center of the screen) to bring up the options for selecting and customizing watch faces.select watchface
  6. Swipe left and right to pick your watchface, then tap the CUSTOMIZE button. (I highly recommend the Modular watch face because it includes timestamp information)
  7. Swipe to the left or right to bring up the display for adjusting complications. Tap on the complication on the screen where you’d like to view your sugar. (In this example, tap in the middle of the screen)Screen for choosing your complication
  8. Using the digital crown knob on the side of the Apple Watch, scroll up and down until you see the watchSugar complication. watchsugar_complication
  9. Press the digital crown knob on the side of the Apple Watch twice to return to your watch face.
  10. Your Dexcom blood sugar complication should now be visible on your watch face. watchsugar for dexcom and apple watch

Important Caveats

First off, the watchSugar App Store item description states that “watchSugar is able to update every 17 minutes on average.” (This is due to a limitation of the Apple Watch complications, not due to Dexcom or the developer)

Since the Dexcom G4 and G5 samples blood sugars every 5 minutes, this means that the sugar displayed on the complication can be 2-3 readings behind. In my brief testing, I did not find this was an issue, but I would highly recommend using the larger complication so that you can see the time that the reading was checked. (in the above image, even though the time was 6:25, the blood sugar reading was sampled at 6:12PM)

Secondly, watchSugar receives blood sugar readings through the Dexcom Share/Follow system. This requires that you set yourself up as a “follower” using the Dexcom Share app. In addition, the complication requires an active internet connection.

 

Dexcom's G5 CGM Syncs to iPhone

Dexcom G5 CGM, iPhone, and Apple Watch: Your Questions Answered

[Last Updated 3/5/2017]

Dexcom released their highly-anticipated G5 continuous glucose monitor (CGM) for diabetes in September 2015. As the first CGM (ever!) that transmits glucose data directly to the iPhone, there’s been a lot of excitement about the revolutionary new device. There’s also been a LOT of questions, and we’ve collected official (and unofficial) answers to all of them.

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New Apple Watch update brings improvements for diabetes

The Apple Watch first arrived to much fanfare exactly six months ago.  Despite some sensational headlines in mainstream press and Dexcom’s bold efforts to fully support the Apple Watch with the Share platform, the overall user experience for people with diabetes was tolerable at best, due to limitations in the aptly-title watchOS (the Apple Watch’s operating system).

In contrast to the lightning-fast, always-visible live CGM views on the Pebble Smartwatch (courtesy of the home-made modifications pioneered by #WeAreNotWaiting/NightScout crew), the Dexcom Share/Follow apps for Apple Watch were clunky, laggy, and not visible at first glance. The few diabetes logbook apps that did support Apple Watch were equally clunky, hindered by the watchOS’s stubborn dependence on the iPhone.

But this past Tuesday, Apple released watchOS 2, giving app creators new abilities such as accessing health sensor data from the watch (e.g. heart rate, activity), downloading data directly from the Cloud via WiFi, and displaying information directly on the watch face. How does this benefit Apple Watch owners with diabetes?

Display diabetes data directly on the watch face!diabetes-apple-watch-complications-smallOne of the Apple Watch’s best feature is the ability to display additional information the Watch Face. These small views are called “complications,” a term reverently taken from the watchmaking world. (Not to be confused with medical complications like neuropathy and blindness). On the original watchOS (pictured on the left), these complications were restricted to displaying data from official Apple apps (e.g. alarm, moon phase, sunset, activity, etc).

With watchOS2, third party developers now can do the same. As pictured above, the CNN app displays the latest headline, and the United Airlines app displays upcoming flight information.

For users of CGM (like the Dexcom Share and Medtronic MiniMed Connect platforms), imagine being able to view your sugar and trend arrow right on the home screen, as pictured in the bottom right in this mockup. In such a scenario, tapping on the icon would take you directly to the app for more detailed information.

For non-CGM users, logbook apps could display complications that show how many sugar checks that remain, as an example. The bottom left of the mockup shows how my app Sugar Streak could show that the user has completed one of the two glucose checks they are trying to complete each day.

So, the summary/zinger: finally, GOOD diabetes complications! =)

Go back in time! (kind of)

See information in the past/futureTime Travel is Apple’s cute name for a clever feature. On the primary watch face, users can wind the digital crown to scroll forward and backwards in time. If appropriate, the complications update to show information that pertains to the displayed time. For example, in the above example, scrolling forward in time shows future appointments and the appropriate hourly forecast.

Continuing the conversation from before, CGM wearers could quickly scroll through their prior CGM readings and trend arrows were throughout the past 12 or so hours. Ridiculously neat!

Speedier Watch Apps That Are Less Dependent on the iPhone

 

For a variety of reasons, the initial release of watchOS did not allow for apps to be run natively on the Apple Watch. (Don’t forget, the original iPhone did not allow users to install ANY apps). When you launched an app on the Apple Watch, you would see the dreaded loading screen (pictured) while it pinged its iPhone mothership to learn what to do next. As a result, every single Apple Watch app had to essentially function as a second screen, helpless without an iPhone nearby.

With watchOS 2, Apple Watch apps can finally run natively. For example, a Watch calculator app can now run without an iPhone nearby. (Before the update it would require an iPhone, sadly).

But what about Diabetes apps, where most of them rely on data from the Cloud? Natively-run diabetes apps will still load significantly faster because the app can still load graphics and the skeleton of the app  instantaneously. Any data will then be downloaded via nearby iPhone or Wifi. The experience is similar to the Facebook app for iPhone: the app launches instantly, but takes a few split seconds to display status updates/photos. Overall, the process still feels fairly snappy.

Furthermore, downloading from the Cloud no longer requires a nearby iPhone! If the Apple Watch is in range of a known WiFi network, the Watch can download data directly from the Cloud.

Now for the Bad News…

Unfortunately, all these nifty features need to be supported by the developer so these features won’t be available until the companies or app creators release software updates.

Adding new features are easier for well-funded startups and companies like Dexcom and Medtronic, but many diabetes apps are built by individuals or independent developers who might not have the bandwidth to readily roll out new features.

At the time of this article’s publishing, not a single top search result for “Apple Watch diabetes” in the Apple Watch app store supported any of these new watchOS 2 features.

What Can’t WatchOS 2 Do? What’s Left on the Wishlist?

Despite its many advances and upgrades, watchOS 2 represents just one more step in the pathway to Diabetes smartwatch nirvana.

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The imminent release of the new Dexcom G5 signifies a HUGE step for CGM users by transmitting glucose data directly to the iPhone (and later, Android). The G5 eliminates the need to carry around the Dexcom receiver, a feature users were begging for from day one.

Unfortunately, the G5 CANNOT directly transmit glucose data directly to the iPhone, even with watchOS 2. Therefore, if you’re going on a run and want to view your CGM data on your wrist, you’ll have to bring along the iPhone as well. Similarly, wireless glucose meters also can’t directly connect to Apple Watches, and will require iPhones as the bridge for communication.

Along those lines, while watchOS 2 allows the Watch to download data over WiFi, we’re not always in range of a friendly WiFi network. Perhaps future version of the Apple Watch will be able to connect directly to cellular networks or bluetooth sensors.

And a final personal pet peeve of mine: the Apple Watch display still doesn’t always stay on. To activate the display, you either have to raise your wrist, tap the screen or press a button. I seem to be a rarity among my friends, but I don’t appreciate having to dramatically lift up my arm in order to check the time or my sugar.

Overall, Apple watchOS 2 introduces powerful new features that will change the way people manage their diabetes. Now it’s up to the developers to do their part.