A few months back my dad bought me an Apple watch to celebrate some of my accomplishments over the past year. Though I was delighted, I didn`t find much use for it and barely wore it, except on special occasions. I thought it was just a device to make me feel cool and show off a bit. The fact I could call or text from a watch was a worthy show off point for me so I thought that was enough. But it never really had any purpose.

Until recently, when I went abroad on holiday. Going on holiday abroad can be tiresome in parts. So much walking to see places, catch flights etc. Unless of course you hire a car, but that's not the point. It probably sounds like I'm writing two different blogs at the moment. Well let's see where the two subjects connect.
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Walking this much in the heat and not so flat terrain would obviously leave you burning vast amounts of calories. You don't realise how much you have worked until you open the activity app on your watch and find you have lost about 300 calories just from sightseeing. Your eyes widen in amazement and you start getting excited. It surely motivates me to exercise more knowing what you can achieve with just a few hours of walking.

Recording exercise is very important because it keeps track of the calories burnt, weight loss, distance of exercise and much more. This is very important because it gives a feel good effect and is extremely motivating.
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I now plan to use my watch to its fullest potential. Not just to show off. I now realise it can do a lot of things that help me. Most importantly, it motivates me to exercise. I mean anywhere. The Apple Watch and I`m sure other wearables is a good device with lots of capabilities including recording fitness. If you think that going on holiday makes you unfit, think again.

As digital health expands its future, a very exciting new technology has emerged in the form of wearable technology. Wearable technology includes items, such as jewellery, glasses and clothing — worn on, in and around the body — incorporating sensors and other electronic technologies. Approximately 10 million wearable devices will be operational in the UK by the end of 2016, with five million sales and the overall figure tripling to almost 33 million units in the next four years. Fitness trackers will lead the way in terms of volume with sales of 1.7 million expected in 2017. Other than fitness bands, smart watches, clothing, and people tracking devices have started being used.

Though fitness tracking devices are the most popular, wearables have become less expensive, less intrusive and more intelligent and is now used to monitor sleep patterns and flexible patches have been developed that can detect body temperature, heart rate, hydration level and more. The artificial pancreas is all set to revolutionise diabetes care. From true wearables through to sensors in contact lenses and stick-on skin patches, even medicines contain digital markers that can send signals to phones and monitors, the quest for knowledge about people beyond the confines of clinics and hospitals is getting more interesting. Wearable technology is now being trialed in improved patient education and real time guidance and advise. 

​Data emerging from wearables are now being used by clinicians, insurers, policy makers and researchers alike to make important healthcare related decisions. Though there is tremendous amount of excitement regarding this technology, adoption has not come without caveats. The two main factors limiting widespread adoption is skepticism regarding accuracy regarding the data and security of the data. Though there are anecdotal evidences of wearables even influencing lifesaving decisions, evidence is a bit thin regarding reliability in all situations. In a situation, when things go wrong, it may be difficult to fix accountability. Secondly, security and confidentiality of the data collected is seen as an issue. There is always a concern that intimate, personal data of people may fall into the wrong hands.

Currently the focus has been mainly in ‘fitness technology’ or ‘health trackers’. These are essentially younger, healthier people who wish to improve their lifestyles and health. There has been a fair amount of success in this group and more people have been motivated to make necessary behavioural alterations and get active. However, it still remains to be seen if this success can be translated to people who are not in the best of shape, have multiple medical issues, who most likely will benefit from continuous monitoring and remote intervention. This is an area which is in need of more careful design thinking and solutions. This is difficult because on one hand is the adaptability of more ill patients to wearables and on the other hands imposition of more stringent regulatory guidelines and laws to prevent improper use.
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These are however early days and there is a lot of investment both financial and intellectual in this field. There is immense optimism and with developments underway, the current gap between health tracking and actual use in healthcare will soon be breached.
                

“Artificial intelligence is growing up fast, as are robots whose facial expressions can elicit empathy and make your mirror neurons quiver” - Diane Ackerman

The practice of medicine often challenges personnel to decide the correct course of action in patients with complicated problems. It is not just diagnostic dilemmas, but also deciding on correct management protocols and communicating a realistic a fairly accurate prognosis, which is called into question. Traditionally, doctors have relied on their own experience, literature, experiences of their peers and communication with more experienced people to arrive at decisions. This very complex problem solving has been the building blocks of medical practice.

The brain has been the most intriguing organ to man and scientists have gone about trying to recreate the same using technology which was further accentuated with the arrival of the computer. Of all the modern technological quests, this search to create artificially intelligent (AI) computer systems has been one of the most ambitious and, not surprisingly, controversial. Scientists and doctors alike have explored the potential what this technology could have in medical practice. The staggering ability of computers to store, assimilate and process vast amount of data led to the hope and belief that one day, such computers may be able to assist and eventually surpass the doctor’s ability to make a diagnosis. Though this sounded attractive to some, it did stir some controversy. But all said and done, scientists and doctors alike had a bold vision by which artificial intelligence could revolutionize medicine and push forwards the frontiers of technology.
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There was of course initial euphoria, which was short lived. Much of the difficulty has been the poor way in which they have fitted into clinical practice, either solving problems that were not perceived to be an issue, or imposing changes in the way clinicians worked. It is yet impossible to replace the clinician at the bedside; yet artificial intelligence does have the potential to make a useful contribution. What is extremely important and being studied is to identify the specific areas of medical practice that are best suited to the introduction of artificial intelligence systems. 

Artificial intelligence (AI) is still in the very early stages of development and in so many ways cannot match up to the human intelligence. But today`s machines are capable of mining and crunching vast amount of data that is difficult for the human mind to do. The complex algorithms of artificial intelligence can be used to analyse electronic patient records and transform them into diagnostic and management tools.

Artificial intelligence is what gives computers the ability to learn, think, reason, and even understand human emotions, allowing computers to do more than just repetitive tasks. Therapeutic animal robots that have been developed to help Alzheimer’s patients which help nurture brain function by delaying cognitive problems that in turn improves quality of life, and reduces the reliance on social services. A very important contribution of AI is in reducing errors due to fatigue. A personal assistant that is able to alert physicians to such errors may help improve outcomes. AI assistants/programs could significantly reduce medical costs by eliminating office visits with online care. With virtual presence technology, using a remote presence robot, doctors are able to engage with patients and staff without actually being there.  They are able to move around and interact almost as effectively as if they were present.  This allows specialists to assist patients that may not be able to travel to see a particular doctor.

The advent of AI in the earlier stages did lead to a sense of insecurity that doctors would no longer be required. However, AI no longer claims to substitute doctors but help the health care professionals by devising newer, more user friendly programs in the discharge of their day to day activities and help solve extremely complex problems in a quick and efficient manner, at the same time reducing costs.
Insights gained by these devices can be useful to influence public health and thus policy decisions. There is a huge educative value to this as newer phenomena may emerge leading to creation of more medical knowledge.
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Currently, the best use in the ability to tap into data created by thousands of healthcare providers and patient visits as well as data on treatments other doctors have provided to patients with similar profiles and use this knowledge to build one`s own opinion.
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Watch this space!

"An innovation will get traction only if it helps people get something that they're already doing in their lives done better".

There is now overwhelming evidence of the use of surgery as a powerful tool in the management of diabetes mellitus especially in people with a high BMI or inadequately controlled diabetes of the type II variety. Surgery improves type II diabetes in nearly 90 percent of patients by: lowering blood sugar, reducing the dosage and type of medication required and improving diabetes-related health problems. Surgery causes type II diabetes to go into remission in 78 percent of individuals by: reducing blood sugar levels to normal,  eliminating the need for diabetes medications. This has also been seen in patients over a long time.

Recent studies have pointed towards the superiority of gastric bypass surgery over lifestyle-medical management albeit with greater adverse events including nutritional problems. The effects of surgery seem to wane with time in time and it needs to be seen who are the real beneficiary of this procedure.
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However, the cornerstone of diabetes management is lifestyle and behavioural modification in the form of nutritional changes, increased exercise and motivation to do so over a prolonged period of time. Surgery alone is not the panacea of diabetes but sustained medical and lifestyle management is needed to reap the benefits of surgery and provide good long term results. Similarly, it is quite imperative that at diagnosis, the person is taken through a period of lifestyle adaptation and medical management before any surgery is done.

These need improved patient education, awareness and support right through the entire journey. There needs to be pragmatic thinking that even if we do well with surgery for 5-10 years, this is little in the long life of people. Now, with ever increasing life expectancy, this maybe an opportunity to improve the health of people not just from a medical perspective but also from a holistic perspective.

Mobile and digital health can play a very vital role. Dissemination of accurate information, education and engagement, monitoring of multiple parameters in real time and intervention including psychological and mental health in appropriate times can help give people with diabetes a voice and influence their own management in a positive way.
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The shifting paradigm of management of diabetes with surgery throws up new challenges which necessitates closer monitoring and action for optimal results. It is imperative that people with diabetes need a coordinated multidisciplinary approach to care so that more but appropriate people can reap benefits.

"Experience is a cruel teacher, it gives the exam first and then the lesson."

It isn`t rocket science to know that clients need real-time personalised experiences on mobile platforms. There is a difference of opinion regarding mobile applications, as younger people prefer apps, but the slightly older are sometimes not particularly comfortable. The smartphone is the most ubiquitous possession, even in the developing world and the challenge for every healthcare provider and professional is to figure prominently in the personalised interfaces to people. Social media is now the new source of information and advice and any information is scrutinised and discussed in groups and amongst people who may never see each other. Information and advice from blogs and chatrooms are sometimes more influential than coming from certified and trained professionals.
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For people with chronic diseases like diabetes, it is quite important that the support is continuous because the time spent with healthcare professionals is small, but the battle against the disease 24/7 and 365 days a year. Health care professionals have to work within a tight regulatory framework with strict guidelines which are sometimes insufficient to guide people regarding specifics. Thus people find the need to read and make conversation with people with similar experiences. In today`s world, the client is more informed, empowered and make more informed choices. However, there is cluttering of information on the internet, which is readily accessible and often confusing. It has thus become mandatory for healthcare professionals and providers to have a significant online presence and maintain a good online reputation. Most services are now judged by their online presence and healthcare is heading in the same direction. An inclusive healthcare expects that the client is involved just not in decision making regarding their own health, but also in the design and execution of any new approaches. There is also widespread cynicism regarding medical practice and the virtual world has now become a place where misconceptions and negative opinions are expressed. This has also become a window to gain insights about client behaviours which can help providers, professionals and policymakers tailor personalised solutions. There is a tremendous amount of data that is being generated regarding clients every minute which can be used effectively for designing and planning solutions. It is here that the problem lies especially in healthcare, where extensive information may not always translate to suitably personalised solutions because the needs are extremely variable and perceptions may not convert itself to fact. All great ideas may not have an equal uptake when services go operational.  

In this new virtual world, it is now vital to be net-savvy and maintain an online reputation. Clients demand trust, integrity and reliability from the providers. They also demand succinct, definite answers to their problems and queries. Levels of accountability are increasing and internet etiquette is evolving. Patient engagement has now extended beyond consultations and communication is more bi-directional. It is now second nature to type in keywords to gain access to information within seconds of hearing. It is also important for providers to handle questions and criticisms in a masterful, matured and professional manner. It doesn`t take long for a stray incident to become news and people to form opinions that stick.
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So, the provider needs to be there and deliver, whether it is in the form of information or services. Providers that can deliver in a coherent, seamless and personalised way will be ahead of the rest.
 

The biggest problem that I face in designing a solution in healthcare is in providing customer delight. This is because, my entire education and training has revolved around finding the correct answers and the thought that something maybe suboptimal or even incorrect is akin to a loss of manhood.

As a medical student, I often wondered what the fuss was about in optimally treating people, but more than two decades of clinical experience has taught me that medicine, especially human behaviour is not always exact science and it is only empathy and continuous iteration will move us in the right path towards success. 
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Success to me is a simple, long term solution to a very complex problem, which alleviates the pains of the patient and the person, easy to use which delights the client that he now encourages other to use. The biggest problem that we face in healthcare is the inability to dissociate the patient from the person. It is the fine line between care and intrusion when breached that causes resistance and rejection. How clear do we need to stay from that line is a matter of judgement which is ruled by extremely personal reasons and has nothing to do with either the socioeconomic or educational attainment of the person. To find a solution of both subjective and objective needs of a person and working in an extremely sanitised legal framework is a challenge. The question of course becomes more difficult when extrapolated to a wider population context.

​With the ubiquitous availability and encouragement to build more technology, we are developing a tendency to leverage more and more technology in healthcare with perfectly good intentions. Some of these should definitely stand the test of time. But many may enjoy initial success, but the long term viability maybe questionable. The most important question is to understand that the bulk of the problem lies in dealing with the chronically ill person. In this group, sometimes dealing with the person becomes more important and the challenges are daily over a lifetime. Many of us are happy seeing good 5-year data, but from an overall perspective what is 5 years in the life span of a person with diabetes.

So, the investment and design needs to be like developing infrastructure where the real returns are over a much longer period. It is more important to develop processes, thoughts and culture which will create the environment for further innovation. This will also help innovators understand client behaviours better and clients will also be tuned to a slightly changed style of practice. The difference in healthcare is that though necessary, innovation directly affects the human body and lives. Greater effort is needed to win the confidence of the person and in most cases ill or potentially ill people, who may have different psyches. Another issue is that a solution means instant relief and gratification for some, which is difficult to fulfill.

In my personal experience, I`ve learnt more about ill people outside the clinical setting, when they opened up more and really began to understand what really ailed them and their illness was not always the primary concern. Secondly, different people`s response as well as approach to disease are different. People communicate about their problems differently, some are open, some would only speak to certain people, so even extensive research may not provide accurate results.
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So there are no right or wrong answers in healthcare and a rocky road awaits all those who chose to tread this path. But that is the thrill with a cause.

The primary focus of diabetes management is centred around medical and behavioural modifications However, factors which determine outcomes in diabetes sometimes revolve around where people are born, live grow and age. As much as influencing medical and behavioural factors are important, it is also vital to address factors like income, education, housing and access to nutritious food, employment insecurity, low educational attainment and poor living conditions as these have a huge bearing on the results of the disease. These factors are collectively called social determinants and are central to the development and progression of diabetes.

Individuals with lower income and less education are 2 to 4 times more likely to develop diabetes than more advantaged individuals. This works in a cyclical process and constant pressure to make ends meet leads to chronic high levels of anxiety and stress leading to unhealthy behaviour like smoking, drinking, use of illicit drugs, self-destruction and neglect. Coupled with this is unhealthy eating and lower levels of much needed exercise, all of which contribute to deleterious consequences. Chronic stress by itself is a harbinger of further health problems.  

The disadvantaged person further may not be able to access health related resources which are necessary to manage diabetes in a strict manner and this may lead to a further downward spiral. In health care systems that are not able to effectively support people with diabetes, sourcing of medications like insulin maybe an issue which eventually is fatal. Further limitations in employment opportunities and less productivity along with low educational attainment may further preclude opportunities to access resources. 

​Social determinants have assumed more importance as in this day and age, we do live in a more `obesogenic environment`. This consists of a more sedentary lifestyle and availability of more energy rich foods. Leading a healthy lifestyle is more expensive. In addition, poor women are more vulnerable to poor nutrition during pregnancy which can raise their child’s vulnerability to the risk factors for diabetes later in life. Since the prevention of type 2 diabetes centers around behavioural and lifestyle modifications of diet and exercise, economically disadvantaged people have less access to it. This leads to a vicious cycle.

The consequences are far from ideal as this puts considerable amount of strain on the already stretched economy as poor health leads to poor productivity and a lower GDP. Though this is glaring in the developing world, the developed world is far from escape. Increasing unemployment with the shift in global economic dynamics have left thousands in the lurch who will be difficult to manage.

The problem with diabetes is that it is a lifelong disease and is severely affected by a person`s day to day activities. It is a difficult disease to manage on the long run, with huge numbers being undiagnosed and presenting late in the cycle. So even with astute clinical and behavioural management, if the social determinants are not taken care of, then the outcomes maybe poor.
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The solution is not simple and needs cross functional coordination across government bodies, private players, organisations like WHO, IDF etc. Mobile Health does have a role to play here in improving accessibility to healthcare, keeping in mind the buying capacity of economically disadvantaged people. But the hidden cost of poverty which lies in travel and paying premium for facilities which is taken for granted for more privileged people will far offset the cost of mobile health. Up scaling of mobile health will definitely drive costs down making this more and more affordable. With the current ever expanding penetration of mobile internet even in areas previously `communication blind` will open up opportunities for healthcare. Secondly, targeted education of the population using innovative strategies is of immense value. 

Despite use of all available means, the occurrence of diabetes seems unchecked. One of the key components in the solution process is effective and sustained behaviour change. It is no longer enough for people to know about the disease, but is imperative to adopt strategies for prevention and those affected to become more skilled at managing this. Even amongst the better-educated persons, there is still confusion as to what it exactly entails.

To enable this transformation in the lives of people, there is now a need to use more robust strategies. The use of commercial methods of marketing to effect behaviour change is called social marketing. The term appears as an oxymoron at first glance, because marketing has never been known to meet anything but commercial needs. However, the primary intent of this process is to understand client preference and barriers before implementing an intended service or programme. This method is more person-centric than traditional paternalistic means.

A vital first step is in planning and cultural segmentation. This involves establishing a goal, which in diabetes care could be prevention of complications and then finding a more culturally relevant tool. In the UK, Type 2 diabetes is up to 6 times more likely in people of South Asian descent and up to three times more likely in African and Africa-Caribbean people. Hence, the goal of behaviour therapy maybe different from the mainstream while population.

It is then important to identify the wants and needs of the target population, factors that influence its behaviour, including benefits, barriers, and readiness to change. It is this information that enables the development of a strategy that is culturally relevant and clinically appropriate. It is vital that communications ensure that they are responsive to cultural values, norms, and expectations and don`t come across as stereotypical, insensitive or patronising.
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The next phase is implementation and evaluation by a process of iteration. The goal of social marketing is a bottoms up intervention keeping in mind cultural sensitivity and building of innovative strategies for behaviour change.

Used correctly, social marketing is a systematic approach and invaluable resource and has the potential to build culturally sensitive, innovative solutions which are people centric. With the advent of mobile marketing, the reach of materials and communication is more extensive. In a single day it is possible to reach 24 million daily users of Facebook in the UK. This makes Facebook nearly five times bigger than The Sun newspaper, and even for older, less affluent people we are seeing usage increase:40% of 40 to 60-year-olds in the C2D socioeconomic group visit Facebook daily. Social channels also allow us to reach people directly when they are thinking about their health. Six million health conversations took place in the social sphere during the past year.
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There are some challenges like the need for upskilling healthcare professionals based on findings, availability of more time and resource and making certain that program strategies and methods are reflective of consumer preferences. Finally, even with the best research and execution there may still remain gaps in the service especially in complex long term conditions like diabetes. But with iteration and innovation there is scope of improvement.
 

We always knew Jim (name changed) had diabetes since he was 8 years old. He always liked to do his bits, as he called it, that is measure his sugars and inject insulin away from everyone. He needed to do this multiple times a day and carried sandwiches with him all the time. We were always inquisitive about him and over the years had got used to his fluctuating moods, hospital stays and frequent absences from social gatherings.

He had grown into a successful young man, despite changing jobs frequently and had begun to age gracefully. He was gregarious and funny and loved the good life. He did talk about his illness, but usually ended abruptly saying that unless one experienced it, one wouldn`t know. Dream big, he did and sometimes too big and needed to be bailed out financially on a number of occasions. He did not like people visiting him when he was ill, but enjoyed the phone call.

He was much loved by friends and colleagues alike and nobody really minded his shortcomings and liked him for who he was. One thing that stood out was his sudden bursts of rage, which was worrisome. Amongst friends, his positives were him and his negatives were his sugar, as if there were two different people who were in one body. Of late he was getting ill more frequently.

It was only apt that I asked him to write this piece about his experience with Type I Diabetes. At first, he said that he did not have time to sit down and write, but would share some insights later on that day. I even offered to ghost write on his behalf. At the prearranged time of the phone call, he sent me a text that he did not wish to play any further part in the interview and wished me luck with my post and to write from what I knew.
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A couple of days later I rang him to find out what had happened. “Diabetes is a big stigma. It is something that I do not discuss outside my very close circle of family and friends. It makes me look vulnerable and weak and may give my employers a chance to take an unkind stance in case there is a problem. I do not wish to have my name anywhere.”

In today`s day of extensive use of social media, on an average I read about 10 stories of people with diabetes a day. There are multiple forums on which people openly discuss such problems. I was shocked to see that 72% of people with Type I diabetes felt stigmatised.

Diabetes awareness and education is far from being anywhere near completion. It is not just that the affected people need to know about the disease that academic institutions and employers need to know that these people can live life and contribute as effectively as anyone else. Most importantly, people with diabetes need to feel reassured that the community at large understands this.

There is a big need for peer and institutional support. Organisations like the Diabetes UK, International Diabetes Federation, American Diabetes Association have been working tirelessly in this field. It’s time for all like-minded people to join hands and educate all stakeholders using all available channels. Mobile Platforms will be particularly useful for both social and disease support.