A conversation on CGM, part 2
How continuous monitoring of blood sugar will impact industries like health, food, insurance and others over the next decade
This is part 2 of a conversation between Henrik Berggren founder and CEO of Steady Health, a digital diabetes clinic and Eric Antonow, formerly at Metabolic. You can read Part 1 here.
Henrik: It’s happening in real-time. People sign up for our service, Steady, and they come in with a wide variety of context. Some have questions about CGM, how it works, how to best use it. So, there is a massive value that these applications layers can provide. Whether you have diabetes or not, the essential question is, “How do I extract the most value from this new data?” And that is a problem that can be solved with software.
Eric: That’s what you seem to have focused on at Steady. How can you help people use this to manage their lives? I have this data, but what do I pay attention to? What do I not pay attention to? How do I make progress? And what support do I need to do that? That’s the layer that most people are going to want, whether they have diabetes or not.
This is the core of the diet community. When people sign up for Weight Watchers or Jenny Craig, they’re for support. They want help getting through this process. In the CGM space, that will happen at the software layer, but I also bet a lot of this will happen at the community layer, which is certainly true in the diabetes community. You can go to online groups on the web and social networks that have formed to help each other manage and interpret their CGM experience. Groups like Diatribe have been invaluable.
You’re starting to see the same thing in CGM outside of diabetes. Follow Levels on Instagram, and they repost other people’s CGM screenshots and stories. I ate this bowl of oatmeal or rice, and my blood spiked like that. Those stories are going to be very powerful for users as well as a source of growth for the companies. So, there will be an application layer, a services layer, combined with a community layer, and I think that’s going to be enormous.
One of them will end up being the Peloton of CGM. They went far beyond a spinning bike. It’s a spinning bike, live classes, support, shoutouts from tier 1 instructors, along with the leaderboard and the community of other people that you’re riding with. You’re not getting a bike but a successful exercise experience. This is going to be motivational and easy to commit to this multiple times a week.
With CGM, it will be the same. I’m not just getting a device on my shoulder; I’m getting advice, guidance, and a community that motivates me to make changes. Those layers are very early but emerging right now.
There’s a whole segment of people struggling with weight loss, at least one third of the population, and they are also people aspiring to bicycle road races. So I would be very surprised not to see many distinct companies show up.
Many of the existing companies and categories will need to spin something up very quickly in response. I don’t think you can be weight Watchers or Jenny Craig and not have a CGM service. That will be true of insurance companies and hospitals and others. So, we’re on the cusp of something quite large.
Henrik: One distinction with Peloton is that this will be much cheaper to try. For $75, you get a whole month of data. That’s an opportunity to run experiments and post them on social media to understand yourself, compare what you’re doing with others, and understand more about yourself. So, the impact-to-price is enormous, and many companies will be impacted by this.
For $75, you get a whole month of data
Eric: That’s a terrific lens to look through this. This is the data you get for doing CGM for one month. Imagine taking data to your physician for your annual physical. The diagnostic quality is better in some ways than the blood labs they can order. If you do this once a year, you can, for the first time, see your metabolic response to foods and whether it’s degrading.
In the US, we have roughly 1.5 million people with type 1 diabetes, 30 million people with type 2, and 100 million people with pre-diabetes: 1/3rd of the population. The largest group has a high probability of ending up with diabetes, and now you can see where they are on that path and help them. It’s so much higher resolution than our current measure, like A1C or a fasting glucose. So, whether you’re Anthem or Kaiser or Stanford health systems, even as a diagnostic tool, I would expect to see programs launch in the next 2–5 years.
Henrik: I am currently obsessed with diagnostics. We do such a poor job today understanding whether someone is at risk for diabetes. We don’t have a good risk scale or articulation of where you are on the journey to a full diagnosis. Half of the people living with pre-diabetes don’t know their condition, and their numbers might not even show up in their labs. They might come in with good fasting glucose numbers, and a minorly elevated A1C, so many doctors will tell them there’s nothing to worry about. We are going to be able to diagnose early and put in some preventative measures that might prevent diabetes altogether.
Eric: A1C is the default measure for most doctors for risk assessment. It is just an average over months, and as an average, it can be incredibly deceptive. You could be having very severe spikes that are masked by this average. We also know from people that treat diabetes closely that the system can just crash. One year the person’s glucose number looks okay, and the next year, the system capitulates, and they have diabetes. We don’t have a ton of data on why and when that cliff happens.
The minute you have granular data predicting the move from non-diabetes to pre-diabetes or type 2, it will be much easier to diagnose early and intervene. That matters for at least one-third of the US population, and the rest of the world is in a similar boat. In countries like India and China, 10% of the population already has diabetes. And with more centralized health care, I expect they’ll be motivated to find solutions. The same is true for most European countries. This is absolutely a global problem. We’re not alone in both the risk and opportunity.
Henrik: I wouldn’t be surprised to see your insurance company pay for you to wear one of these devices for two weeks every year. It will be part of your regular checkup or labs. It will show up in the mail, you’ll just put it on, and it will be connected to their system. If something is wrong, they’ll have a specific care plan to help you.
Eric: Let’s take a moment to talk about Apple and Google. They’ve had access to some diabetes data on the phones and, in some cases, the watches. I expect to see some real innovation in the next six to twelve months, particularly as these new CGM devices come up. Do you have any quick thoughts on that?
Henrik: Apple has been rumored for a long-time to be working on glucose monitoring or a CGM. And Google has been working with Dexcom through Verily, and they’re in the process of acquiring Fitbit. So, it’s going to be interesting.
Eric: These wearable devices have mostly been about paying attention to movement. We started with counting steps, and they added sensors for heart rate, and those have gotten more sophisticated. We can detect some arrhythmias and now we have HRV, heart rate variability. That let’s them connect that to stress and sleep. All of that has very limited diagnostic value, but with continuous glucose monitoring, you are now involved in meaningful insights and real healthcare.
All of these devices, when paired with a CGM, will move into a health diagnostic category on par with blood labs. You can do it in partnership with your doctor or on your own with one of these services. It’s going to completely shift consumer health to a different space. For many people, it will make healthcare a first-person experience and responsibility. This is your body — the tools and insights are on your phone, not in your doctor’s office or some lab. So, psychologically, it feels much more in your hands than someone else’s. You don’t have to go to someone else to ask, “Am I healthy?”
Henrik: I think that notion of first-person health is incredibly powerful. The power and responsibility are shifting from mostly the physicians back to the person. I don’t know if you coined this idea, but the depth of diagnostic insight or diagnostic value in the CGM devices is so different from any health tracking we’ve had before. It’s a good proxy of overall value that comes from this data set.
Eric: Totally. A whole category will emerge called something like “CGM Health.” There will be an entirely new set of businesses in CGM Health, and the existing ones — whether they’re hospitals, doctors, dietitians, or insurance companies — will have to get into it, too. It’s the category that’s emergent.
A whole category will emerge called something like “CGM Health.”
I’m curious in the context of Steady: Do you see this behavior of first-person health, particularly as people get CGM devices?
Henrik: Absolutely. In diabetes specifically, we’ve been treating everybody with a care model that’s one-size-fits-all. If you have a diabetes diagnosis, you get a quarterly visit with your doctor for the rest of your life. This is regardless of what you’re struggling with and so on.
With this data and insight, we can be much more custom for every single person. We can spend more time with the people that are really struggling with something. Maybe they had their first child, maybe they just moved or changed jobs. All of those impact food access, exercise, and lifestyles. For people who are doing well, we can see that in their hourly data and take a different strategy. We can answer specific questions but they need less of our time.
We let them be in control of when they need help, but we can now be proactive. So, typically, we reach out to them and say, “Hey, we’ve seen that your numbers have not been as good as we want them to be for the past two weeks. What’s been going on with you?” That kind of opens the door to a different level of care and support.
Eric: You can imagine a very analogous conversation for someone who’s on a diet. If you’re trying to help someone manage weight loss, you don’t have data to see what’s going on. If you give your physician or dietician access to your CGM data, they can help monitor and support you. That’s hard to imagine right now, but we’re not far.
Henrik: That’s such a big piece. We need to help people build behavioral changes over time. The feedback and learning loop is just too long. You can think back to your behavior over the last month to try and to triangulate what you ate. It just doesn’t work.
Eric: People can debate how quickly this will happen, but I think, because of social media, at least awareness of CGM will be fast. It will be very much like Keto over the last few years. You’ll watch people posting CGM data on Instagram or wherever. You’ll see influencers or emerging fitness and diet people. They’ll start posting their CGM journey, and that will educate a few million people. It will be very niche, but it will grow quickly.
I also expect to see an “Al Roker” of CGM. In 2002, when he got gastric bypass surgery, it was much more rare. He came back to the Today Show after surgery, and everyone saw the shocking results. He was a different person. Those surgeries are roughly 10x more popular now, and Roker is responsible for making many more people aware of it. Someone high profile will do that with CGM.
I expect to see an “Al Roker” of CGM
Henrik: Yes. That’s right. Who’s going to be Al Roker of CGM? This is been a good conversation. Thank you, Eric.
This is part 2 of a conversation between Henrik Berggren founder and CEO of Steady Health, a digital diabetes clinic and Eric Antonow, formerly at Metabolic. This conversation is also available on YouTube and you can read Part 1 here.
