Steady Health: A digital diabetes clinic

Moving beyond finger sticks and quarterly hospital visits

Today we’re launching Steady Health, the first full-service digital diabetes clinic in the US. Steady combines the power of continuous glucose monitors and the convenience of telemedicine to deliver a new type of care to patients. Head to our website to find out more.

2020 is an amazing year to be alive. Wearable devices like Apple Watches, Continuous Glucose Monitors (CGMs), and Oura Rings are not only widely available, they’re providing us with more data than ever before — helping us better understand how we sleep, eat, and exercise. But, thus far they haven’t gone all the way to working with your doctor, to directly improve your health and medical care. Steady is changing that by leveraging wearable devices to become the first digital diabetes clinic that provides modern and connected care.

Over the last year, we’ve been piloting a new way to help people live the lives they want by providing exceptional diabetes care in a convenient package. We’re focused on two of the oldest and most antiquated parts of the care experience: finger sticks and quarterly visits to the hospital. I’ve had diabetes for 20 years and for most of that time have struggled with using a glucose meter to measure my blood sugar level, and bringing those measurements to my endocrinologist. This is the reality for the majority of diabetes patients in the US, and I’m painfully aware of how much it sucks.

“Steady has helped me tune almost every dimension of my life with diabetes. Having a team of experts sit down and review my data, at my side, has really helped to answer questions I otherwise could not.”

– Steve

Combining the power of continuous data with the convenience of telemedicine

Steady is built on two really exciting healthcare innovations: Continuous Glucose Monitors (CGM) and telemedicine.

For those of you who don’t know what a CGM is, it’s a small wearable that syncs your blood sugar numbers with your phone every 5 minutes (read more about it here). It completely removes the need to prick your finger and even tracks your blood sugar levels while you sleep, exercise or sit in meetings. I’ve been using one every single day for almost 3 years, and it’s been a huge improvement to my quality of life. If you’re already using a CGM but not using Steady, follow along as I believe you’re only getting a fraction of the value it can provide you.

A progress report we send to our members each month

Wearing a CGM and using Steady means we can be there with you whenever you need us. Through our platform, you can automatically share your blood sugar numbers, diet, exercise, and medication with your care team. No more manual uploading or printing out PDFs to bring to your doctor’s appointments — our team is always up-to-date on how you are doing.

We even reach out proactively to you if we notice that your levels are trending below your personal goal. Now your doctor can help you when you need it, not only when their schedule permits.

Asyou know, diabetes is a chronic disease that is always present in your life. It doesn’t follow a quarterly schedule or wait for your next visit. So, why should your doctor? Steady provides all care digitally using text messaging and video.

  • Stressed because your levels are high? Message your care team in our app.
  • Need a new prescription? Send a text to our Member Guide.
  • Can’t get away from work?Video chat with our doctors on your phone.

Our licensed medical team specializes in diabetes care and has years of experience both helping people manage it and living with the disease themselves. If you live in a suburban or rural area of California, this is a chance to get care from one of the best teams in the field, all without having to travel a single mile.

It also doesn’t matter if you are Type 1 or 2, or what kind of medication you are on. If you need help managing your blood sugar, we’re here to help. With our model, we can work with you on lifestyle changes for everything from eating the right breakfast to finding an exercise routine that fits you the best.

“I’ve learned more in this appointment than in the last 15 years”

– Sara

Finally, you might ask, how is Steady different from the many apps and coaching services already out there? The big difference is that we take full responsibility for you as a patient. This means we replace your current endocrinologist or primary care provider for all of your diabetes care. We coordinate labs, referrals, prescriptions and everything else you need to stay healthy. We know that living with diabetes is already a full-time job and we’re committed to giving you great care in a convenient way.

Our digital clinic launches today

Today we’re launching v1.0 of Steady, the first full-service digital diabetes clinic in the US.

We’re starting in California but will be opening in more states later this year.

To sign up, head to our website and click “Get started” to download our app. Steady’s monthly subscription plan costs $60 and gives you easy access to our care team, platform and help with everything from labs to prescriptions. For more cost and insurance information visit our Membership page.

We’ve been piloting an early version of Steady with founding members for a few months. If you’re curious about what their experience has been, check out some reviews on Yelp and find testimonials on our website.

“I can’t believe I’ve gone 10 years without them… The knowledge and expertise, and the encouragement and support are unmatched. I’m so glad I found them, and I’m never letting go”

– Michelle

If you’re living with diabetes, give Steady a shot and I’m confident you won’t regret it. If you know anyone touched by this disease, please send it their way as it might make a difference.

Henrik and the rest of the Steady team

The ultimate guide to Continuous Glucose Monitors (CGM)

Whether you have diabetes, are struggling to improve your diet, or are just curious to understand how your blood sugar changes over the course of a day, a continuous glucose monitor (CGM) can be a really valuable tool. In this article, I’ll explain what a CGM is, how it works, and what you can learn from using one. I’ll also review three different models that are currently available in the US, and review their functionality, price, and more.

What is a Continuous Glucose Monitor?

A CGM is a small wearable device that you attach to your body to measure the concentration of sugar in your blood. Monitoring blood sugar levels is critical for anyone living with diabetes, but can also give insight into how things like food, exercise, and medication affect your body.

Without a CGM, measuring your blood is both painful and cumbersome. The most common way to do this is via the finger prick method — you prick your finger, place a drop a blood on a test strip, and insert it into a meter to get a single reading. With a CGM, you automatically get an updated reading every 5 minutes. This makes it far easier to keep track of your levels throughout the day, even while sleeping or exercising.

There are three main manufacturers of CGMs on the market today: Dexcom, Medtronic, and Abbott. I’ll be comparing their latest models below.

How do CGMs work?

All CGMs on the market today use roughly the same technology. They are invasive, which means they puncture your skin to measure glucose through interstitial fluid found just a few millimeters below.

Source: Abbott

The sensor’s filament is coated with glucose oxidase that converts glucose into hydrogen peroxide, which reacts with a platinum receiver. This generates an electric signal that is then sent to a chip located inside the outer casing.

These signals are then sent to an external transmitter (either a custom device or your phone) where an algorithm is used to predict the actual glucose level in your blood. This algorithm is not 100% accurate, but has high precision and is approved by the FDA for use by both patients and doctors. In fact, it is shown to be more accurate than some finger prick meters.

What can you learn from a CGM?

At any given moment, 42 different factors can impact your blood sugar level. This means there are many things we can learn from gathering and analyzing more data. The three most impactful categories are diet, exercise, and medication, closely followed by sleep and stress. Some examples of things you can learn include:

  • Which meals spike your levels, leading to fatigue and hunger?
  • What time should you eat dinner to ensure stable overnight glucose levels?
  • Which type of exercise has the least impact on your levels?
  • What happens to your levels on six vs eight hours of sleep?

Which CGM is the best? Let’s compare the Freestyle Libre, Dexcom G6, and Medtronic Guardian.

In this section, I’ll compare the three major brands in the US today. I’ve personally worn a CGM every single day for the past three years, have tested several different models, and have used over 100 individual sensors. I am also in regular contact with all three manufacturers through my work at Steady Health.

Abbott Freestyle Libre

The Freestyle Libre from Abbott

Let’s start with the most popular model, the Freestyle Libre from Abbott. It’s the most common device due to its sleek design and low cost, but it’s not delivering data continuously, as it requires you to actively scan the sensor with your phone to download the latest data. (It’s actually considered a flash glucose monitor, or FGM.) The sensor itself stores up to 8 hours of history, so as long as you scan regularly you won’t miss any data.

The LibreLink App

Functionality: The sensor is low profile, easy to insert, and stays on pretty well. Towards the end of each session, you might want to put on some tape to ensure it stays on. It has a 14-day wear time and a 1-hour warm-up period before it’s ready to use.

The app experience is basic but works well. It shows you daily patterns, average glucose levels, and other standard charts. It also allows you to log events like meals and exercise, but does not support pictures which makes it harder to use for food journaling.

Cost: The price is its largest benefit. Every sensor can be worn for up to 14 days and the cash price is around $60 per sensor. If you have commercial insurance, many pharmacies guarantee a max out of pocket amount of $75 per month. This means you can each sensor for $37.50.

In summary: Great wear experience, 14 day wear time and affordable, but only has basic app functionality. I consider Freestyle Libre to be a great choice for anyone that is curious about CGM and doesn’t need all the bells and whistles.

Dexcom G6

Dexcom G6 (source)

Next up is the G6 from Dexcom. This device is the most advanced CGM on the market as it sends data directly to your phone via Bluetooth. The data it provides is also available in an API so you can easily access it in raw form.

The Dexcom G6 app

Functionality: The G6 sensor is both larger in size and higher profile than the Libre, but still small enough to not be in the way. It has more of a medical look and the adhesive around it is bigger too. It has a 10-day wear time and a 2-hour warm-up period before it can be used.

The app experience is similar to the Libre: basic, but works well. You can log events, but pictures are also unsupported.

The biggest advantage is that it does deliver data continuously directly to your phone. This means you can easily set up automated alarms and see your latest numbers via a connected watch.

Cost: The Dexcom G6 is significantly more expensive. Every sensor is about $115 if you pay out of pocket, and unlike the Libre, you also need a separate transmitter (which sends data from the sensor to your phone) that’s attached to it. Transmitters cost about $240 and can be worn for three months before running out of charge. So all in all, you are looking at $425 per month for a complete sensor and transmitter set.

In summary: Dexcom has all the features you want, including a Bluetooth connection and open API, but this is reflected in its hefty price tag. If monitoring your levels closely is important to you, it’s a great choice.

Medtronic Guardian Connect

Medtronic Guardian Connect

The Guardian Connect from Medtronic is the least popular CGM of the three. It’s lagging behind both in overall functionality and experience, but has a few advantages as well.

Medtronic Guardian Connect

Functionality: The Guardian sensor lies somewhere between the Libre and the G6 in terms of size, and has a relatively low profile. But, it only has a 7-day wear time and a longer 2-hour warm-up period. The Guardian also requires calibration via a finger prick measurement done twice a day; this is a significant drawback as it is both painful and cumbersome.

One big advantage of the Guardian Connect over Dexcom is that the transmitter is rechargeable and reusable.

The mobile experience is on par with the others and supports automated alarms, smartwatch support, and more. You can similarly log events in the app, but pictures are again unsupported.

Cost: Due to the rechargeable transmitter, the monthly cost for the Guardian Connect is somewhat hard to predict. Every transmitter costs $775 and a box of 5 sensors is $553. If we assume the life of a transmitter is 24 months, the monthly cost of this system is $474.

In summary: Since the Guardian Connect system requires both daily calibrations and has a significantly shorter wear-time, it ends up being both more expensive and less usable than the other models.

How to get a CGM?

To get your hands on a CGM in the US you need a prescription. If you have any type of diabetes it should be relatively straightforward — just ask your doctor during your next visit or sign up for Steady and we will prescribe one for you. If you don’t have diabetes the cheapest option is to ask your Primary Care Provider for a prescription. You can also use one of the relatively new CGM consumer services on the market, but be aware that these may cost you up to five times more per sensor than just going directly to your PCP.

I hope this overview is helpful for anyone looking to learn about CGMs, the different models, and which one to use. If you already use a CGM today and struggle with blood sugar control, check out Steady Health, as we specialize in CGM-based care for diabetes: https://steady.health/

The value of a care team in my pocket

A portrait photo of Parteek laughing

My name is Parteek Saran, and I’m a designer and avid cyclist living in San Francisco. I’ve been living with Type 1 Diabetes for most of my life, and I am still looking for better ways to improve control of my blood sugars. This is the story of how the team at Steady Health has been helping me lately.

The status quo of traditional care 

After living with Type 1 Diabetes for 17 years, I had gotten into a pretty typical routine: I met with my endocrinologist, they asked me about my numbers, and then suggested one or two changes to my insulin treatment. We validated how well the changes worked the next time we met, typically 3 to 6 months later. If a particular adjustment went too far and caused recurring low blood sugars, I had to come up with a band-aid solution to the problem until the next visit.

Diabetes management should be an iterative process, and I always wished I could have involved my endocrinologist immediately in finding the root of the problem and making the proper adjustment

For example, if we changed the carb-ratio settings in my insulin pump but did not accurately hit the target, I would have to override the pump’s dose suggestions manually until my next appointment, which could be months away. Doing this for months was cumbersome, but also made it difficult for me to learn, and ultimately made it impossible to achieve the blood sugar control I wanted. Diabetes management should be an iterative process, and I always wished I could have involved my endocrinologist immediately in finding the root of the problem and making the proper adjustments.

Introducing Steady

But this all changed three months ago when I found Steady Health. I can communicate with them anytime in the Steady app, and not only do they have specialized doctors on the team, but also Certified Diabetes Educators and Care Coordinators that support me with things like education, lab orders, and prescriptions. Let me give you an example of how it works:

I recently noticed that I was having low blood sugars around lunch more often. My initial reaction was to subtract some insulin from each breakfast and lunch dose, thinking that would be an easy way to prevent the low blood sugars. But instead, I sent a message to Steady and my Certified Diabetes Educator, Aimée. She replied on the same day, asking me to log my meals by taking a photo with the Steady app. Aimée calls it “tracking”, and it enables her to give me very precise advice based on my actual data. My continuous blood sugar data and physical activity are captured by my phone automatically, so no there is no extra work required on my part to capture them. 

Screenshots from my Steady app

After a couple of days tracking, Aimée and my doctor, Dr. Wu, suggested that my carb ratio settings needed to be adjusted. Based on my data, I was more sensitive to insulin in the morning and therefore needed less insulin. I put the new settings into my insulin pump and then continued to track everything through the Steady app for a few more days. At the end of the week, we met to evaluate how the changes were working.

There are a couple of options for how I can interact with the care team at Steady. Typically, I’ll use the messaging platform in their app, but I can also schedule a video call or come in for a visit to their office. This time, I decided to do an in-person visit with Aimée, who had put together a presentation based on my data since making the carb ratio changes.

A screenshot of my data from Steady

Aimée showed me how I responded to different meals, and how I had reduced the number of low blood sugar readings by 50% while increasing the time I have normal blood sugars (Time in Range) by almost 10%. It was relieving to see how quickly we had found more effective settings with minimal effort!

Within just one week, we had identified the problem, tested a solution, and validated the results. And I did it all by simply messaging with my care team within the Steady app. 

After 17 years of living with Type 1 Diabetes, I am finally focusing my energy on making improvements rather than just trying to preserve the status quo!

Peace of mind

Since joining Steady three months ago, I have a new companion for my journey through life, always ready to support me. I get more personalized advice than ever and have learned how to interpret new patterns in my day-to-day management. I’m learning how seemingly small details affect my blood sugar significantly and deciphering them piece by piece.

After 17 years of living with Type 1 Diabetes, I am finally focusing my energy on making improvements rather than just trying to preserve the status quo!

This story is written by Parteek Saran and published by Steady Health.

Click this link and sign up for a free consult call and learn if the Steady Health care model is right for you

Steady Health’s Chia Seed Pudding

hia seed pudding has become increasingly popular within the diabetes community as it has little impact on blood glucose, is easy to make, tasty, very customizable, and is a very low-cost breakfast or snack. Breakfast can often be the hardest meal of the day for people with diabetes. Starting every day in good control could be life-changing. A few weeks ago, the Steady Health team had a chia seed pudding taste test and voted for their favorite recipe!

Here’s the recipe:

  • 1 cup of light coconut milk
  • 4 tablespoons of chia seeds
  • 2 tablespoons of honey
  • 1 teaspoon of vanilla extract

Mix all ingredients together in a bowl, cover, and refrigerate overnight.

Yup, that’s it! It’s that easy! Get your mason jars out and start filling them with chia seeds!

For the ingredients that we used, one of our Steady team members, who has type 1 diabetes, bolused for 20g of carbs for 1 cup of our chia seed pudding (this is what we estimated, may vary depending on the ingredient brand or product you buy). Check out their CGM data below!

Screenshot of Steady Health team member’s CGM data from 6am to 1 pm. One cup of chia seed pudding with some sliced almonds at 9:20 am! Yum!

For more inspiration and ideas, check out Diatribe’s 50 Shades of Chia Pudding.

To learn more about Steady Health, email us at hello@steady.health or go to www.steady.health

A1c vs Time-in-Range

What is A1c? What is time-in-range? How do they relate? Why is the diabetes community moving more and more towards time-in-range?

What is A1c? In simple terms, Hemoglobin A1c (HgbA1c, HbA1c or A1c) is the average blood glucose level over the past 2-3 months. An A1c test measures the amount of glucose that attaches to red blood cells. Since these red blood cells survive for 2–3 months, A1c can reflect someone’s average glucose levels over that same time period.

What is time-in-range? Time-in-range is the percentage of time you spend in a target blood glucose range for a given time period. Time-in-range has only become possible with the magic of a continuous glucose monitor (CGM). CGM allows people with diabetes to measure their blood glucose levels all day, 24 hours a day without pricking their finger every minute. CGM is able to give insight to how much time is spent in the standard range of 70–180 mg/dL, time in high (standard greater than 180 mg/dL) or time on low (standard less than 70 mg/dL).

Improving your time-in-range can improve short- and long-term health and avoid diabetes-related complications. Using our tool, we can also look at time in your personal target range if you have one (some examples: 70–140 mg/dL, 80–160 mg/dL, etc.), in addition to the standard range.

Consensus on Time in Range. Diabetes Care 2019 Jun; dci190028.

What are the limitations of A1c? When is A1c unreliable?One limit of A1c is that it cannot tell you anything about fluctuations in your blood glucose values throughout the day and night. If your A1c is high, all you know is that your average blood glucose for the last 3 months has been on the higher side. But, you still can have serious, unrecognized low blood glucose values. On the other side, if your A1c is low, you may be spending a lot of time in the low range without knowing what time of day and what the possible causes are for them. This can mislead some people into thinking they have great control and are “at goal” with an A1c below 7%.

In fact, two people can have an A1c of 7%, but one actually has very stable BGs, whereas another has a lot of variation, including lows.

Same A1c, but completely different time-in-range.

This variation in BG values cannot be captured by an A1c. This is only possible with a CGM.

Why is the diabetes community moving more and more towards time in range? For people with diabetes, it’s become much easier to access time-in-range data with technology like a CGM. Time in range is readily available and we can access it almost instantly. Getting an A1c requires the patient to go to a lab and have their blood drawn.

Another benefit of time-in-range is the ability to select time periods and compare them. Let’s say you make a new change in your diabetes management on June 10th. If you want to see how this new change has affected you, you can just select to see your time in range for before and after June 10th. This is a huge benefit that CGM and time-in-range have provided for people with diabetes. You no longer have to wait 3 months to see the effects of a new change in your diabetes management.

A1c has been so dominant in this sphere because it’s been proven to correlate to macrovascular complications (coronary artery disease, peripheral arterial disease, and stroke) and microvascular complications (diabetic nephropathy, neuropathy, and retinopathy). Time in range could provide the same value as A1c — they have been shown to have a strong relationship (see image below). Therefore, time in range doesn’t replace A1c, but for people using a CGM, it could add these advantages of being more available, accessible, and customizable.

Relationship between Time-in-Range and HgbA1c

To learn more about Steady Health, email us at hello@steady.health or go to www.steady.health

Thanks to Calvin Wu, MD, Henrik Berggren, and Björn Hansell, MD. 

Misunderstood & Oversimplified - The Complicated Nature of Diabetes

One doctor’s realization that a lot of thought and effort goes into managing this disease well

My name is Calvin Wu, and I’m an endocrinologist — a physician that specializes in hormone-related diseases including diabetes. I’ve been on the front lines of the diabetes epidemic for years and am convinced that we’re not getting anywhere with our current approach to this disease. That’s why I joined Steady Health, and together we’re on a mission to revolutionize the patient-provider experience and deliver diabetes care in a more thoughtful and meaningful way. The following story is about my personal journey towards embracing the complexity of a disease that I had once underestimated.

Despite ongoing efforts and major advances in drug therapy, diabetes care remains suboptimal and largely unchanged between 2005 and 2016. Adapted from Kazemian P et al.

I’m embarrassed to say that I used to think that managing diabetes was easy.

Some of my earliest experiences managing blood glucose revolved around using formulas to derive a starting insulin regimen for hospitalized patients with diabetes, followed by continual dose adjustments to try and keep their blood glucose within a reasonable range. The process was generally straightforward — a high glucose reading by lunchtime probably meant I should give more insulin the next morning to cover for breakfast, whereas a drop in blood glucose overnight probably meant I should reduce their evening dose of long-acting insulin. For something so seemingly menial, I enjoyed being able to see the positive impact of my efforts by the next day, and found it inherently gratifying to work out a regimen that reliably maintained blood glucose at goal.

A limited point of view

I didn’t fully appreciate back then how narrow a view I was getting of diabetes management. Many physicians like myself learn to practice medicine by primarily taking care of sick, hospitalized patients during our residency training, but the experience of managing diabetes in the hospital setting is controlled and decidedly artificial — treatment is limited to insulin, we specify the meals patients can and can’t have, patients are generally confined to their beds, and nurses (not patients themselves) collect the glucose measurements and administer each dose of insulin. Not surprisingly, people’s diets and lifestyles start to look very different after they leave the hospital, and one can only imagine how well an insulin regimen tailored to their hospital stay fares in the real world. When patients came back for follow-up, they often were not giving their insulin or checking their blood glucose on a regular basis, leaving me with little data with which to make an informed clinical decision. If blood tests suggested that glucose levels were high, the knee jerk response was to increase their doses of insulin overall, when in reality that might not be the appropriate intervention.

I didn’t fully appreciate back then how narrow a view I was getting of diabetes management.

Although I empathized with my patients, I didn’t really know what they were going through either. I didn’t have any personal experience with diabetes, nor did any of my close relatives or friends. Up until that point, I had never poked my finger to measure my blood glucose level, nor had I ever given myself an injection — these were tasks that nurses (not doctors) taught patients to perform. Meanwhile, I would routinely advise patients to exercise regularly and to adhere to a healthy low-carb diet, without a concrete understanding of what that actually meant. When that didn’t work, I didn’t ask enough about or appreciate the importance of their lifestyle choices or management strategies. Instead, my medical training had largely emphasized medications as the answer, and managing type 2 diabetes in particular (for which more treatment options exist besides insulin) became an exercise of “choosing the next medication” when others had failed. In truth, I chose to pursue endocrinology because I was fascinated by the elegance of the body’s hormonal feedback loops, not because I was especially interested in diabetes.

More than meets the eye

Imagine, then, how baffled I was when my senior co-fellow told me at the start of my endocrinology fellowship that “managing diabetes is hard.” To be fair, I had always been tasked with managing all of a patient’s medical problems in primary care — diabetes was typically only one of many concerns I had to address during a 15–20 minute visit, so I only had time to graze the surface of a multifaceted disease. Having made the decision to subspecialize, however, I could now focus my entire attention on diabetes and a small handful of other endocrine disorders, and it became readily apparent why my co-fellow felt the way he did.

Imagine, then, how baffled I was when my senior co-fellow told me at the start of my endocrinology fellowship that “managing diabetes is hard.”

I became very aware of how misguided the practice of blindly increasing long-acting/basal insulin to counteract high fasting morning glucose levels could be, after uncovering that patients were routinely struggling with dangerously low blood glucose levels (hypoglycemia) or compensating with maladaptive behaviors (such as eating not due to hunger, but to prevent their blood glucose from dropping too low). I learned to inquire very specifically about what patients were actually eating, realizing that giving a set dose of insulin for every lunch, for example, didn’t make any sense if people weren’t eating similar meals day after day.

I learned the hard way to ask about injection site rotation, after several patients developed severe hypoglycemia as a result of my continuing their home doses of insulin in the hospital. Repeated injections into the same exact location had created scar tissue from overuse, which prevented the injected insulin from absorbing properly. However, the proper administration of insulin into another unaffected site by the nurse would then subject these patients to the full unbridled glucose-lowering effects of that dose, resulting in seizures or loss of consciousness.

I encountered insulin resistance at its most extreme while quite literally managing diabetes “on steroids” at a cancer hospital. It was routine here for patients to receive massive courses of corticosteroids as part of their chemotherapy regimens, which could transiently but dramatically increase insulin resistance and cause glucose levels to skyrocket. Trying to keep up with the ensuing glucose fluctuations required frequent and astonishingly large-scale medication adjustments that had me second-guessing myself at every turn.

Putting myself in my patients’ shoes

As my naïve perspective on diabetes management matured, so did my understanding of the patient’s experience. I made a dedicated effort to put myself in my patients’ shoes and learn everything I could, from pricking my finger and injecting myself with saline, to trying out every diabetes device on the market I could get my hands on. I had always had a vague understanding of carbohydrate counting, but forcing myself to practice it with my own meals helped me realize how difficult and intensive the process truly was. Meanwhile, my patients taught me to appreciate the nuanced effects of differing meal compositions, varying forms of physical activity, and emotional states on blood glucose.

An example of the multiple factors a person with diabetes is juggling at any given moment. From: Adam Brown, https://diatribe.org/42factors

But by far the most eye-opening was the experience I gained from attending diabetes camp at Camp Conrad Chinnock as part of the volunteer medical staff. Seeing kids between the ages of 7 to 12 have to check their blood glucose before and after every snack or activity, double-checking their insulin dose calculations before meals, waking them up in the middle of the night to check their blood glucose and giving them something to raise it if it was too low — it all finally hit me how omnipresent their disease was in nearly every aspect of their lives. I was deeply humbled by the layer of complexity it added to doing all the things that I took for granted in daily life, but also by how these kids did not let their disease slow them down. I began to re-evaluate the burdens it places on others as well — be it the pregnant woman with gestational diabetes worried about her unborn child, or the gentleman intent on avoiding the horrible complications of type 2 diabetes that all of his relatives have suffered.

Finding a new direction

Now, more than ever, I understand that managing diabetes is complicated. And for the patients who have it, managing diabetes is relentless, and sometimes just plain hard. I feel blessed that I don’t personally struggle with this disease day in and day out, and I know better than to judge a patient with diabetes for not taking perfect care of themselves. Coming to these realizations has made managing diabetes as a physician more meaningful and relatable, and far from being bored by this subset of endocrinology, I now find the unique challenges it poses to each individual incredibly interesting and rewarding to tackle. With the number of US adults with diabetes projected to nearly triple to over 60 million by 2060 and little question as to where I can have the greatest impact, I even made the conscious decision earlier this year to make diabetes the primary focus of my career.

Our consultations at Steady Health are designed to be collaborative and focused on the individual’s data and goals

As I strive to hone my craft, I have come to realize that diabetes care has to be personalized to be truly effective. In the past, this often took a lot of time and effort outside of a traditional visit and wasn’t always possible, but the ambitious care model we have developed at Steady enables me to spend a full hour getting to know my patients at their first visit, build on that relationship over messaging and video, access and monitor their data remotely, and use that data to make informed clinical decisions and collaborate on goals tailored to the individual. These days, I find that I am more often advising patients on how to better manage their meals, lifestyle, and strategies around blood glucose levels than I am writing a new prescription for them, and it’s satisfying to see that that’s actually having a greater impact. Looking back to a time when I used to find diabetes formulaic and one-dimensional, I think I’ve come a long way. For that, I have my patients to thank — because they have been, and always will be, my greatest teachers.

A special thanks to Henrik Berggren, Aimée José, Sid Ghodke, & Karin Wu for their feedback and suggestions.

Behind the Scenes: The Design of Steady Health

How we designed a patient-focused location from start to finish

The challenge in designing a modern clinic like Steady Health is to put together a space that has all necessary clinical tools but reflects a new approach to care, specifically diabetes care. While interviewing Chloe Blain, the designer behind Steady, she explains,

“Our main goal for the clinic was to highlight Steady Health’s human-centered mission and make members feel comfortable.”

Our founders, Henrik and Björn, shared similar sensibilities so we focused our efforts on statement elements to reinforce these core values. The consultation room, shown below, has display shelves with simple, ornamental objects that put a human feel in the space, while still having containers and space for clinical tools.

Björn, our Chief Medical Officer, explains that the goal for the consultation room was to design an equally comfortable space for everyone; to create a feeling of collaboration and signal a lack of hierarchy in the room. This is the reason for the round table and multiple chairs, “We wanted our members to feel like they can bring a friend or family member into their appointment for extra support,” (type 3 friendly!)

Steady Health consultation room

For being a technology-forward company, you won’t find many screens or gadgets laying around. “You may notice that there are no computer monitors in the consultation room, and even the screen on the wall dissolves into artwork when it’s not in use. We felt that it was important to focus on the technology enabling a human experience — not just the tool itself”, explains Chloe.

We also found an alternative way to scribe office visits. Taking notes has become more common in medicine as detailed documentation is legally required, while the expectation for doctors to pay attention to their patients is also critical. “The intuition is to have everyone in the same room, but we wanted to try having a scribe listen in from outside the room. We felt that it could be distracting to have a third person in the room that isn’t taking part in the conversation,” Björn explains. This allows the conversation and collaboration to take place between the main players — the clinicians and the members.

“It would be easy to say we’re tech-driven and make it look sleek and high tech, but it’s actually more modern to hide the technology in the background to support the work we’re doing as people,” Björn explains.

For the front office, in order to maintain a high degree of openness we have with our members, a transparent divider was chosen to separate the clinic space from the office space.

View from the front door, transparent divider, and desk between clinic space and office space.

Chloe further explains this deliberate choice, “It empowers members to look behind the scenes, get involved, and take control of their health. Similarly, the divider provides a psychological barrier between clinic and engineering spaces, but it is see-through. It is playful and translucent but is composed of rigid and opaque elements. It strikes a balance between comfortable and clinical, relaxed and professional. The vertical wooden elements also help emphasize the high-ceiling, which is important in a small space.”

“It empowers members to look behind the scenes, get involved, and take control of their health.”

Our team worked quite a lot to get the right amount of transparency for the divider, “We went through many rounds of figuring out what the right amount of space would be between the wooden bars. We didn’t want people to feel watched, but still wanted to allow them to see movement,” explains Björn.

Steady Health founders, Björn (left) and Henrik (right), chatting in Steady’s office lounge area

“Soft elements were chosen to create a welcoming space. Natural elements and greenery universally evoke calmness and well-being.”

The space, in general, has a professional, yet comfortable and inviting feel. I asked Chloe about the color scheme of the space, “Soft elements were chosen to create a welcoming space. Natural elements and greenery universally evoke calmness and well-being. The color palette is about natural materials and muted tones. Soft greens are associated with life, freshness, and safety, and lend themselves well to healthcare environments. Honest materials such as solid, oiled oak suggest professionalism and confidence. Rich finishes such as cork and textured fabrics are sound-dampening and bring comfort and intimacy.”

To learn more, visit steady.health or email us at hello@steady.health

Thanks to Henrik Berggren and Björn Hansell, MD. 

After decades living with diabetes, Steve finally broke new ground

How CGM and a diabetes clinic called Steady Health changed his care

Since his diagnosis in 1980, Steve’s diabetes care had remained relatively the same. He used finger sticks to check his blood glucose and a sliding scale to calculate how much insulin to use for each meal based on his current blood glucose level. For this treatment to be successful, he chose many of the same, specific foods and mealtimes. Steve wasn’t encouraged to dose insulin depending on the content of his meals, and this made it impossible for him to avoid high blood sugars. It cemented a feeling that it was impossible to achieve good blood sugar control. Steve says that he was often puzzled by this “fixed” approach to care, and describes it as “almost blind management”. Even though he felt he was doing what he could, Steve could not get his blood glucose under the level of control that he wanted.

“I was puzzled by how ‘fixed’ the sliding scale was, it felt like a lot of guesswork — almost blind management.”

In addition to feeling frustrated from high blood sugar and the fear of dramatic lows, another aspect stressed Steve even more; He knew that prolonged high blood sugars put him at increased risk for long-term complications like kidney failure, heart disease, and even blindness.

These prolonged high blood sugars can be measured by a blood analysis called Hemoglobin A1C, and Steve’s personal goal was to get his below 7%. He went to see his endocrinologist regularly, made all the adjustments they suggested, but never got his A1c lower than 8%. With a stagnant approach to his care, Steve’s personal health goal was hindered.

Steady Health’s first step was to get Steve started on a continuous glucose monitor (CGM). A CGM shows a blood glucose reading every 5 minutes and gives a trending arrow of where it is heading to help make informed decisions. No more finger sticks. No more guessing. Even with these benefits, Steve was pretty reluctant to the idea of having a device fixed to his body. Since being diagnosed with diabetes, he has always just wanted to be like everyone else, and having a device attached to him only exaggerated his differences. At the same time, he was curious about what he could learn about his blood glucose while using a CGM. After talking to us and reading our founder’s medium post, Steve jumped at the opportunity.

Getting a CGM

39 years to date, the biggest and most impactful change in Steve’s diabetes care was starting on the Dexcom G6 CGM. “If you’re only doing finger sticks, you’re only getting snapshots and not filling in the blanks. I was testing before meals and that’s about it. If I was feeling low, I would test. If I was feeling high, I would test. I have a pretty good internal meter so I knew when I was going low, but not when I was going high. Now, I’m much more in tune with how my meals are not only affecting my glucose levels, but also my dosing.

CGM data enables instant feedback and fills in the blanks for people with diabetes. But, to do a proper analysis of why someone is going high or low, we need to compare different instances and have information on how food, exercise, stress, etc. is affecting them. We have our members track these meaningful events in their day to day in the Steady app and then we’re able to see it alongside their CGM data:

The Steady care process

After a 2 week tracking period, Steve came in for an In-Depth Analysis appointment (which was much longer than his typical 15 minutes Endo visit!). During this session, he met with our clinical team of Endocrinologists and Certified Diabetes Educators to talk through his data and collaboratively develop insights on how he can improve his daily decisions for better long term health. Our model of care is set up to help every member reach their goals and live healthier lives.

After working with Steady, Steve says he gained a completely new perspective on his blood sugar management, “I was seeing little things that I never really knew, my eyes had been opened.” Through Steady’s analysis of his CGM data, Steve found out that his blood glucose naturally rises between 6–8 am. Before having a CGM, he never knew that. How could he? Now, he wakes up, gives himself a bolus, and starts every day in better range.

Another thing Steve learned from his own data was that short-acting insulin sometimes lost its effect before his dinner had been completely absorbed, which led him to have high blood sugars overnight. With Steady, he figured out a way to manage those meals, “The coaching sessions with Steady helped me learn new things about how to manage blood sugars and try things I wouldn’t have tried on my own. I bolus in a completely different way than a year ago. I still take the same amount of Humalog, but I take it differently.

One day of Steve’s tracking period: the green dots are his blood glucose values, he logged pictures of food and drinks shown at the bottom, and the blue circles display the units of insulin he administered.

Steady app messaging

A new feature Steady provides is quick, direct messaging with our care team. Messaging allows members to contact Calvin, our endocrinologist, or Aimee, our nurse, and diabetes specialist, with any questions about prescriptions, insulin doses, or symptoms and get a response directly from them.

This showed to be extremely beneficial when it came to adjusting Steve’s basal dose. For the last 20 years, Steve’s doctor had been moving his Lantus dose up and down trying to find the right amount. At Steady, Calvin gave Steve instructions to complete an overnight basal test and to send an in-app message after doing it. When he messaged Calvin the next morning, right then and there, they adjusted his basal dose.

Steve was taking 24–26 units of Lantus before Steady, and now he’s taking… wait for it… 16 units! That’s a lot less insulin! When he was on 26 units of Lantus, Steve was having frequent lows, rebounding with too much glucose and ending up high, swinging back and forth. By sending his doctor only a handful of finger stick values, and making the next adjustment, Steve continued to struggle to get where he needed to be. With Steady, he was able to message his endocrinologist, get a response and change the dose in less than 24 hours.

“I feel like I was getting very traditional care from my previous endocrinologist, where now I’m getting a very modern, upgraded version of care from Steady.”

Technology has come a long way in diabetes care. Steady Health, fortunately, has been designed with this new technology in mind.

Results with Steady and CGM

Before joining Steady, Steve explains diabetes as a nagging voice in the back of his head, “You’ve managed diabetes for nearly 40 years, why don’t you have this under control?” After being with Steady for 6 months, Steve’s A1c dropped from 7.8% to 6.8%. A whole point lower and finally at his goal.

“I had such a clear goal of getting my A1c below 7% and I’ve hit that goal. I’ve won. Steady helped me win. Now I’m setting new goals, ones that will help further improve my management.”

Steve’s A1c lab results from 2016 to 2019

Along with dropping his A1c a whole point, Steve also increased his time in range by almost 20%. Time in range is the percentage of time that someone with diabetes spends in the standard glycemic range of 70 to 180 mg/dL. In November, Steve started with a time in range of about 70%, and by April he had increased his time in range to almost 90%.

Improvements in Steve’s time in range from first joining Steady in November 2018 to April 2019.

He dramatically decreased his time spent in a high blood glucose range (over 180) and in a low blood glucose range (under 70), which were two of the goals he set in his appointments.

Steve was able to decrease both his time in high and time in low drastically from first joining Steady in November 2018 to April 2019.

“Because of Steady, I’ve seen the most radical improvement in my management in the last 6 months and I’ve completely changed my diabetes care… Steady overall has made me healthier and I have much better control in managing the disease.”

To find out more about Steady, go to www.steady.health or email us at hello@steady.health

Thanks to Henrik Berggren, Emma Lane, and Björn Hansell, MD. 

Steady Health: Modern diabetes care

Using data and experience to radically improve people’s lives

Last year, I experienced something remarkable. Using data from a wearable device, I learned more about my body in 5 months than I had done in my previous 18 years living with diabetes.

Through data analysis and experimentation, I completely changed how I think about the management of my condition and learned about how food, exercise, medication, sleep, stress, and many other factors were impacting my body.

The change had a tremendous effect on my life. I reduced my A1C to 5.3%, the best it has been in my entire life. I’m on less insulin, lost 10lbs, sleep better, have more energy and a more even mood. I feel better than I have in 20 years. How did I do it? You can read my story here. What I want to share with you in the next few minutes is how we’re working on helping the 100 million Americans that are struggling with blood sugar control improve their lives.

What does diabetes care look like in 2019? Well, very similar to what it looked like in 2009, and in 1999, the year I was diagnosed. I go to an endocrinologist every 3 months for a checkup where we review some numbers, I get my prescriptions renewed and if my A1C is above 7%, then I get told “eat better”, “exercise more” and “don’t smoke” — the same advice I’ve been given for the past 20 years. To be fair, not all doctors are like this, some review data in detail, spend extended time with their patients and have concrete recommendations for how to improve. But, these superstars are a rare occurrence as the health care system doesn’t support the effort that it requires.

Through my research on the state of diabetes care in the US, I learned that very few care providers utilize data or technology to improve care on an individual level. There are 3 major reasons why:

Lack of training

The data and technology surrounding diabetes have changed tremendously over the last 5 years. Patients now have wearable devices that report 300+ data points per day. That’s two orders of magnitude larger than the number of finger sticks we used to have. Yet, many clinicians don’t get any training in how to analyze this data.

Fragmented tools

The toolset that clinicians have at their disposal is fragmented. Pump data is in one place, CGM data in another and everyone is using different apps and systems. And, while the tools are great at telling us where someone is right now, very few can tell you if you’re on a path to improvement.

Outdated model

The traditional care model based on quarterly visits doesn’t make much sense anymore. The A1C test is becoming less relevant as we now have continuous data that can be collected remotely, patients are frequently making adjustments on their own, and, data takes time to understand and interpret.

Introducing: Steady Health

I realized that in order to have an impact on today’s care, we have to solve all these challenges. But building software that helped with data analysis for clinics would not be enough, issues with training and the overall care model would remain. Instead, we decided to take a different approach: Steady Health is a completely reimagined care model for diabetes, focused on data and experience, enabled by software.

Steady Health is a completely reimagined care model for diabetes, focused on data and experience, enabled by software

Our care model consists of two distinct components that together enable better outcomes: Data and CoachingWe’ve built a comprehensive suite of tools that allows us to collect and analyze data from our members and the devices they wear.

Relevant data like food, exercise, medication, blood glucose and more are easily available to our clinicians enabling deep understanding of every member, the life they are living and how it impacts the management of their diabetes. These insights let us give truly personalized recommendations that are both more accurate and easier to adhere to than generalized guidelines.

We run on software and specialize in Continuous Glucose Monitoring. Data is collected continuously and remotely which means we can automatically notify our clinicians of events that are impacting our members, recommend interventions and follow up on outcomes. Our software also dramatically improves the experience and efficiency of our business where things like self-scheduling, messaging and data analysis are all available to our clinicians and staff.

Our analysis tool Glue helps our clinicians find insights in food, exercise, medication, and CGM data

Coaching is done almost exclusively over chat and video. It’s more convenient for our members as they don’t have to travel to our physical location and allows our clinical team to have lightweight and more frequent interactions.

Finally, Team-based care is at the core of Steady. To serve our members in the best way possible we have an Endocrinologist, a Care Coordinator and a Certified Diabetes Educator (CDE) all working together with each individual. They ensure all of our members get the help they need when they need it.

A space for improving, together

We deliver full-service diabetes care to our members which means that we also have a location where we provide coaching, yearly physical check-ups and anything else that might require a face to face meeting.

Our location is built with experience in mind. Coming to Steady feels empowering and we’ve designed an environment that allows for collaboration between our care team and our members.

Better care, better life

What does all of this sum up to? Diabetes care that helps members live healthier lives. Care delivered through an experience that fits the needs of a complex condition, while at the same time being more convenient for the member. With Steady, you get a personalized care plan based on actual data, that covers diet, exercise, and medication from a team specialized in diabetes. Whether your goal is to live a long and healthy life or to reduce the stress around diabetes and blood sugar management, we help you get there.

We’ve been working with members for a couple of months and we’re excited and proud of the feedback we’ve gotten.

“Steady Health completely changed my perspective. It’s like Diabetes Care Utopia.”

Aida A.

“Having your team to listen and look at my data has been a game changer. I wish all people with diabetes had access to Steady.”

— Courtney O.

We’re just getting started

We truly believe that the Steady model of care can have a big impact on the 30 million people that are currently diagnosed. But, our mission is larger than that. We also believe that giving care based on data to the 80 million Americans that have with pre-diabetes will improve health and prevent many from full diagnosis. We’re entering a new time where what we eat and how we exercise can be tailored to each and every individual on the planet.

The journey towards personalized nutrition starts now

On behalf of the entire Steady team of engineers, clinicians, investors, members & advisors — thanks. We’re pretty excited about the road ahead.

Visit our website to find out more ➡ https://steady.health/

Connecting with diabetes patients through data

A doctor’s first meeting with Continuous Glucose Monitoring

After six years of practicing internal medicine at a Swedish County Hospital, I moved to San Francisco to build a personalized, tech-enabled diabetes clinic. This story is about how patients helped me identify the next step in my career.

Four years ago, one of my patients with Type 1 Diabetes brought a continuous glucose monitor (CGM) to my office for the first time. A CGM is a device that attaches to your skin, and a thin filament is inserted a couple of millimeters to measure the glucose level between cells. The sensor transmits data wirelessly to a smartphone app that calculates the corresponding level of glucose in your blood.

A CGM sensor on the back of my arm

My patient loved the device since she no longer had to prick her finger every time she wanted to measure her blood sugar. It also showed if her blood sugar was trending up or heading down, which helped her make smarter decisions about how much insulin to take. After some research and help from our diabetes nurse, I figured out how to hook the CGM up to my computer to view the data, and I was blown away by the depth of information! Until that day, I had done my best to give people advice around their insulin treatment after looking at a few spot measurements per day, but now I had a continuous curve that showed me exactly what had happened after each meal and insulin dose.

Learning from patients

There was just one problem: I had no training in analyzing this type of data, and it was hard to find any documentation on how to go about it. So I did what every doctor should when encountering a new problem: I learned from my patients. After all, they make hundreds of treatment decisions every day!

The first thing we reviewed was the Ambulatory Glucose Profile (AGP). AGP is a visual representation of average blood glucose by the time of day, overlaid with glucose variability where we could see just how much their glucose fluctuates.

An AGP showing blood sugar trends for the past month (source: Dexcom Clarity)

Understanding trends in CGM-data

The AGP is an excellent tool to quickly grasp how you have been doing over the past couple of weeks. It also provides some clues if there is a particular time of day where blood sugar management is more challenging.

Let’s pretend that the graph above is yours. We can see that your average blood sugar is highest in the afternoon and comes down around midnight. The obvious next question is: Why does your blood sugar increase? To answer this question, we have to take a closer look at a single day, and this graph is from last Tuesday.

A graph showing blood sugar variations during one day (source: Dexcom Clarity)

As you can see, blood sugar increased in the afternoon. So the obvious question is: What did you eat for lunch, and how might you have avoided this increase in blood sugar? Let’s say that you had a lunch containing 30 g of carbs and took 3 Units of fast-acting insulin to cover it. A couple of more questions come to mind.

  • Was there really 30 g of carbs in that meal, or was that just a guesstimation?
  • Is it right for you to take 1 unit of insulin for 10 g of carbs?
  • Was the meal a rice bowl with carbs that are absorbed quickly, or a salad with lots of fiber that delay the gastrointestinal uptake?
  • Did you take your insulin 20 minutes before eating (a pre-bolus), when you started eating, or even after eating?
  • Did you exercise after your meal, or did you sit down in your car, stuck in traffic, stressed out over going late for a meeting?

These factors all have a profound impact on blood sugar levels. In fact, there are up to forty-two factors that can affect blood sugar, and that’s why those daily decisions can be so tricky.

You need to log more than just blood sugars

Now, I want you to stop for a short moment here to ask yourself: “What did I have for lunch Tuesday last week?” Do you remember all the details? Most people don’t! So I asked my patients to log their food and insulin and bring their diary to their next appointment.

The resulting discussions were inspiring! I started to appreciate how challenging it is to manage blood sugar levels, but I also got lots of insight into why some people found it overwhelming to figure out how to handle situations that others seemed to manage so easily. The question started to rise within me: Could I empower those struggling patients to learn about their bodies, improve glucose control, and reduce the risk for complications like heart attacks, kidney failure, and even blindness?

I had started to build some skills when it comes to interpreting data and talking about it with my patients, but a few hurdles remained. First of all, I didn’t have access to my patients’ data until they were in my office. Most patients found it very difficult to set up the software needed to upload data to our system from home, and to juggle the cgm-data and hand-written notes took a lot of time from us talking about blood sugar management. Using the tools we had, our meetings were not long enough to dive deep into the details of their blood sugars. I continued to work with a few very motivated patients logging their behavior, but when it came to my dream of empowering patients that struggled, I had come to a dead end.

The solution to my problems — Steady Health

And that was when I received a call from my friend Henrik. He’s an engineer living with diabetes who had learned a lot from analyzing his CGM-data and wanted to help more people with diabetes to go on the same journey. And it turned out we had both identified the same fundamental problem, that the tools available to patients are fragmented and poorly integrated into health care. So many months of research, we decided to build a system that allows people to share their data with health care and helps doctors and nurses analyze the results. But we didn’t want to stop there. We knew that traditional healthcare organizations are ill-equipped to provide the personalized and continuous care needed to support people with chronic conditions, and we wanted to do something about that too!

So we decided to build Steady Health, San Francisco’s first clinic specialized in helping people to learn about blood sugar management based on CGM-data. We have a fantastic care team with years of experience of coaching people with diabetes to reach their goals. And they work in tandem with our engineers to create tools that help them analyze data and communicate smoothly with patients between visits.

We are currently wrapping up our first pilot project, where we have worked closely with 12 people living with type 1 diabetes. They have used our app to track their blood sugar and the behaviors that affect it. I’d love to tell you what we have learned and describe the coaching model that they helped us develop, but that is another story that deserves a post of its own. Stay tuned!

To learn more go to http://www.steady.health or email us at hello@steady.health

Thanks to Henrik Berggren and Aimée José.