A friend died of diabetic ketoacidosis. He loved technology and seeing people succeed. Thinking of him with this news. Miss you Dan.
Grateful we're moving forward on so many fronts in the world.
Automated glucose control will be the next frontier in so many areas of healthcare. I'm still skeptical that anyone will be able to noninvasively and accurately sense blood sugar, but I'm glad people (especially kids with T1) will have one more tool to help them. I hope they can figure out the reimbursement side to get it into the most hands possible!
Automated glucose control is already available via wearable insulin pumps combined with CGMs in a 'closed loop' system.
None have been approved for hospital use as of yet, which is the next frontier.
Why is hospital use so important?
> Automated glucose control will be the next frontier in so many areas of healthcare.
What areas do you have in mind outside of diabetes management?
Blood glucose levels affect lots of health functions. Diabetes represents an extreme end of the spectrum where the body's ability to regulate these fluctuations fails, but just because your body can get your levels in control eventually doesn't mean you won't suffer from the negative effects of it needing to do so.
Maintaining consistent glucose levels improves mental health, weight management, sleep quality, muscle recovery, systemic inflammation, cardiovascular health, and may even slow aging. There isn't much clinical data at the moment on how to use blood glucose measurements to control glucose levels outside of people with diabetes (there are lots of things that impact it besides just sugar intake), but there are definitely major theoretical benefits if it can be worked out.
Also, just reducing the incidence of diabetes would be no small accomplishment. About 3.5% of global disability adjusted life-years (DALYs) are due to diabetes. As of 2021 it was the 7th largest contributor of global DALYs.
sample of 1, but yeah changing my diet (very low sugar, more veggies) did alter my health visibly and rapidly. to the point that if I eat something too sweet too fast i have a very mild headache soon after, my system readjusted to not seek levels i grew up with
Woah. I have ADHD and most of these symptoms.
Cardiac surgery, burn units, ICU, neuro come to mind. All have been studied to show mortality and complications improvements with AGC, but unfortunately the commercial technology has not materialized yet.
Why is a hospital setting so different that AGC can not be used? Or is the temporary use of such not yet approved?
Ketones have some dieting and weight loss applications, so I guess you could do better real time tracking of how you're digesting carbs and when it's okay to eat? maybe
They are specifically relevant to trying to enter a fasted state.
The presence or absence of ketones in your blood can tell you whether or not (say) that coffee you just drank took you out of the fasted state (that you were in for not eating overnight).
Whether or not you are in a fasted state matters not just for weight loss, but also for things like longevity (when you are in a fasted state your body cleans up dead cells that contribute to things like cancer, whereas in a non-fasted state it leaves them lying around).
Adding any amount of milk to a coffee adds carbs. And a large number of people add _some_ amount of milk.
I think I drink coffee but I really drink lattes…
Preventive medicine is a bit one. If your fitness watch could measure blood glucose, I think it would be a ton more impactful in terms of health outcomes.
In what way? Nondiabetic folks self regular glucose just fine on their own.
Can you be specific about what your bloodwork results showed and what special insights your CGM gave you and what behavioural changes it led to?
My anecdotal experience from doctor colleagues giving CGM to patients is that it does 3/5ths of fuck all to everyone except those with actual insulin dependent diabetes (T1 or T2) because when you get down to it the insights aren’t that great and most people actually aren’t that invested in shifting the dial on their health that much. But I’m fascinated by examples to the contrary
Does a step counter do that? All studies I've seen say they don't cause people to adapt their behavior
Also rare genetic issues like GSDs and FAODs may benefit immensely from dual glucose and ketone metering. Next we need potassium and magnesium meters and that will benefit the people with rare renal wasting syndromes like Gitelman and Bartters
I’m willing to bet we can see longevity improvements from better blood sugar control. Not 100% certain but extremely likely, this would include potential heart attack and dementia reduction…
This has been tested actually. A clinical trial looking at tight blood sugar regulation was aborted after it resulted in multiple cardiac events.
That's not a fair representation of what happened. That study was going for _aggressive_ control - beyond what any normal person would do. They were combining multiple drugs to force blood sugar down rapidly, including right after meals (when it _should_ be going up).
Paying more attention to your blood sugar and acting reasonably to keep it in check isn't giving anyone heart attacks.
From the AI
> The concern was not that lower glucose is inherently bad. Rather, pushing blood sugar down rapidly and very tightly—especially with insulin and multiple glucose-lowering drugs—caused more episodes of hypoglycemia, weight gain, and treatment complexity. Severe low blood sugar can trigger abnormal heart rhythms and other cardiovascular stress. The intensive-treatment arm was stopped early after about 3.5 years because it had a higher death rate, although the exact mechanism was not definitively established.
Interesting! Found this overview: https://emcrit.org/pulmcrit/tight-glycemic-control/
Metabolic psychiatry is rising, though very slowly. You do "epilepsy keto diet", and may work in bipolar/schizophrenia (need GKI 1-2, it's not keto for weight loss). But you don't need the continuous monitor, normal ketone monitor is fine, because the food list is very narrow.
The continuous monitor should help until you get the hang of the diet, it's a bit hard to maintain, but if it works, worth it.
"management" is the key word. Early diagnosis might help a lot not just with T1 but also T2.
Early diagnosis would save a lot of pain and suffering... and money.
I worked with an older T1 and apparently a bit less than half of kids diagnosed with T1 are diagnosed unconscious during a DKA event in the ER. "Treatment" cost, or at least requested revenue LOL, is at least $30K for an ER visit like that, and it also costs at least some months (years?) off their expected lifespan.
Figure about 0.5% of the population in the USA is T1, you read stuff like "about two million T1 diabetics" in the USA. So early T1 diagnosis would save the country overall about $30B just in DKA treatment alone at time of initial diagnosis.
If you could screen an entire population for less than $30B total lifetime cost, it would be financially rational to prescreen for T1 rather than waiting for ambulances to present incredibly sick kids. And potentially profitable.
Prescreening the entire population for metabolic disorders is quite plausible as a "tech startup idea" as the alternative is waiting for them to arrive in an ambulance while extremely sick/nearly dead. Lets say it could be done for $10B, leaving $10B for startup profit (charge insurance companies $20B which is not bad....) and $10B in lowered health care costs for the country in general, not to mention less suffering in the population. A win-win scenario.
IF blood sugar related disorders could be pre-screened for less than $10B total cost. A solid "maybe"? Plausibly a startup doing blood sugar prescreening would be a "multibillion dollar company" although not a trillion dollar unicorn. Still a good idea.
Metabolism, and the endocrine system in general, is very responsive to physical activity. Even in athletes, glucose can have significant ups and downs when it gets intense.
It would be interesting to see this technology branch out into monitoring hormones, minerals, vitamins, etc. For all of human history, the closest we've had to realtime monitoring is just our mood. It would be life changing for anyone to have this feedback.
I wonder if there are any legs in an internal sensor that pushes out its reading every x? That seems pretty plausible.
Invasive CGMs (Continuous Glucose Monitor) and minimally invasive CGMs exist. It's the non-invasive CGMs which are being worked on because managing an implant or having something always poking through you is a big annoyance+risk compared to wearing a watch, ring, or patch.
The problems for these non-invasive options so far is they either too easily fail to work, are bulky/expensive, give very ballpark accuracies, or some combination thereof.
A good read on this topic is The Pursuit of Noninvasive Glucose: 'Hunting the Deceitful Turkey'.
That’s the one
The biggest problem is that they are racist. Optical blood sugar sensing devices were developed a decade ago. They were pretty accurate for pale white people, ballpark for most skin tones and don’t work at all for Black people. Good luck bringing that to market. Apple threw out the whole product and restarted with infrared.
You got me thinking about possible hollow spots INSIDE my leg to put a sensor :P
There are 6 month implantable CGMs, they're just quite expensive.
Internal as in swimming in the bloodstream?
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Ketones are only going to be present if you are exceptionally bad (very high carb diet) or exceptionally good (very low carb diet) at managing your blood sugar. It's not going to be terribly useful for your average diabetic who has fairly good control over their blood sugars.
A measure which acts as a high and a low pass filter on a band of less risk which can be monitored by other means, or subject to improvements on measurements and narrow the central zone?
Sounds bloody useful to me.
> your average diabetic who has fairly good control over their blood sugars
I think it's huge for diabetics. It's a mental toll for them. They hate having to constantly prick themselves to take readings. It's awkward, inconvenient and you have to do it multiple times to be sure you got a good reading. And worse of all, it's possible to forget to take a reading when you need to.
I don't understand. All of the diabetics I know personally (one type 1 and two type 2 diabetics) use continuous glucose monitors and have for some time, so they rarely need to prick their fingers anymore. Ketone levels can be checked with a urine test.
Which makes me think the market for these is diet-focused folk. Get the FDA to clear it on medical grounds for a specific usecase then sell it more broadly.
This already happens with CGMs. The bulk of the sales is with people who want them for lifestyle monitoring even though they're only medically cleared for diabetes use.
The difference is that these only measure blood sugar, while the new system also measures ketones, of keto diet fame, which are leading indicators of a really dangerous situation called diabetic ketoacidosis. It's treatable with a hospitalized IV insulin drip, but can be avoided if you have some advance notice.
My mom had T1D onset in her 50s. (It's usually thought of as a children's disease.)
She figured it out because she recognized the symptoms of ketoacidosis. That sent her to the hospital, which has thankfully allowed her to outlive her pancreas.
Diabetic ketoacidosis only happens in T1D, or when you have something extremely wrong going on metabolically (like failing organs, etc).
Normally it should never happen. It happens at ketones like ~10+ mmol, and it's ~impossible to go more than ~6 for a healthy human even eating 100% fat and fasting for a week+ and doing marathons or whatever all at the same time.
The keto diet, can actually help in T1D, by keeping blood sugar more stable overall, but you still need insulin, just less.
It can happen in people with uncontrolled T2D as well. My cofounder is a pediatric ICU doctor who has treated hundreds of DKA patients.
Also there wasn't really a relationship of the keto diet to the rest of my post, just using it to contextualize a technical term with one that might be more familiar.
Ah yes, I see what you mean! Ketones are not inherently bad, just the accumulation of them w.r.t having diabetes. Should have made that more clear.
Those ‘only’ measure glucose levels. As the article says, this is the first approved device that monitors both ketone and glucose levels.
Ketones don't come from nowhere, they come from your body breaking muscles down in a last ditch effort to control sugars after they are dangerously elevated for extended periods of time, I'm talking 500+ over weeks. It's sort of like adding a "your car has been completely out of gas for one week" monitor to your "gas tank level" monitor.
Um, no ? Ketones come from fat burning, not muscle.
In T1D with no insulin, muscle break down from gluconesis will increase blood sugar in the blood even more. The absence of insulin also makes ketone production unrestricted, so you end up in ketoacidosis.
Muscle is used when you don't have fat, or when you eat completely nothing (burn both fat & muscle).
Like I've gained ~10KG of muscle while on keto diet. Blood sugar at 70-100 depending on scenario. Usually on the lower end.
These are the same CGM technologies (Dexcom = Stelo and Lingo = Libre), just aimed at the over the counter "health and fitness" market.
This is not verified info, but I would assume these are either A) the exact same device, just with different marketing B) "binned" production runs that did not meet the accuracy threshold for clinical/prescribed use, but are otherwise "good enough" for someone looking to healthmaxx.
I can all but guarantee you they are the same device. IDK if they are even binned differently. The software is the main difference.
The "real" device gives you what it measures as your real highs and lows while the OTC devices won't report high highs or low lows.
I have a Stelo (I was curious and diabetes runs in my family) while my wife has the Dexcom.
I t Looked into the OTC ones and it does seem they’re binned versions. The failure rate appears to be higher too, which is more acceptable in a non life threatening device.
It also probably gives the companies really valuable data.
You can read the Stelo out into XDrip with some settings adjustments, last I checked, so it is just some “light” software tweaks between sensors.
No FDA authorization I guess
Nope that was two years ago.
https://www.fda.gov/news-events/press-announcements/fda-clea...
How long has the tech existed to do this?
Does anyone know if something like this is required to be approved by the FDA? Like if someone were to make one for the hobbyist/weight loss market, would that even be legal?
It depends on intended use. If it is to diagnose, cure, treat, or prevent a medical condition then it is a medical device that may need approval. If it's not intended for anything medical, it doesn't need FDA approval. For example, clinical thermometers are class II medical devices, lab thermometers aren't medical devices at all. If the device were genuinely only marketed for general wellness, it would be exempt.
Basically yes, take a look at the not for human consumption drug, sorry medicine market.
Was analogs in the 2010s, Obama had to pass the analog act low… now it’s back with peptides and glp 1 which aren’t scheduled but..
Yeah I guess make enough money and then lobby for the benefit of your audience base or for future proscuation
I have to imagine Apple was pushing for similar functionality but probably got distracted over the last few years due to the lawsuits.
Apple would want to make something non-invasive. I don’t think this is non-invasive. It looks a lot like the existing CGMs, but it does more.
Reminds me of this warning: https://youtu.be/S6Jiei4Wup4 (Youtube Short from the Drey Dossier)
bet marathoners and ultra runners will start using this to improve performance
(don't have a problem with that, but it's predictable)
too bad it's not "wearable" like a watch but that might be coming eventually too since Garmin has a patent on it
* https://the5krunner.com/2026/02/06/garmin-non-invasive-blood...
(btw Fenix 9 launched today but it's same hardware as Fenix 8 and no glucose feature)
Amateur cyclists already wear CGMs, and as a type 1 myself, they see mine and start asking all about CGMs. It must be so boring for them to worry about fluctuations between 85 and 120.
I don’t think amateur cyclists will have much to gain from this other than satisfying their curiosity.
Before buying one, just know that fit cyclists will appear glucose intolerant on a CGM. See Fig. 1 at https://pmc.ncbi.nlm.nih.gov/articles/PMC10933193/
There has been talk, but as one who hangs around those circles I've not heard of anyone actually doing it. But I'm sure someone is. At the same time, what I'm reading is that CGM won't give a non-diabetic any actionable information.
a regulated blood sugar level aids massively in cellular repair, inflammation reduction, and immune response. These are well studied and established. I could absolutely see a top athlete using AID in the future as part of a recovery routine, but I can also understand reluctance to adopt anything new or weird.
A few years back, there were a number of startups that essentially resold prescriptions of the ABT/DXCM CGM and provided personalized meal/exercise-response analytics on top. Seems like traction has been tough going, though. Dialing back from "anyone with potential metabolic issues" -- what's a realistic market? Something like high-level athletes and/or bio-hacker enthusiasts are the only folks who seem to care. On the low end, the OTC options are eating away as well.. they are less accurate, but probably solve the use case better for a pre-diabetic "once-a-year/occasional" wear use case.
Talking to ultramarathoners and cyclists, I think lactate is a biomarker that is tracked (POC blood samples) and would be more immediately useful for training/performance. AID might be construed as a form of doping, IMO.
I definitely think it would be considered a form of doping to use it in competition
Already banned:
There doesn't seem to be a continuous lactate sensor on the market. Lactic acid production and/or clearance are definitely useful data w.r.t. exercise (many training regimens talk about lactate thresholds) and also useful in in-patient settings.
No disagreement about AGC in the hospital -- there is a lot of lab/titration work in current clinical workflows for monitoring patient glucose levels.
I am curious how this will help. During training? During the actual race, the strategy is to eat a much as you can without puking.
I am aware of the "eating wins races" strategy for endurance sports.
Glucose and ketone monitoring seems a natural, more precise extension of that strategy. Isn't the point of carb-cramming to get more glucose into your blood stream, where your muscles can convert that into forward motion?
Yes. But you don't need to monitor glucose levels to do this. Because it's well known you can productively use as much as you could manage to consume (without vomiting). So all the device will ever tell you (if you're in the middle of significant endurance event) is that you need to raise your blood sugar. It'd be no more actionable than a writing 'your blood sugar is low' on your hand with a sharpie.
> to improve performance
How? Like, what is the mechanism where this is useful?
Monitoring glucose and ketones can help you develop metabolic flexibility and let you grok how easily your body cuts over to ketones. Knowing your personal realtime glucose and ketone levels helps you understand just how much carbs will kick you out of ketosis or keep you in it. Glucose monitoring will help you avoid large crashes that can lead to low energy. Among other things!
More on metabolic flexibility: https://www.levels.com/blog/what-is-metabolic-flexibility-an...
My understanding is that essentially all high-level endurance athletes are just maximizing their simple sugar intake at all times (during exercise) and knowing blood glucose/ketone levels wouldn't change anything about that intake, nor would it have any impact on crashes.
All high level endurance athletes are on high carb diets all the time and are never anywhere near ketosis (unless something has gone very wrong)
I thought this was going to be a non-invasive sugar-level device, but it looks like in fact the innovation here is that a popular CGM line can now do ketones?
non-invasive continuous blood sugar measurement is mired in patents and technical challenges. Turns out it's really difficult to disambiguate the absorption lines of glucose from other similarly shaped molecules when you're also dealing with untangling skin conductivity, transmissivity, sweat, inflammation etc.
I also think there's no financial incentive from incumbents to develop something like this. Why would abbott develop something that works "forever" if they can milk people buying new sensors every 10~14 days.
For abbott, no. But what about for Garmin, Apple, Samsung, or Google?
Diabetics would snap up a smart watch which does accurate glucose monitoring in a heartbeat.
> There is a major IP holder in the space who is asserting their ownership,
Is it a secret? Why not name them?
As a T1 diabetic, can confirm.
Seems to be the case, yeah
science is awesome
As someone who has to deal with type 1 diabetes every day, this is marketing nonsense. No one needs ketones in the sensor - we need high-quality sensors, and Abbott's are only mediocre at best. They are not as bad as Dexcom, which is appalling, but they are still far from the superior quality of Medtronic/MiniMed which measure glucose exceptionally well.
Ketones are rare. They can kill you, but before that happens, your blood sugar usually rises enough for you to realise you may have ketones and start using test strips to measure them. Instead of this marketing gimmick, Abbott should have focused on improving the quality of their glucose sensors which is far more important.
I tend to agree that making the sugar measurements more robust is worth more than measuring the ketones at all. However, low sugar and high ketones can happen. And just getting notified when ketones pick up can be worth something too. The additional measurement is not useless seen from my perspective.
As an example: I was on a study that gave T1D patients Dapagliflozin (Farxiga). During the study, while on a long hike, I was hovering at low sugar and consequently insulin supply was mostly cut off for an extended period. As I started to to feel unwell, I measured ketones. I was briefed as preparation for the study to measure ketones when something seems wrong. Otherwise I wouldn't have thought of measuring ketones. Might not even have carried the kit.
On that occasion, the ketones were way above 1 mmol/l: a very high value. Protocol would have required me to call the study doctor due to the high level. Since it was a Sunday, I spared her, shot some insulin, ate a sandwich, and continued my hike. I could do that because I was not alone on that hike. I knew that if my situation deteriorated, somebody would be around to call rescue.
At the study debriefing I mentioned the incident and they said that adding to the effect of the Dapa, I was probably dehydrated, which led to the rare situation of both low sugar and high ketones.
All in all I think that if the sensor makers exhaust possible improvements for the glucose, it can make sense to add the ketone measurement as a safeguard. Having high sugar can have many reasons, and it often takes me a while to get to measuring ketones. Getting the signal of rising ketones, I would react faster a few times a year in situations where my insulin supply is broken.
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So she was merely ahead of her time.
The use case was never the problem. The problem was that it did not work.
You should understand the difference between taking a single drop of blood and trying to run a battery of tests on it, and sticking a probe into your extra cellular matrix to continuously monitor changes. It’s small, but it’s having a constant shifting flow of fluid at all times so it’s getting far more than one drop.
Who?
Theranos lady.
Huh, makes 0 sense to me, blood tests w/o much blood isn’t same as glucose checking, we’ve been able to do that w/o much blood for…a long long time.
That silly patch idea?
Looked after my son who has T1D for now 5 years, checked keytones maybe 20 times. Compared to blood glucose which we check look at every 5 minutes.
Maybe this is more for Type 2 or other diabetes, or for people prone to DKA. Or it is for people with a working pancreas who think looking at their blood sugars (and now keytones) tells them something like soothsayers reading tea leaves
Considering that DKA accounts for 160k hospital admissions a year, your lived experience translates poorly to such a flippant dismissal.
[0] https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.htm...
I agree, but there are a lot of factors going on to contribute to that number.
For example, about 20% of that number is because someone is finding out for the first time they have T1D [1].
Insulin costs and monitoring costs are also going to be a pretty big contributing factor. CGMs and finger sticks aren't cheap.
IDK how often it happens that ketoacidosis happens when glucose appears to be fine, I assume it's pretty rare.
[1] https://www.sciencedirect.com/science/article/pii/S016882272...
A CGM that has ketone levels is quite literally pointless. If you have a CGM in the first place you would know if your sugars were high enough for long enough to get DKA.
DKA is what killed the legendary Dan Kaminsky.
Mate they won't understand. People generally are exceptionally ignorant about type 1 diabetes and also eager to fall for marketing gimmicks like this one. They have no idea what type 1 diabetes is.
For anyone who doesn't get it: glucose is checked every five minutes because it changes very often, jumping or falling dangerously. It's a nightmare. Checking glucose is 1000 times more important than ketones which are almost never a problem. If you get accurate glucose readings you are highly unlikely to ever experience ketoacidosis in the first place. Before ketones become a problem, glucose has to stay high for hours. Abbott is pulling this marketing trick instead of improving the quality of their sensors. Libre 2 is absolute crap. Libre 3 is somewhat okay and sometimes even mediocre - which is still a pretty bad situation. Bad glucose sensor is a nightmare and it can kill a person or a child much likely than ketoacidosis. It will actually lead to ketoacidosis by showing incorrect glucose readings. Now I wonder whether they added a ketone sensor as a failsafe for their low quality glucose sensors.
No one asked them to add a ketone sensor as an add-on to their glucose sensor, except maybe their marketing department. People want higher quality glucose sensors that fail less often and are more accurate. Glucose sensors, not ketones!
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Finally. I really dont want to buy yet another watch device unless it provides blood sugar detection.
There are and have been continuous glucose monitors available for some time, and you can even get one if you don't have diabetes - I'm wearing the Lingo one right now.
All this device adds is a simultaneous ketone check, which is really only relevant to diabetics and not as much of a benefit because ketone levels are often checked with a urine test.
He was my roommate in 2001 in San Jose.
We came up with the idea of having a place where nerds could come together to hang out and learn from each other and we decided to call the concept "Hacker Dojo". I had a sign laser engraved in 2002 at a state fair to memorialize the idea but we didn't actually get to open a Hacker Dojo until 2009.
There's a conference room in it called Kaminsky.
Dan was not a very good roommate but man, his brain worked in weird and wonderful ways, and it was inspiring how he could just rabbit-hole on stuff other people didn't find interesting until he MADE it interesting and found things nobody else had.
I miss him too. What a gift he was to the world.
Thank you for sharing his memory with us.