Wellness Apps – Are They Good For My Health?

Wellness Apps – Are They Good For My Health?

Over the past 10 years, the boom in smartphones has led to a similar surge in all types of smartphone apps, particularly disease and wellness-related apps.   By 2014, there were already over 40,000 of such apps available with the number probably approaching or surpassing  100,000 today.  Industry estimates are that by 2018, over 50% of the more than 3 Billion smartphone and tablet users, will have downloaded mobile health and wellness apps resulting in the mobile health market expected to reach $20 billion in revenue in 2018.


With so much choice, we should ask: “Which ones are good for my health?”


Back in late 2013, the IMS Institute for Healthcare Informatics, a global authority in healthcare-related information for decision makers and policy makers , conducted an extensive and comprehensive analysis entitled Patient Apps for Improved Healthcare.  They identified over 40,000 apps that qualified for their analysis, from diverse sources ranging from consumer fitness tracking  to hard science-based apps for disease. 


The number of apps has vastly expanded since that report, yet the key findings do not appear to have changed.  These findings were:


·      The vast majority of apps had less than 500 downloads.  Six apps accounted for about 15% of the estimated 660,000 downloads on Google Play.  One example is MyfitnessPal, a calorie tracking app since acquired by Under Armour.

·      There was little correlation between app development and major health care challenges – the factors driving healthcare spending.  One glaring example: the vast majority of healthcare dollars are spent  by the elderly for chronic diseases,  yet only 8% of those >65 years old  have ever downloaded an app.

·      Doctors saw multiple hurdles before prescribing apps to their patients:.  Major ones were that there was too little evidence that apps had clinical benefits, and there is a lack of infrastructure for prescribing apps (“How do I do this?”).  Other issues included data security and the possibility of increased liability,

·      Payors, such as Medicare and medical insurance providers, saw some similar barriers, such as wanting to see evidence of improving health like reduced hospitalization, before reimbursing for mobile apps.


A 2014 editorial in the Journal of the American Medical Association referencing this study (Powell et al. In search of a few good Apps, JAMA 2014) indicated that some sort of certification or app review process/organization is needed, trying to apply the same approach that medicine traditionally used in conjunction with public and private organizations to assess the value of medical type products. 


One of the suggested solutions was an organization called Happtique, which entered the app certification business.   Unfortunately, this has been a challenge – the diversity and sheer number of apps make it hard to develop a set of criteria that can be applied and understood by all.  In fact, Happtique instead made the criteria so complex that it discouraged most useful apps from seeking such certification.


Since apps are usually in the hands of the patient/consumer directly, how are we to assess them? 


First, consumers have to become better at understanding evidence-based solutions.   Often evidence shows that obtaining precise health information from wearable sensors like FitBit and the Apple Watch can be very inaccurate at times, such as tracking one’s heart rate during vigorous exercise.


Second, consumers need to consider whether the FDA has reviewed the app. The FDA has started issuing guidelines on which apps/software products would fall under their  oversight as a medical device.  Unfortunately, since the FDA is typically understaffed, they have not been able to police this area so far.  Generally, if you are a consumer and an app tries to provide you medical information, particularly about disease, it is likely to need FDA review unless the information is primarily educational in nature (in which case they should reference the studies they use).


Third, consumers should search the internet to see if there have been legal actions by states to restrict what an app can say or do.  For example, in a recent article in Wired magazine (Wellness Apps Evade the FDA, Only to Land in Court, Wired, 2017) it was noted that  the New York Attorney General had come to a settlement with a number of apps, such as MIT Media Lab spin-off Cardiio, which claims to measure heartbeat from the smartphone camera alone, for cash penalties and required changes in advertising.


Smartphones aren’t going anywhere and health apps are growing exponentially.  It is our burden as patients and consumers to do some of the hard work to make sure that the apps that  we are downloading and trusting are truly good for our health.

Too Little Sleep: It Ain't Pretty!

Too Little Sleep: It Ain't Pretty!

All of us have noted at one time or another that someone we know looks “tired”.  We often don’t give it a second thought but we are quite good at assessing someone’s sleep condition just by observing them.


As we have discussed in previous blogs, Americans generally don’t get enough sleep.  A 2014 Gallup survey (Gallup-Healthways Well-Being Index) of 7,058 U.S. adults found that 42% usually get less than seven hours of sleep per night, the level generally considered necessary for healthy sleep.  Furthermore, this survey found that getting more hours of sleep resulted in higher well-being index scores, peaking at eight hours of sleep per night.  Conversely, getting less sleep resulted in lower levels of well-being.  Two of the five elements of well-being are social and physical.


Recently, a study published in the Royal Society Open Science Journal (Sundelin et al, 2017) examined how people perceived those who had restricted sleep.  Twenty-five subjects were deprived of sleep for two days, and then photographed for assessment by 122 raters on how much they would like to socialize with the individuals in the photos.  The raters were not only statistically less likely to socialize with the sleep-restricted individuals, but they also perceived the poor sleep-deprived souls as less attractive, less healthy, and, of course, more sleepy.   These findings were consistent with previous studies suggesting that people are less likely to socialize with others who they perceive to be less attractive.  Therefore, perception of attractiveness may partly reflect how tired or sleepy you appear.


This study has many implications including, how people perceive shift-workers --health care workers, for example -- in their professions.  Are we less willing to work with these folks or be cared by them?  Would you be willing to trust your health issues or legal problems, for example, to a healthcare provider or lawyer who looked exhausted?  Poor sleep can affect not only your health, but can also influence your readiness to trust and receive care from others. Is there such a concept as “second hand fatigue”?


Not only is too little sleep unhealthy; it isn’t pretty either.

Sleep and Alzheimer’s Disease, The Chicken or The Egg?

Sleep and Alzheimer’s Disease, The Chicken or The Egg?

Over the past few years, there has been a lot of research linking sleep disorders and Alzheimer’s Disease (AD).  Anybody who has taken care of people with AD knows that the patients have very abnormal sleep patterns.  The big question researchers have been asking lately is whether the sleep disorder is due to AD alone, or could sleep disorders, in fact, cause or worsen AD.  What came first, the sleep disorder or the AD?

What do the latest data show us?

We discussed this subject a bit in a previous blog on Mar 22, 2017 (“We Need More Sleep. So Why Don't We Get It?”), researchers (Xie et al. Science 2013) had found that brain activity is quite pronounced during sleep in helping clear out metabolic products from awake periods.  Specifically, one of the key metabolic products removed was beta-amyloid, the protein linked to Alzheimer’s disease.  Additional research published this year in the journal aptly-titled “Brain” (Ju et al) looked at the effect of even a short period of sleep deprivation on beta-amyloid.  Researchers had health adult volunteers undergo sleep disruption while being monitored and then performed spinal taps to sample the brain fluid (cerebrospinal fluid) for beta-amyloid.  They found that even one night of sleep disruption increased beta-amyloid level and, over several days, this lead to increases in another protein linked to AD, called tau.  This is a remarkable finding suggesting that even acute sleep issues will increase the risk of the AD-related protein buildup.

The next logical question was whether this directly was linked to future AD and not just a lab test finding.  Just last month, at the Alzheimer’s Association International Conference in London, three different studies from researchers in Illinois (Hogan et al) examined this question.   All three studies found that over a period of three years, patients with sleep-disordered breathing had greater increases in deposits in the brain of beta-amyloid, an early biomarker of dementia and AD.  This was true in both normal patients and those patients who already had some mild cognitive impairment -- suggesting that it was not just an association for people already having some cognitive issues, but can potentially worsen dementia and AD.  Although these studies do not prove a causal link , they are among the first long term studies showing worsening cognitive function in patients specifically linked to sleep disorder.


We know sleep apnea is linked to numerous other chronic conditions such as high blood pressure, stroke, diabetes, heart disease, mood disorders, and obesity.  All this latest evidence suggests that we should add AD to the list.  An intriguing question is whether sleep disorders may cause dementia or Alzheimer’s Disease – or any of the conditions mentioned above It So with AD, it appears that sleep apnea is both the chicken and the egg. 


Since there are good treatments for sleep apnea - but not for AD and dementia - getting yourself tested for sleep apnea is a good way to rest more easily at night…and face a brighter future each morning.

Are Fitness Trackers Fit to Track Your Fitness?  Part 3:  Sleep Tracking

Are Fitness Trackers Fit to Track Your Fitness? Part 3: Sleep Tracking

Welcome to the third part of this series examining: are fitness trackers fit to track your fitness?  In this three-part series, we are reviewing the scientific data on the accuracy of such trackers for the three most popular uses: 1) activity/step count tracking, 2) heart rate tracking, and 3) sleep tracking.


In our first part, we examined activity/step count tracking noting that research suggested that most activity trackers seem to track steps relatively accurately, BUT it’s questionable whether this information prompted a change in people’s behavior or activity.


In our second part, we examined heart rate tracking and found that current wrist-based heart rate devices are inadequate to track heart rate –, particularly when the user is exercising.


Today we examine sleep tracking. 


Sleep tracking by Americans using consumer wearables has become an incredibly common activity.  Forrester research estimated back in 2015 that 10% of US adults use a wearable fitness/sleep tracking device regularly and up to 50% indicated they would consider one.   Nearly all measures of sleep using wearables are derived from the principles of body movement developed many years ago by researchers using accelerometers (movement detection sensors).  The scientific name for this is called actigraphy.  Although actigraphy has been well validated with medical grade devices (often costing >$1000), actigraphy-based measurements in consumer devices are not well validated unlike the testing done on step counts or heart rate in consumer devices (and wearables).

One recent study published in 2015 in the journal Sleep (Meltzer et al) evaluated the the accuracy of Fitbit compared to medical-grade actigraphy devices, as well as to the gold standard for sleep monitoring, polysomnography (PSG).  PSG is performed in a specialized sleep laboratory with over a dozen sensors and electrodes attached to a person.  Researchers looked at three common measures that are often displayed or reported, namely, total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE – measured as a percentage of TST divided by time of lights-out to lights-on).  The study foundthat PSG and medical-grade actigraphy agreed with each other.  However, Fitbit Ultra, independent of how sensitive it was set, either overestimated or underestimated the three measures above by approximately 10-20%.   In real numbers, Fitbit Ultra in Sensitive mode would underestimate TST by over 100 minutes and, therefore, underestimated SE by over 20% (83.4% with PSG vs 62.7% with Fitbit).  This level of error could lead to misinterpretation and anxiety on the part of potential patients worried about whether they sleep well.  Such anxiety is not just a theoretical risk.

Another study published in 2017 in the Journal of Clinical Sleep Medicine (Baron et al) reported three cases of patients who went for medical treatment based upon their consumer wearable sleep data.  Patients had anxiety and often refused the medical treatment suggestions -- like cognitive behavioral therapy -- because they often felt distrust of their doctor when the accuracy of their wearable was questioned. 

As one patient in this study noted to his physician, “I know you don’t like this, but my Fitbit tells me…”  The study authors noted that this may have “affected the therapeutic relationship” between patient and doctor.  They further described this behavior as follows:

We termed this condition “orthosomnia,” with “ortho” meaning straight or correct, and “somnia” meaning sleep, because patients are preoccupied or concerned with improving or perfecting their wearable sleep data.

In conclusion, sleep testing with consumer wearables is not well-validated to measure clinical health or medical conditions.   In fact, the handful of studies that have been done suggest that not only could the data be inaccurate, but could also result in anxiety and potential negative medical consequences to the patient such as “orthosomnia”.    The fact that medical-grade actigraphy devices already exist suggests that companies making consumer wearables could produce accurate devices if the market demanded the accuracy. 

My recommendation: demand accuracy in your sleep tracking devices – then sleep well knowing you did what you could!

Are Fitness Trackers Fit to Track Your Fitness?  Part 2:  Heart Rate Tracking

Are Fitness Trackers Fit to Track Your Fitness? Part 2: Heart Rate Tracking

Welcome to the second part of this series examining: are fitness trackers fit to track your fitness?  In this three-part series, we are examining the scientific data on the accuracy of such trackers for the three most popular uses: activity/step count tracking, heart rate tracking, and sleep tracking.

Today we examine heart rate tracking.