Thursday, March 26, 2009

Diabetes Supplies Art Initiative

"Diabetes Supplies Art" is literally art made using diabetes supplies, with the purpose of educating people about the challenges of diabetes treatment. The result is often powerful and full of emotion, and very creative.

See a great video, photos, and other art here:

Thanks to Manny Hernandez, the eloquent founder of for bringing this to my attention.

Tuesday, March 24, 2009

Zume Life launched!

After more than three years of really hard work, we are finally launching our Zume Life service. (Don't believe anyone who says these things are done by a couple of guys in their garage over a couple of months in their spare time!)

Here is our press release:

Zume Life Launches Service to Ease Life for People with Chronic Illnesses

iPhone application + website for personal health management

Los Altos, CA - March 25, 2009 - Zume Life ( announced today the launch of its personal health management system, targeted at consumers with complex health regimens—those with multiple chronic conditions (diabetes, heart disease, depression, autoimmune diseases, cancer, obesity, etc.)—to help them manage their daily, ongoing self-care tasks by making it easy to remember, record and review those tasks.

Today, we face a global epidemic of chronic disease that can only be addressed by helping people take better care of themselves. Millions of Americans, and many more across the world, are living with chronic conditions that require dozens of health-related activities to be done every day—multiple drugs at different times, keeping track of different symptoms, and paying attention to what they eat and how often they exercise. They have to do this properly and consistently for the rest of their lives.

Not surprisingly, people find this nearly impossible to do. “Non-adherence” is a major problem, impacting not only the health and well-being of those individuals and their families, but also placing an enormous financial burden on society. “People would like to do better,” said Zume Life CEO Rajiv Mehta, “but they can’t just put aside the rest of their activities and responsibilities to focus only on their health. While they of course want better health, what they want most is freedom to live their lives rather than being trapped by the chores of self-care. Our system gives them that freedom, and paves the way to better health.”

The Zume Life system has two components:

  • The "Zuri" iPhone application that helps users remember to do various health-related activities and to record those activities
  • A website that helps users and their caregivers to review on-going health patterns and the interrelationships amongst different activities, and to respond quickly to changes in health.

Tailored to the needs of each individual, the system provides support for:

  • All medications (Rx, OTC, supplements, home remedies)
  • Common biometrics (weight, blood pressure, blood glucose, temperature, peak flow, etc)
  • Symptoms (anxiety, mood, pain, wheezing, etc.)
  • Food journal and basic metrics (calories, carbs, and points)
  • Exercise journal

“The medical community has noted for a long time that if we could get people to properly follow their therapeutic regimens, this would have a bigger impact than almost anything else we do,” said Zume Life Chief Operating Officer Priya Kamani MD. “We have spent a significant amount of time understanding the challenges that people living with chronic conditions have and in response have developed tools that help people be more successful in taking care of themselves.”

Since January 2008, a prototype Zume Life system has been used by 200 people, ranging in age from pre-teen to those in their 70s and with dozens of different chronic conditions. Users noted significant improvements in their motivation and confidence in taking care of their own health, ability to stick to their health regimens, and overall health and sense of well-being.

Consumers can sign up for the service at After a one-month free trial, the service is priced at $35 per month or $300 per year, plus $4.99 for the Zuri iPhone application.

About Zume Life

Zume Life's vision is to empower and motivate individuals to become fully and effectively engaged in managing their own health. It is our experience that most people are genuinely interested in being in the best possible health and that a supportive, positive and motivating environment combined with convenient and effective tools can significantly improve self-care efforts. Additionally, we believe that healthcare professionals can more effectively assist their patients if they have a better picture of their patients’ day-to-day health and if their patients have the tools to better implement and adhere to the prescribed regimen.

Zume Life was founded in 2006, and is funded by private investors. For more information, please go to

Media Contact:

Rajiv Mehta, Zume Life

(650) 823-3274

Tuesday, March 17, 2009

New Analysis of Earlier Adherence Studies Quite Revealing

In response to my earlier post about adherence (Health Myths #1: Adherence & Red Beads), I received an email from one of the leading researchers in this field pointing me to the most current analysis which dramatically changes the accepted wisdom on medication adherence, while adding support to the point I was making.

Numerous surveys of adherence studies have noted that adherence rates during clinical trials vary widely—43% to 78% according to the Osterberg & Blaschke paper I refered to.

Well, some people decided to go back and reanalyze data from past studies, looking at the data far more carefully than earlier researchers. Essentially they decided to break "overall adherence" amongst a population into two components: how well did people execute their regimen while trying to adhere to their medication regimen, and when did they decide to discontinue the regimen. What they found was that most "non-adherence" was actually due to people simply discontinuing the regimen -- they were no longer trying to take their medication. Of those trying to be adherent, only about 10% were unsuccessful on any given day.

This new analysis can be found in Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically complied dosing histories by Bernard Vrijens, et al., published 14 May 2008. Well worth reading for anyone interested in this topic.

This paper supports, quite strongly, my key pointwhich is that we must help people be more successful with adherence, rather than assuming that they don't care. As the paper says "Patients who execute poorly need help integrating their daily dosing into their routine ... our data suggest the value of ... helping patients to integrate their dosing into daily routines." This is precisely what we have found as well. People have difficulty integrating their health activities into their busy lives. Therefore, Zume Life's efforts, from the start, have focused on developing a tool that makes this integration easier. Many fundamental design decisions stem from this focus, including helping users with the full spectrum of their health activities (not just pills, but all medications as well as biometrics, moods, symptoms, food, ...), and having a mobile device as a critical element of the overall solution.

The paper also notes that "ongoing information on the quality of execution [to the medication regimen] might signify impending early discontinuation, possibly allowing an opportunity to intervene early to prevent treatment interruption". Absolutely!! Such early-warning indicators can have great benefit. If a person is tracking their overall health, there could be many such indicators, based on a wide variety of factors the person is tracking. For example, at the start of a new anti-hypertensive medication treatment, a person may choose to record various symptoms that are known side-effects—perhaps "chest pain", "weakness/fatigue", "breathing difficulty", and "lightheadedness/dizziness". Just a reassuring note from a caregiver observing the person's progress, such as "I see you're not feeling well. This is quite normal. It'll pass in a few days. Keep up the good working on sticking to your regimen", could be a very helpful intervention that keeps the person from discontinuation. Similarly, observing poor execution of another health activity scheduled for the morning could guide the doctor to an evening schedule for the new hypertension medicine.

Finally, the paper notes "implications for practical clinical management" including drugs with more "forgiveness". Presumably there are tradeoffs involved in making drugs that are taken just once a day versus multiple times a day, and between drugs that are more or less forgiving. We can change the drugs to make adherence easier, or we can improve people's capability to adhere so that "better" drugs (from a medical perspective) can be used. I imagine that it would be better to increase people's capability, so that drugs can be more finely tuned.

Although such studies are almost always very limited in their focus, often studying just one medication rather than a person's entire health regimen, it is encouraging that they support a more nuanced view of non-adherence. Perhaps it will help accelerate dispelling the myths surrounding poor adherence.

Tuesday, March 10, 2009

Holy cow, what a ride!

I love this quote from Robert Nerem, a bio-engineering professor at the Georgia Institute of Technology. It comes from a speech he gave as the recipient of the 2008 Founders Award from the National Academy of Engineering. In closing he listed what he calls "The Rules of Life: The Planet Earth School". The last of these rules, #15, is:

Finally, life's journey isn't to arrive
at the grave
safely in a well preserved body,
but rather to skid in sideways,
worn out,
shouting—holy cow, what a ride!

There are many ways to interpret this, but in the context of health, what I take away is that you should live your life such that you focus on truly living rather than on preserving your health. Health is a means to an end, not an end in itself.

The full speech is definitely worth reading. If you're not into engineering, you can still enjoy the rest of Prof. Nerem's 15 rules. The speech can be found in The Bridge, the quarterly journal of the National Academy of Engineering (pages 61-63).

Monday, March 9, 2009

Good Books: The China Study

In the past couple of years, three books about food have made a big impression on me. One was Michael Pollan's best seller In Defense of Food: An Eater's Manifesto. Another was The Way We Eat: Why Our Food Choices Matter by Peter Singer and Jim Mason. The one that was most surprising however was the unfortunately named The China Study: The Most Comprehensive Study of Nutrition Ever Conducted by Dr. T. Colin Campbell and Thomas M. Campbell II.

Because of that title, I would never have picked the book off a shelf ... I live in the US, not in China, and though I like Chinese food it doesn't make up much of my diet. I only paid attention because a friend who had been battling with cancer told me that it is was a "must read".

Dr. Campbell makes a bold claim, "I propose to do nothing less than redefine what we think of as good nutrition. You need to know the truth about food, and why eating the right way can save your life", and delivers!

The book references a wide range of scientific studies to explain the effects of diet on health. Not just "the China study" of the title, but many, many other studies as well. For many specific diseases, the authors explain the available scientific research and what is known about cause and effect within the body. You learn both that such and such has a high correlation to good health, but also how that can be explained by what we know about the workings of the body.

Reading it, you will learn that so much of what is told about good diets via official government guidelines and accepted medical practice is just plain wrong. For example, you learn that drinking milk is on the whole bad for your bones, and that animal-based protein is not necessary and is in fact harmful. It is not the case that science supports those established medical practices and the "food pyramid" guidelines. Rather those mis-guided instructions are due primarily to political considerations, lazy science, and closed mindedness.

Political considerations are not limited to the lobbying power of the big players in the food business. It also includes the limited-vision of the accepted "good guys" such as academia, the medical community, and even health-oriented advocacy groups (e.g. American Heart Association).

Lazy science is reflected both in researchers generally focusing their efforts on just one variable (making the research and analysis easier), but also in consumers (often journalists) of this research extrapolating the results to situations far beyond the limited confines of the original research.

Closed mindedness comes mostly from people assuming that what they know to be true is in fact true. Dr. Campbell relates how this was true even for himself. He grew up on a farm—cows, pigs, chickens, as well as plants—and "knew" that beef was good for you. One of the first projects in his professional career was to find ways of increasing animal-protein intake in the Philippines. A project he firmly believed in. His faith in this view started to waver as he noted his own research showing that the protein-deficiency health issues were greatest amongst the wealthiest Filipinos, who ate the most meat, and least amongst the poorest, who ate the least amount of meat. That was many decades ago. He's learned a lot since then, and written a fantastic book to help the rest of us.

Michael Pollan summed up his book as "Eat food. Not too much. Mostly plants." The China Study will help you understand why this is a good idea.

Sunday, March 8, 2009

Health Myths #1: Adherence & Red Beads

What gets us into trouble

is not what we don't know

It's what we know for sure

that just ain't so

Mark Twain

This is the 1st in a series of posts on widely held and pernicious health myths.

The Myth

There's a lot of talk about improving quality in healthcare. Compared to other industries healthcare lags far behind in adopting the concepts and applying the tools of the quality movement. There is a lot that can be applied, and not just for improving the quality of systems but also for dealing with people.

One of those people-issues is adherence. The problem of poor adherence—the inability of patients to follow their medication regimens accurately and consistently—is widespread and well known. The likely benefits of improved adherence are also well accepted: "Effective ways to help people follow medical treatment would have far larger effects than any treatment itself" (Lancet, 1996).

Given its importance, many studies have been conducted to understand the problem and numerous efforts have been made to solve it. A wonderful overview of medical studies on this topic is Adherence to Medication by Lars Osterberg and Terrence Blaschke. And, many efforts have been made to increase adherence, including more education, easier regimens (e.g. 1 pill a day, rather than 2 or 3), and financial rewards and threats. Nothing seems to make much of a difference.

At first glance, it seems absurd that adherence is so poor. After all, how hard can it really be to take a pill on a regular schedule? Even self-injections (such as for diabetics), though unpleasant, are not especially difficult.

This has led to the myth: people don't adhere because they don't want to; people don't care about their health.

The Red Bead Experiment

Dr. Edward Deming, one of the founders of the quality improvement, used the "Red Bead Experiment" to teach a key point about quality. This experiment is really a performance piece, a skit.

The cast: three workers, a foreman, and a quality inspector

The situation: a bin is filled with beads, of which 80% of are black and 20% are red. The workers use a special paddle to collect beads from the bin, and place these beads in a second bin. The quality of the workers' performance is judged by the percentage of black beads versus red beads in the second bin. A higher percentage being better quality.

The action: foreman tells workers what is expected. Workers transfer one paddle of beads. Quality inspector determines that the second bin has roughly 80% black beads. Foreman fumes and exhorts workers to do better. Workers do their job again, quality inspector checks again, and again the result is about 80%. Foreman is livid, yells at, threatens, demands better performance. Workers try again, quality inspector checks again, 80% again.

The lesson: the workers are limited by the tools at their disposal. There is simply no way to get a higher percentage of black beads out of the first bin with the given paddle. The problem is not one of worker competence or motivation, but of capability. In this case, as in many others, capability must be improved through better tools and processes.

The Reality

The situation with adherence is much the same. The problem is not simply one of poor knowledge or desire—even smart, motivated people have poor adherence. It is in fact a problem of capability.

It is true that each particular activity in a health regimen—taking a pill; checking and recording weight; recording lunch in a food journal; noting an event of pain or nausea—is relatively easy to do. But, if you have 20, 30, 40 or more such activities spread throughout each day, as is common for people with chronic illnesses, it is difficult to do them properly and consistently every day, forever. If you also have a normal, busy life, with the activities and responsibilities of family, work and society, it is in fact extremely difficult. This is why adherence is so poor! It's almost impossible to be properly adherent. At least without better tools.

Quite simply, people need help remembering all of their scheduled health activities and need an easier way to keep track of all them. People need tools or services to make remembering and recording much, much easier than it is today.

To significantly improve adherence, we must discard the myth of irresponsible patients, and take on the challenge of developing tools that help people. We've got to give those workers better paddles if we want fewer red beads.

Saturday, March 7, 2009

Under Our Skin: Chronic Lyme Disease

Last week I saw a screening of Under Our Skin a documentary about chronic Lyme Disease. It interweaves two stories. One is the personal journeys of a few individuals—the course of their illness and their struggles to cope. The other is that of the battle between a healthcare establishment that denies the existence of this disease and a few brave (or quack, depending on your perspective) doctors helping those individuals.

The pain, the suffering of those afflicted is undeniable. Their courage, in following the regimens of those pioneering doctors, is also undeniable. Both the practical difficulties and the side-effects are daunting. But, the results are spectacular. After years of destroyed lives, people are able to live fairly normal lives.

And yet, the dilemma facing the medical establishment is also made clear. The sufferers have a wide variety of symptoms—in the movie, several minutes go by as people rattle off their symptoms—and these seem to vary day-by-day, week-by-week, person-by-person. In addition, those pioneering doctors use an enormous cornucopia of medicines and other forms of treatment. Medicine is by nature and practice a reductive science. Something this amorphous simply cannot be accepted. Until “chronic Lyme Disease” can be identified much more crisply, it cannot be classified as a disease, and there can be no established treatment guidelines.

The film did not give me confidence that two sides could easily be reconciled. Perhaps the medical industry will give in to the forceful and emotional demands of sufferers to officially accept this disease and its treatments as legitimate. More likely, as shown in the film, the medical establishment will succeed in shutting down what they perceive to be quack-doctoring.

It is clear that both Lyme Disease sufferers and the medical establishment would benefit tremendously from Zume Life.

Individuals, and their families, would have far more success adhering to their complex regimens and keeping track of their myriad symptoms, with Zuri’s reminder and recording functions. They and their doctors would see more clearly and more quickly what works and what doesn’t, and change treatment appropriately.

The rich data captured by the Zume Life system would also permit medical scientists to better understand the situation. Sophisticated data analysis techniques could be applied, resulting in conclusions acceptable to the medical community. Perhaps everyone will be able to see “chronic Lyme Disease” as clearly as its proponents do today. Or perhaps we will find that there are in fact several distinct conditions, each having its own unique signature of symptoms and appropriate treatment.

Friday, March 6, 2009

The Challenges of Surviving an Organ Transplant

Recently I met a woman whose husband had had a liver transplant. We were both on a flight and our trip-length discussion started off as casual conversation of “what do you do?” Her eyes lit up as I described Zume Life, and our focus on helping people take better care of themselves, of making it easier for people to manage their own health. What I described was not theoretical to her; it was her day-to-day reality.

Over 25,000 people receive organ transplants in the US every year (data). Their lives up to the moment of their transplant have naturally been very difficult. But, what comes next can be overwhelming for the patient’s family caregivers—a long, arduous, demanding, and tricky process of bringing the patient to a healthy state.

She showed me a folder, that she always has with her, which held reams of blank and filled-out worksheets of her husband’s daily health activities. Each day, spread throughout the day, she had to remember and record 30-40 specific health activities: 5 different biometrics, 17 different medications (Rx, OTC and supplements), and notes on food, symptoms, moods, activities and other notable events. Many of the medications had complex requirements (e.g. dosage dependent on a biometric measurement, “no food 1 hour before or 2 hours after”, different schedules for different days, etc.). In addition, the regimen changed constantly based on her husband’s changing health situation and the doctors’ interpretation of these changes. Being able to adhere strictly to this complex regimen and keeping very good notes is critical to her husband’s successful recovery.

As his health is so poor, due to both the underlying problems and the effects of this bombardment of powerful medications, the burden of adherence really falls upon her, and other such family caregivers. My fellow traveller explained that she was able to manage—hard work but doable—given her professional experience managing the details of large, complex projects. But, for many others in her organ transplant support group, this situation was overwhelming. They just couldn’t cope, they just couldn’t manage. They needed help, and she felt that Zume Life’s system was absolutely essential.

Through this conversation I also came to appreciate why the post-transplant situation is so demanding. Having never really thought about it, I assumed that once you replace a bad organ with a good one you’re on your way to recovery. It’s not so simple. The body is a complex organism, with lots of different working parts. If one component is working poorly, everything else is affected; the body has come to achieve an equilibrium where it continues to function in some manner despite the poorly performing organ. After that organ is replaced, all the other body parts are still working as they were before, creating havoc, and a big portion of post-operation activity is keeping the body from spiraling out-of-control.

Hundreds of thousands of dollars spent on the operation ... and then we leave families to create their own spreadsheets! Clearly we need to do better.

The Importance of Self-Care

Addressing the challenge of self-care is the most important health issue of the 21st century.

Over the past century there has been a tremendous advance in overall health due to advances in health-care technologies: in medical science, in the education and practices of healthcare professionals, and in efforts devoted to public health. These advances have led to a huge improvement in the overall health of society, enabling people to live much longer and to avoid and survive diseases and accidents that would have been deadly in the past. Because of these reductions in the impact of catastrophic events beyond our control, health is now much more a function of people's own daily, ongoing decisions and activities. People's state of health is much more dependent on their ability to take care of themselves and the actions that they take in their daily lives. Yet, people are struggling in their efforts, as is clear from prevalence and continued rapid growth of chronic illnesses.

"Healthcare" is really "sick care". The healthcare industry, the medical profession, are there to fix you up, as best as they can, when your health gets really bad. But, they can do little for your day-to-day health, as doctors and nurses simply cannot be by your side all the time. Healthcare is not scalable to continuing care. The paradigm of healthcare is simply inappropriate to addressing the current situation where chronic illness is the major health issue.

For the next great improvement in health, what is needed is a tremendous advance in self-care capabilities.

I'm trying to do something about this through my efforts in leading Zume Life. Zume Life's vision is to empower and motivate individuals to become fully and effectively engaged in managing their own health. It is our experience that most people are genuinely interested in being in the best possible health and that a supportive, positive and motivating environment combined with convenient and effective tools can significantly improve self-care efforts. Additionally, we believe that healthcare professionals can more effectively assist them if they have a better picture of their patients’ day-to-day health and if their patients have the tools to better implement and adhere to the prescribed regimen.