Personalized nutrition apps could provide valuable data to people trying to eat healthier, though more research must be done to show effectiveness.
As a type 2 diabetic, Michael Snyder has long been interested in how blood sugar levels vary from one person to another in response to the same food, and whether a more personalized approach to nutrition could help tackle the rapidly cascading levels of diabetes and obesity in much of the western world.
Eight years ago, Snyder, who directs the Center for Genomics and Personalized Medicine at Stanford University, decided to put his theories to the test. In the 2000s continuous glucose monitoring, or CGM, had begun to revolutionize the lives of diabetics, both type 1 and type 2. Using spherical sensors which sit on the upper arm or abdomen – with tiny wires that pierce the skin – the technology allowed patients to gain real-time updates on their blood sugar levels, transmitted directly to their phone.
It gave Snyder an idea for his research at Stanford. Applying the same technology to a group of apparently healthy people, and looking for ‘spikes’ or sudden surges in blood sugar known as hyperglycemia, could provide a means of observing how their bodies reacted to an array of foods.
“We discovered that different foods spike people differently,” he says. “Some people spike to pasta, others to bread, others to bananas, and so on. It’s very personalized and our feeling was that building programs around these devices could be extremely powerful for better managing people’s glucose.”
Unbeknown to Snyder at the time, thousands of miles away, a group of Israeli scientists at the Weizmann Institute of Science were doing exactly the same experiments. In 2015, they published a landmark paper which used CGM to track the blood sugar levels of 800 people over several days, showing that the biological response to identical foods can vary wildly. Like Snyder, they theorized that giving people a greater understanding of their own glucose responses, so they spend more time in the normal range, may reduce the prevalence of type 2 diabetes.
The commercial potential of such apps is clear, but the underlying science continues to generate intriguing findings.
“At the moment 33 percent of the U.S. population is pre-diabetic, and 70 percent of those pre-diabetics will become diabetic,” says Snyder. “Those numbers are going up, so it’s pretty clear we need to do something about it.”
Fast forward to 2022,and both teams have converted their ideas into subscription-based dietary apps which use artificial intelligence to offer data-informed nutritional and lifestyle recommendations. Snyder’s spinoff, January AI, combines CGM information with heart rate, sleep, and activity data to advise on foods to avoid and the best times to exercise. DayTwo–a start-up which utilizes the findings of Weizmann Institute of Science–obtains microbiome information by sequencing stool samples, and combines this with blood glucose data to rate ‘good’ and ‘bad’ foods for a particular person.
“CGMs can be used to devise personalized diets,” says Eran Elinav, an immunology professor and microbiota researcher at the Weizmann Institute of Science in addition to serving as a scientific consultant for DayTwo. “However, this process can be cumbersome. Therefore, in our lab we created an algorithm, based on data acquired from a big cohort of people, which can accurately predict post-meal glucose responses on a personal basis.”
The commercial potential of such apps is clear. DayTwo, who market their product to corporate employers and health insurers rather than individual consumers, recently raised $37 million in funding. But the underlying science continues to generate intriguing findings.
Last year, Elinav and colleagues published a study on 225 individuals with pre-diabetes which found that they achieved better blood sugar control when they followed a personalized diet based on DayTwo’s recommendations, compared to a Mediterranean diet. The journal Cell just released a new paper from Snyder’s group which shows that different types of fibre benefit people in different ways.
“The idea is you hear different fibres are good for you,” says Snyder. “But if you look at fibres they’re all over the map—it’s like saying all animals are the same. The responses are very individual. For a lot of people [a type of fibre called] arabinoxylan clearly reduced cholesterol while the fibre inulin had no effect. But in some people, it was the complete opposite.”
Eight years ago, Stanford's Michael Snyder began studying how continuous glucose monitors could be used by patients to gain real-time updates on their blood sugar levels, transmitted directly to their phone.
The Snyder Lab, Stanford Medicine
Because of studies like these, interest in precision nutrition approaches has exploded in recent years. In January, the National Institutes of Health announced that they are spending $170 million on a five year, multi-center initiative which aims to develop algorithms based on a whole range of data sources from blood sugar to sleep, exercise, stress, microbiome and even genomic information which can help predict which diets are most suitable for a particular individual.
“There's so many different factors which influence what you put into your mouth but also what happens to different types of nutrients and how that ultimately affects your health, which means you can’t have a one-size-fits-all set of nutritional guidelines for everyone,” says Bruce Y. Lee, professor of health policy and management at the City University of New York Graduate School of Public Health.
With the falling costs of genomic sequencing, other precision nutrition clinical trials are choosing to look at whether our genomes alone can yield key information about what our diets should look like, an emerging field of research known as nutrigenomics.
The ASPIRE-DNA clinical trial at Imperial College London is aiming to see whether particular genetic variants can be used to classify individuals into two groups, those who are more glucose sensitive to fat and those who are more sensitive to carbohydrates. By following a tailored diet based on these sensitivities, the trial aims to see whether it can prevent people with pre-diabetes from developing the disease.
But while much hope is riding on these trials, even precision nutrition advocates caution that the field remains in the very earliest of stages. Lars-Oliver Klotz, professor of nutrigenomics at Friedrich-Schiller-University in Jena, Germany, says that while the overall goal is to identify means of avoiding nutrition-related diseases, genomic data alone is unlikely to be sufficient to prevent obesity and type 2 diabetes.
“Genome data is rather simple to acquire these days as sequencing techniques have dramatically advanced in recent years,” he says. “However, the predictive value of just genome sequencing is too low in the case of obesity and prediabetes.”
Others say that while genomic data can yield useful information in terms of how different people metabolize different types of fat and specific nutrients such as B vitamins, there is a need for more research before it can be utilized in an algorithm for making dietary recommendations.
“I think it’s a little early,” says Eileen Gibney, a professor at University College Dublin. “We’ve identified a limited number of gene-nutrient interactions so far, but we need more randomized control trials of people with different genetic profiles on the same diet, to see whether they respond differently, and if that can be explained by their genetic differences.”
Some start-ups have already come unstuck for promising too much, or pushing recommendations which are not based on scientifically rigorous trials. The world of precision nutrition apps was dubbed a ‘Wild West’ by some commentators after the founders of uBiome – a start-up which offered nutritional recommendations based on information obtained from sequencing stool samples –were charged with fraud last year. The weight-loss app Noom, which was valued at $3.7 billion in May 2021, has been criticized on Twitter by a number of users who claimed that its recommendations have led to them developed eating disorders.
With precision nutrition apps marketing their technology at healthy individuals, question marks have also been raised about the value which can be gained through non-diabetics monitoring their blood sugar through CGM. While some small studies have found that wearing a CGM can make overweight or obese individuals more motivated to exercise, there is still a lack of conclusive evidence showing that this translates to improved health.
However, independent researchers remain intrigued by the technology, and say that the wealth of data generated through such apps could be used to help further stratify the different types of people who become at risk of developing type 2 diabetes.
“CGM not only enables a longer sampling time for capturing glucose levels, but will also capture lifestyle factors,” says Robert Wagner, a diabetes researcher at University Hospital Düsseldorf. “It is probable that it can be used to identify many clusters of prediabetic metabolism and predict the risk of diabetes and its complications, but maybe also specific cardiometabolic risk constellations. However, we still don’t know which forms of diabetes can be prevented by such approaches and how feasible and long-lasting such self-feedback dietary modifications are.”
Snyder himself has now been wearing a CGM for eight years, and he credits the insights it provides with helping him to manage his own diabetes. “My CGM still gives me novel insights into what foods and behaviors affect my glucose levels,” he says.
He is now looking to run clinical trials with his group at Stanford to see whether following a precision nutrition approach based on CGM and microbiome data, combined with other health information, can be used to reverse signs of pre-diabetes. If it proves successful, January AI may look to incorporate microbiome data in future.
“Ultimately, what I want to do is be able take people’s poop samples, maybe a blood draw, and say, ‘Alright, based on these parameters, this is what I think is going to spike you,’ and then have a CGM to test that out,” he says. “Getting very predictive about this, so right from the get go, you can have people better manage their health and then use the glucose monitor to help follow that.”
The opioid crisis depicted with a map of the USA filled with oxycodone and hydrocodone pills.
The largest ever seizure of fentanyl in the United States – 254 pounds of the white powder, enough to kill 1 in 3 Americans by overdose – was found under a shipment of cucumbers recently.
A policing approach alone is insufficient to take on the opioid crisis.
Those types of stories barely make the headlines any more, in part because illicit drugs are no longer just handsold by drug dealers; these sales have gone online. The neighborhood dealer faces the same evolving environment as other retailers and may soon go the way of Sears.
But opioids themselves are not going away. I could make an opioid purchase online in about 30 seconds and have it sent to my door, says Joe Smyser. The epidemiologist and president of The Public Good Projects isn't bragging, he's simply stating a fact about the opioid crisis that has struck the United States. The U.S Drug Enforcement Agency, social media companies, and some foreign governments have undertaken massive efforts to shut down sites selling illegal drugs, and they have gotten very good at it, shuttering most within a day of their opening.
But it's a Whac-A-Mole situation in which new ones pop up as quickly as older ones are closed; they are promoted through hashtags, social media networks, and ubiquitous email spam to lure visitors to a website or call a WhatsApp number to make a purchase. The online disruption by law enforcement has become simply another cost of doing business for drug sellers. Fentanyl, and similar analogues created to evade detection and the law, are at the center of it. Small amounts can be mixed with other "safer" opioids to get a high, and the growth of online sales have all contributed to the surge of opioid-related deaths: about 17,500 in 2006; 47,600 in 2017; and a projected 82,000 a year by 2025.
All of this has occurred even while authorities have been cracking down on the prescribing of opioids, and prescription-related deaths have declined. Clearly a policing approach alone is insufficient to take on the opioid crisis.
Building the Tools
The Public Good Projects (PGP), a nonprofit organization founded by concerned experts, was set up to better understand public health issues in this new online environment and better shape responses. The first step is to understand what people are hearing and the language they are using by monitoring social media and other forms of public communications. "We're collecting data from every publicly available media source that we can get our hands on. It's broadcast television data, it's radio, it's print newspapers and magazines. And then it's online data; it's online video, social media, blogs, websites," Smyser explains.
The purpose was to better understand the opioid crisis and find out if there were differences between affected rural and urban populations.
"Then our job is to create queries, create searches of all of that data so that we find what is the information that Americans are exposed to about a topic, and then what … Americans [are] sharing amongst themselves about that same topic."
He says it's the same thing business has been doing for years to monitor their "brand health" and be prepared for possible negative issues that might arise about their products and services. He believes PGP is the first group to use those tools for public health.
Looking At Opioids
PGP's work on opioids started with a contract from the Substance Abuse and Mental Health Administration (SAMHSA) through the National Science Foundation. The purpose was simply to better understand the opioid crisis in the United States and in particular find out if there were differences between affected rural and urban populations. A team of data scientists, public health professionals, and cultural anthropologists needed several months to sort out and organize the algorithms from the sheer volume of data.
Drug use is particularly rich in slang, where a specific drug or way of using it can be referred to in multiple ways in different towns and social groups. Traditional media often uses clinical terms, Twitter shorthand, and all of that has to be structured and integrated "so that it isn't just spitting out data that is gobbledygook and of no use to anyone," says Smyser.
The data they gather is both cumulative and in real time, tabulated and visually represented in constantly morphing hashtag and word clouds where the color and size of the word indicates the source and volume of its use.
Popular hashtags on Twitter relating to the opioid crisis.
(Credit: The Public Good Projects)
The visual presentation of data helps to understand what different groups are saying and how they are saying it. For example, compare the hashtag and word clouds. Younger people are more likely to use the hashtags of Twitter, while older people are more likely to use older forms of media, and that is reflected in their concerns and language in those clouds.
Popular words relating to the opioid crisis gathered from older forms of media.
(Credit: The Public Good Projects)
A Ping map shows the origin of messages, while a Spidey map shows the network of how messages are being forwarded and shared among people. These sets of data can be overlaid with zip code, census, and socioeconomic data to provide an even deeper sense of who is saying what. And when integrated together, they provide clues to topics and language that might best engage people in each niche.
A Ping map showing the origin of messages around the opioid crisis.
(Credit: The Public Good Projects)
Opioids Speak
One thing that quickly became apparent to PGP in monitoring the media is that "over half of the information that the American public is exposed to about opioids is a very distant policy debate," says Smyser.
It is political pronouncements in DC, the legal system going after pharmaceutical companies that promoted prescription opioids for pain relief (and more), or mandatory prison terms for offenders. Relatively little is about treatment, the impact on families and communities, and what people can do themselves. That is particularly important in light of another key finding: residents of "Trump-land," the rural areas that supported the president and are being ravaged by opioids, talk about the problem and solutions very differently from urban areas.
"In rural communities there is usually a huge emphasis on self-reliance, and we take care of each other; that's why we enjoy living here. We are a neighborhood, we come together and we fix our own problems," according to Smyser.
In contrast, urban communities tend to be more transient, less likely to live in multigenerational households and neighborhoods, and look to formal institutions rather than themselves for solutions. "The message that we're sending people is one where there is really no role whatsoever for self-efficacy...we're giving them nothing to do" to help solve the problem themselves, says Smyser. "In fact, I could argue it is reducing self-efficacy."
Residents of "Trump-land," the rural areas that supported the president and are being ravaged by opioids, talk about the problem and solutions very differently from urban areas.
The opioid crisis is complex and improving the situation will be too. Smyser believes a top-down policing approach alone will not work; it is better to provide front-line public health officers at the state and local level with more and current intelligence so they can respond in their communities.
"I think that would be enormously impactful. But right now, we just don't have that service." SAMHSA declined multiple requests to discuss this project paid for with federal money. A spokesman concluded with: "That project occurred under the previous administration, and we did not have a direct relationship with PGP. As a result, I am unable to comment on the project."
The Milken Institute Center for Public Health, a think tank that is working to find solutions to the opioid epidemic, had an upbeat response. Director Sabrina Spitaletta said, "PGP's work to provide real-time data that monitors topics of high concern in public health has been very helpful to many of the front-line organizations working to combat this crisis."