An Eye to the Future of Healthcare

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In May 2020, 4 months into the U.S. pandemic, my mother, a type 2 diabetes patient, decided that enough was enough. After 24 years of having diabetes and 10 years of injecting herself with insulin daily, she was tired — tired of her medications, tired of checking her blood sugar every day, and tired of living with diabetes.

I was in high school when my mom was first diagnosed. Overnight, my mother’s health was no longer a given. She was the foundation of our home, and now she had a serious illness, one that I didn’t understand much about other than that it would affect her for the rest of her life.

As someone born and raised in India, my mother loved rice and naan and the occasional dessert of gulab jamun. Like so many patients with type 2 diabetes, she largely knew what she needed to do to keep her condition under control, yet struggled to do it. Time and again, I witnessed her come home from a doctor’s appointment highly motivated to lose weight and eat the right things, but by her next visit a few months later, her old habits would return.

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After years of poorly controlled sugars, she was put on insulin. Every day since then (or at least on most days when she felt up to it) she would steal herself away to a quiet corner of our home, draw up a syringe of insulin, and inject herself in the abdomen. But during the pandemic, this routine had become too much for her. She wanted out.

Years earlier she had learned of the idea of “curing” diabetes from me. At the time, I was a newly minted internal medicine physician and researcher at the University of Chicago. One of my patients was an elderly African American gentleman who lived on the South Side of Chicago. He had developed type 2 diabetes as a young man and had been on insulin for years. More recently, he had gotten serious about his health. As he ate healthier and shed pounds, his blood sugar fell, and with it the number of his diabetes medications. When I took him off the last of these medications, he asked me a simple question: “Dr. Nundy, am I cured of diabetes?”

My reflexive answer was to say, “Of course not. You can’t cure diabetes.” But I hesitated and told him I would need to get back to him. As I walked the labyrinth of hallways that led from my clinic through the hospital to the research offices where I made my second home, his question nagged at me. I knew that type 2 diabetes wasn’t a condition that went away, and yet somehow his seemed to have.

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Reviewing the latest research online, I found an article published a year earlier about this very question. The advent of gastric-bypass surgery had enabled some type 2 diabetes patients who had undergone the weight-loss procedure to get off all of their medications. A small group of experts had convened to define this state and choose a name for it, ultimately deciding to borrow from the field of cancer: diabetes remission. Patients with type 2 diabetes were in remission if they maintained a normal blood sugar without the aid of diabetes medications for at least 1 year.

My patient hadn’t had weight-loss surgery, but he seemed to otherwise fit the criteria. My next question was: How often did remission from type 2 diabetes occur naturally? To answer it, I partnered with a team of researchers at Kaiser Permanente, which had one of the largest data sets in the world of patients with type 2 diabetes. When I initially proposed the study, they were incredulous. They had been studying their data for years and had never noticed any patients in remission. But they were intrigued enough to try. After a year’s worth of data cleaning, false starts, and iterative testing, we came to a conclusion: remission or cure from type 2 diabetes was rare but possible. My patient was right.

When I told my mother that achieving remission was possible, she became interested in the idea but wasn’t sure where to get started. A year or 2 later, I told her about a startup company named Virta, which had created a program to help patients with type 2 diabetes do just that. The program, which they called diabetes reversal, was based on years of research showing that a ketogenic diet — a diet so limited in carbohydrate intake that the body burns fat instead of carbohydrates — could help 60% of patients with type 2 diabetes get off insulin and nearly all of their medications.

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The problem was that the treatment was very complex to administer. Often, patients needed a lot of support from nutritional experts to follow the ketogenic diet, as well as medical supervision to carefully decrease their medications so their blood sugar wouldn’t get too high or too low. Most doctors didn’t know about type 2 diabetes reversal, and the few who did didn’t have the staff or systems in place to properly manage it. Virta had solved these challenges and now had a growing cohort of patients who had successfully reversed their diabetes.

The Virta program still required a major commitment — one that my mother wasn’t quite ready to take on. But in the middle of the pandemic, with nearly daily news reports about how COVID-19 was worse in patients with diabetes, my mom was finally ready to move forward.

She went to the Virta website and signed up for the service, agreeing to pay for it out of pocket. Soon she was uploading her medical records to the site. She then downloaded the Virta app and was given a series of videos to watch to learn about the diet, how the program worked, and what to expect.

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Soon after, my mom met her Virta doctor, Jeff Stanley, MD, via videoconference using the app. He helped answer her questions and approved her to begin the program. A few days later, my mother received a bright blue box in the mail. In it, nicely packaged, were a wireless scale, a wireless glucometer, an instrument for measuring her ketones, and a recipe book. She could use the app to log her glucose and ketone measurements and what she had eaten. It also enabled her to connect with other patients in the program who were dealing with many of the same questions and struggles, and to message a health coach who understood the ins and outs of the diabetes reversal program and could get in touch with Stanley whenever necessary.

The program was tough. The diet upended her life and for the first several days left her with bad headaches and fatigue. She had a lot of questions early on and texted her coach multiple times a day. Then her team introduced her to a fellow Virta member in Chicago, who like my mother was from India and a vegetarian. He shared a number of recipes and tips about maintaining a ketogenic diet with Indian vegetarian foods, which were a lifesaver for her.

Her progress was encouraging. Within three days of starting the program, Stanley messaged her to decrease her insulin dose. After over 10 years of being on insulin and only experiencing dose increases, she went from 25 units a day to 10 units, a dramatic reduction. Within weeks, she was off insulin completely. And months later, she still is.

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My mom’s story illustrates the promise of digitally enabled care. Her care itself isn’t digital. There’s no robot, no AI. She has a doctor and a health coach, even though she’s never met either one in person. Instead, she sees them virtually from the comfort of her own home.

But that’s not what I mean by digitally enabled. She could just as easily see Stanley and her health coach in person in a clinic from time to time, and her program would still be digitally enabled, because digital technology is making a difference to her care in a host of additional ways:

First, my mother is connected to her doctor and her care team in ways that she never was before. That connection is not just about the data that is sent wirelessly to them. It’s also about the personal connection she has with them — a connection strengthened by her ability to communicate with them whenever she needs to.

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Second, her care is continuous. Between visits, she is sending data daily on her weight, blood sugar, ketones, and progress adhering to the diet. This data helps reinforce the relationship she has with her care team and shortens the feedback loop between them so her care is more proactive.

Third, her care is collaborative. She benefits from having access to a care team, including a doctor, a coach, and peers, who work together to address her needs. She also benefits from having her family and informal caregivers brought into the process.

Fourth, her care is personalized. The reversal team understood her preference for Indian food and a vegetarian diet from the get-go. They also continued to tailor the service to her ongoing needs. Weeks into the program, when my mom flew cross-country to Seattle to be present for the birth of her granddaughter, they adjusted their recommendations to account for the few days it would take for her to get settled into a new routine.

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Fifth, her care is responsive to the latest scientific evidence and expert guidelines. My mom was able to get access to a cutting-edge service based on science that most doctors aren’t even aware of. And it’s a service that has clinical pathways built in to ensure that her care is safe and effective.

Months into the program, my mother remains off insulin but still hasn’t figured it all out. There are days when her sugars are a little high and days when she struggles with her diet. But when I recently asked my mom whether she’s glad she joined the program, her response was: “Beta, I’m living the life I want to now and finally getting the care I need.” This future is all any of us can hope for.

This excerpt was adapted from Care After Covid: What the Pandemic Revealed Is Broken in Healthcare and How to Reinvent It (McGraw Hill, May 2021) by Shantanu Nundy, MD, MBA, chief medical officer of Accolade. In the chapters that follow, the author discusses how the future of healthcare is digitally enabled, using data and technology to strengthen the trusting, caring relationships that are central to healthcare.

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Last Updated May 13, 2021

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