Welcome to Forum 360.

I am Mark Welfley, and thank you for joining us for our global outlook with a local view.

Futurists once predicted that the wristwatch would become obsolete in 15 years, and perhaps that prediction would have come to pass.

Were it not for the advent of the Apple Watch.

The Apple Watch ushered in the era of wearable technology and a new booming market was born.

The market for wearable smart health devices, including trackers, monitors and sensors, was valued at $13.8 billion in 2020 and is expected to balloon to 37.4 billion by 2028.

Today, we'll take a closer look at wearable healthcare technology.

With Doctor Ben Allencherry, a cardiologist at the Cleveland Clinic.

So welcome Dr. Allencherry.

tell me a little bit about your background.

and why the heart?

Yeah.

So, Mark, thanks for having me on.

my background, you know, I started my schooling in Maryland.

met my wife in med school, and then we came to Ohio, and it was great.

I picked the heart, because my dad was a lung doctor, and he was always like, you know, there's a lot of intervention and change happening in cardiology.

Thankfully, I liked it when I was training, and I figured that this was the the most diverse way that you can affect patients in imaging and interventions.

so I found myself in the heart and I specialize in advanced cardiac imaging.

So I like to be on kind of involved with technology and the newest late breaking, things in the, in the cardiac space.

So that's how I ended up in advanced cardiac imaging and cardiology.

Yeah.

Okay.

We hear a lot about the word in medicine.

preventative health.

what is that?

Yeah, that's a good question.

So I think in the past, prevention was broken down into primary and secondary prevention.

And the way they think about this is primary means I haven't had a heart attack yet.

And I'm trying to prevent that.

And secondary means I've had some sort of event, a heart attack or stroke.

And now I want to prevent further events.

And now that paradigm has kind of changed, where we're focusing on risk factor modification.

So we use words now like primordial prevention, which is can we eliminate the risk factors.

So you can think about that as tobacco cessation programs for the whole society.

Weight loss programs.

So that's can we target the risk factors that then cause cardiac disease.

And then we think about the new definition of primary prevention where those patients who have those risk factors can we modulate those.

So if a patient comes to see me in clinic and is overweight or is a cigaret smoker, that's where I talking about primary prevention can I stop those risk factors.

The next is secondary prevention, which is what I think is probably the most interesting now is can we find what we call subclinical disease.

So you may see it on commercials.

calcium score where they do this Cat scan of your heart you'll have no symptoms.

And they they are able to somewhat predict what's your risk of having a cardiac event in the next 5 to 10 years.

And that's the next step is can we do low risk sort of prevention interventions that can tell someone like, hey, Mark, your risk in the next ten years is 5%.

You should probably be on this medication to lower your lipids.

And the last part is the what I discussed earlier is those patients who have had an event, how much can we prevent a second event.

So prevention is really changed.

And there's a lot of different subcategories of it.

Yeah.

So getting into the topic of wearable healthcare technology, which kind of folds into preventative health, as you've defined it, and we kind of read as we redefine what is wearable healthcare technology.

And I can see some examples of them.

Yeah, I think recently wearables has been in the, in the news and everything for being like smartwatches like I have on now.

But we in medicine have been using wearables for a while, so some of the listeners may know Holter monitors.

There's newer ones ZIO patches, which are basically monitors that are put on the chest to look for heart arrhythmias.

like if you go to your doctor and say, I'm having periods where I think my heart's racing, they might put this on.

It's sometimes two weeks, sometimes four week monitor, and you can trigger it if you feel something.

And then it gives the doctor a little snippet of what's happening in your heart.

So we've been using Holter monitors for a while now.

We've been using ambulatory blood pressure cuffs.

So you you walk around for 24 hours with the blood pressure cuff, and that's in hopes to see, hey, do I just have white coat hypertension or am I actually having high blood pressure or low blood pressure at home?

So those are all defined as wearables, basically technology that's used to kind of monitor you in a remote setting.

and it's easily accessible.

Now things changed with the Apple Watch and certain other competitors.

now wearable technology includes almost every smartwatch that can be used in the deliverables it offers.

Is vast.

It can offer you heart rate monitoring, pulse oximetry.

So what you're oxygen status is blood pressure.

there are further things down the road.

but wearable technology has really boomed.

Like you said in the intro.

within the last 9 to 10 years.

So it's, it's one thing to know of this advancing technology of the sensors and the trackers in the monitors, and know that they're out there.

at what state is the medical profession or the Cleveland Clinic at adopting them?

As valuable as, you know, as meaningful contributions to, a patient's health?

It's a great question mark, because anytime there's new technology, it has to be approved in many different ways efficacy, safety.

But the main thing is how can it affect the medical care that a patient gets.

And I think the biggest thing, and I'm a bit of a cynic, is we have to understand the accuracy of these devices.

because if you give me a bunch of data which these watches give, but the data is only 50% accurate, that might actually be more of a harm to the patient.

so to answer your question, how are we using it in the medical field?

Overall, I do think in the it would be naive for us as doctors to just ignore the data.

So we have to keep trying to embrace it and understand the limitations, but also understand the strengths.

For example, if you have a patient who has one of the most common heart rhythm disorders called atrial fibrillation.

If the patient sends you a mychart message, and is like, hey, on my watch, my heart rate is now jumped up to 100 and 40s when normally it's in the 70s.

While that could be artifactual or inaccurate in that patient, I might say, hey, my pretest probability is rather high.

Perhaps I bring this patient in and we get an understanding of are they in atrial fibrillation?

So I think in the right patient it can help.

In the general population.

We have to have a discerning eye because it can lead to more tests that are unnecessary if we act on faulty data.

I think you mentioned in the, in our discussion before the interview that, sometimes it can create a kind of false sense of, of, maybe panic in, in certain patients because of their heartbeat has spiked.

And normally that would be normal or it is normal for them.

But now that they can track it or see it, they think, oh my gosh, you know, something terrible is happening.

And then, you know, and then their lives are interrupted in a sense, because they've got to go to the hospital or whatever.

Right, and have it checked out.

and so I think what I'm hearing you say is that you basically come down the side of their valuable, but with, with a discerning I think this and I think that's what you said.

I think it's first of all, it's amazing technology.

What we've done in the last 30 years.

And from the MD side, the medicine.

The doctor said we also have to evolve with the technology.

the sooner we can get a good grasp of the technology, the better it is for the patients.

I think at least me growing up, we're always associating the things that you that physically touch you, like the, the blood pressure cuffs and the, you know, whatever.

They're they're touching you to get a reading.

And now, you know, there are sensors that can actually can read that.

And so to my mind, I think, well, how could something that's not touching me know anything of about me?

but, this kind of, this next generation of wearables is, is exactly in, in that space.

-It's wild, being the end user.

When you read about the technology, it's, it's amazing the bioengineers are doing a great job .

I want to move into, nanotechnology.

You could define maybe what that is.

I mean, I think of it as a bunch of little computers, but what is it?

How is it being used in in medicine now?

what's it's in our interaction with kind of wearables.

-So nanotechnology and medicine, first of all nanotechnology.

We can think of nano is, I believe it's one billionth, so nanometer, one billionth of a meter.

So basically really small.

We're on the scale of things we cannot see with the naked eye and the relationship to medicine.

It's now pervaded many different areas.

So in diagnostics, in therapeutics.

But I think the most common thing is outside of cardiology, some of our vaccines are used with nanotechnology.

And the for the listener, the way we can think about nanotechnology is in the past you would give a drug, say an antibiotic that affects the whole body.

what if I told you that if we could figure out for you, Mark, as a person, I can figure out your disease.

We figure out exactly the particle we need to target.

And instead of just giving the whole body exposure to this particle, we can use nanotechnology, which is basically engineering the delivery of the drug to only specifically target that area that we want.

So things where it's being used in medicine, most of it is investigational now.

but say, for example, you have a patient who comes in with, chest pain and we think of the worst thing is heart attack.

and if I told you that I could draw a blood test that using nanotechnology is so specific to sense any sort of damage to the heart that within an hour, we can rule you out of having a heart attack.

so we have very specific test markers now, called Troponin.

But even more down the pike is this nanotechnology where you can mark and label, hey, the muscle from the heart is being leaked into the blood.

Can we figure that out?

Yes or no?

If the answer is no, then you're not having a heart attack.

So that's an example of nanotechnology and diagnostics in therapeutics.

You may have heard.

So cardiovascular medicine really changed 20, 30 years ago with, statin therapy to lower lipids.

Now we are getting into the, the area of molecules affecting your DNA.

So can we in the patient who has high risk, high cholesterol, can we change the DNA just to touch, to tell the patient's body, hey, stop making these dangerous cholesterol particles.

And that could be a one time injection.

So that's all using nanotech analogy.

You will hear this in the next 2 to 5 years.

It's already in medicine.

It's already published.

it will become widespread very shortly.

But this is an area of nanotechnology that is honestly a bit challenging to understand, but it is the next sort of frontier.

If you're just joining us, welcome.

This is forum 360 and my name is Mark Welfley.

And I'm here with my guest, Dr. Ben Alencherry and Dr. Ben Alencherry is a cardiologist at the Cleveland Clinic.

And we are talking about wearable healthcare technology and currently nanotechnology.

So going back to nanotechnology for just a second.

So do these nanos.

Are they, injected into the blood and then pulled back out again for analysis?

Or is there like a computer or a sensor or something that can be put over the skin to figure out what these nanobots are saying or how are they read?

Yeah.

So it depends what you're looking for.

So in investigational studies now, there is, there are nanoparticles that are being used to label, for example, high risk plaques in your arteries.

And these specific labels can then be seen on imaging studies.

So for example in my area it's cardiac MRI.

So MRI of your heart you can label the patient's high risk plaques with these nanoparticles.

And then when you put them in the MRI scanner they light up.

So that's one example.

other examples include it's not about extracting it after you give them.

But like I said before about changing the the DNA.

are on a very genetic level that you can then track the production of lipids or cholesterol after.

And then you understand how the effect of the drug is.

Now I will say, like everything, we have to have an understanding of the side effects.

So anytime you put anything in the body, the body recognize it as, as a foreigner and there can be an immune reaction.

So that's why thankfully in the United States, we have very rigorous sort of testing.

And we understand these things before any sort of release.

but that's kind of how we monitor and different applications.

When you go into the literature, it is more than just the two that I suggested.

Nanotechnology is being used in a lot of different fields.

When I did some research on nanotechnology, the word vaccine keeps coming up that, the nano nanotech, the nanobots are being used, for vaccination.

Does that mean that those parts stay in the body for a longer period of time?

as a vaccine is typically, you know, something that you acquaint the body with it, then it can fight off that disease or whatever when it comes back.

So it's a it's a good question.

First of all, I'm not an immunologist.

from my understanding of it, the nanoparticles that we're using are specifically useful for targeting the immune system.

what I know of them is that we need to have a longer half life of these nanoparticles, meaning they can't just be put into the body and then then they degrade right away.

Because what we want with vaccines is we want the body to create an immune response.

to speak to that specifically, it would be on a specific vaccine basis.

But the real I think the promise in vaccines is for targeted therapy.

So while now in the US we're so concerned about the Covid vaccines, actually, I think the best utilization of nanotechnology is can we use vaccines to to treat some things that are more widespread.

So there's research going on about vaccines against malaria and rheumatic heart disease.

So strep infections in the more in the poorer portions of the world where the morbidity from those diseases is through the roof.

And if you could figure out a way to kind of curb the spread of that disease, the effect would be humongous.

so I'm hopeful.

I know we're very centered on Covid vaccine, etc., but this application can be done on a widespread level.

-It's interesting.

Thanks.

comment if you, if you can on technology in the battlefield.

What's being done there if anything?

So I think thankfully I think the at least the US military has has a good amount of censorship that I don't know, the cutting what we do know is, and it ties into a point that we should know, is the American public is when the military is using it, you know, that there's classification, etc.. but the point of your data being used publicly.

So I saw about the Strava app, which is an app that's used for runners Cyclers social media.

Basically, when you go on a run, you put it on and you can share with your network, but that data is actually publicly seen and the company owns it.

So the question then becomes, and I believe this was this happened with our military was if you're using that data in a in a camp, etc., that data can be seen.

so all I know now is that the military uses a ton of smart data, but with a lot of sort of, protections on that data.

And I think that relates to us now, specifically with the, the battlefield, the things that we know that are really cool is they have smart vests and smart helmets, for example, smart vests, since I'm involved in cardiology, is they have ECG sensors on those.

So when you go to the doctor and you get a 12 layer electrocardiogram to tell you a heart rhythm, they can extrapolate from your heart rhythm and how it relates to your stress level.

So when they're running, how high your heart rate goes and how easily it comes down, they can kind of figure out the exact sweet spot of where training the soldier too much, too little, and perhaps more personalized.

The preparation of soldiers.

We're already doing that in athletics.

so they're on the cutting edge of that.

and I think it's super interesting.

Let's look forward ten years.

Like where will the industry, the market, the technology be for wearable healthcare technology?

Like where are we headed?

More of the same.

Will there be some some dramatic breakthroughs?

What what do you see?

So I think there'll be more of the same.

It'll be a huge market share.

like, I have two young children.

I'm sure within the next few years, they'll be asking for theirs.

But what I really think is we still we are at the cutting edge of of pushing boundaries on what we can do remotely.

but I think that there will be, a push for health equity here.

I think that we will get a sense of how to do this and how to apply this technology to the people who are in the poorer areas of our cities in America, because as much as these technologies are great and we're understanding, we're getting cutting edge imaging technology, if you cannot apply it to the person living down the street, it becomes a challenge.

so I think that in the future, in the next ten years, we will see a drop in the price point of these.

We will hopefully have a better understanding of how we can apply the smart technology, and then we'll try to use it to to get a sense of how we can help health equity.

Because when it comes to health care expenditures, we are neglecting a certain population.

And those populations, the the amount that their costs on the health care society overall is, is a lot.

But if we can try to make health equity a bit more universal, then I think that's where in the next ten years we can make the biggest sort of improvement.

As a cardiologist, no pun intended, but shocked me with a statistic about the heart that, you know, that most people like me wouldn't know.

I think the biggest shocking thing that may open everyone's eyes is, though we are getting more advanced still, the number one cause worldwide of morbidity and mortality is high blood pressure and untreated high blood pressure.

So I think, though you watching the show and we can get really romanced into different technology, like shooting light sensors in your skin and understanding what your heart rate is.

The biggest thing is if you have the basic disease, high blood pressure, diabetes, it is control of those diseases and we have very good drugs for those now.

So while we have an eye to the future, we must understand like what we know now, which is a lot and treating high blood pressure.

I include diabetes in there.

But treating these bread and butter diseases can really reduce the morbidity and mortality of the population overall.

so you said we have a lot and I took that to mean a lot of data.

And that's my question is, so all this data is in databases and in and with doctors and with other medical professionals, should we as, as patients be concerned where our data is going?

Our data is getting there.

Who's looking at it?

privacy, HIPAA.

where does that comment on that intersection of HIPAA privacy, data privacy and data with wearables?

So I think with medically licensed wearables, like your doctor giving you a Holter monitor, the amount of securities those have to go under is, is a lot we can't access the data at home.

There's firewalls set up by our by our hospital systems.

I would say you asked me, should we be worried?

I would not say a word.

We should be wary.

you should always have an understanding of where your data is going.

For example, with my smartwatch, I have a ton of data there.

They know.

They know where I run, where I bike.

so I would always be wary and understand that, you know, anything that you're particularly sensitive about.

That's stuff you don't want to make public.

But this is the new age is understanding.

Where is my personal data going?

but I would I would put some puts people at ease from medically licensed, wearables, Holter monitors, etc.

those go under such rigorous testing by not only the FCC, but also the FDA that I feel very comfortable in that data sort of security.

Yeah.

As things go, that will be the next step is how do we make sure that everyone is secure?

want to talk about radio waves for a second?

Right.

we hear, that, you know, radio waves are bouncing off us all the time with cell phones and so forth.

and now we have devices that are on our wrist, around our neck, on our bodies, transmitting radio waves, essentially data, to a tower or whatever.

should be concerned about radio waves and, and their effect on us.

The more we have these devices near us.

So I think over the last 70 or 80 years, we've learned a lot about this and about the we called the stochastic and deterministic effects of radiation.

We'll put it that way.

in my line of work we use radiation a good amount in Cat scans.

And so we have some understanding of what this is.

And the amount of radiation that's emitted from a, from a small smartwatch is very low.

the relationship to how close it is to your skin, that matters.

But the overall amount to get to a threshold where it would cause something is very low.

Now where I find my guidances, CDC, the FDA has a good understanding of what these are and these are rigorously tested before a health care wearable enters the market in the United States.

And I can only speak to the United States.

So they do get a sense and they have these thresholds of these devices, because what they're wondering is the health health risk associated with it, but also the interaction, like we'll just trigger your washer to go off.

so I feel comfortable knowing that we have very sort of rigorous agencies in the United States that that really support getting an understanding of what device that enters the market, what its effect is.

By and large, when patients ask me this, I tell them that as of now, anything that is released in the United States has been sub that threshold to cause any sort of meaningful damage.

Now we're learning more about this stuff long term.

And I think on the bigger scale, things that matter more as when we get repeat Cat scans on patients, what is the what is the effect of radiation?

And that's something that's at the forefront of health care.

And we're really trying to minimize that, that sort of radiation dose.

So overall, I think to answer your question, I am thankful that here in the States, we have those agencies that are that are really involved in this, and I trust them, I trust them because of the work they do, the rigor that they do.

but there is some radiation that is involved with each of these technologies.

Anything that's Bluetooth has a small amount.

We hear the saying, what you wear says a lot about you.

And this is true.

And with the advancements in wearable health care technology, we might also add to that quote that what you wear can tell you a lot about yourself.

I would like to thank Dr. Ben Alencherry for being here today.

Encourage each of you to keep your eyes and mind open.

Until next time on Forum 360.

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