Dr Arbinder Singal employs digital therapeutics to achieve weight loss and diabetes remission. He started Fitterfly for personal reasons―he had lost two cousins to diabetes. In an exclusive interview with THE WEEK, he talks about his innovative technology that tackles diabetes. Excerpts:
In the last decade, there have been a lot of studies on diabetes reversal. How is Fitterfly contributing to that?
When somebody talked about diabetes reversal a few years ago, I used to laugh about it as a doctor. Because as medical professionals, we never believed that diabetes was a reversible condition. But when we started building the Fitterfly digital therapeutic programme, I was the first patient on it. I was pre-diabetic.
But as a doctor, I am a little wary of using the word reversal because it can mislead. And now a lot of companies, which are not run by medical professionals, are using the word reversal very casually to lure the patients. I am just worried about where we are headed in terms of clinical accuracy when we use the term ‘reversal’.
I think the most important thing to understand about diabetes remission is that it is a whole lot of effort. People get diabetes because of two reasons. One, it runs in families. Second, the environmental impact in terms of bad food choices, less exercise, stress and sleep issues. And most of the time people just focus on a low-calorie diet. But that by itself is inefficient, because people can do bouts of low-carb or keto or low-calorie diets for maybe two or three months, and get into a state of diabetes remission. But eventually, if they cannot sustain it lifelong, it is going to come back. So from that perspective, our research over the last three years has shown that if you just give a diet plan, that is often not sufficient for long-term results. So, we decided to tackle this in a very different way.
At Fitterfly, our first step is to assess the patient’s nutrition―from which a diet plan is derived―and mental health. We assess how open they are to a behavioural change and what the stress assessments are showing. There is a qualified, 20-member psychologist team, which does a psychographic profiling of the patient in terms of adaptability to behaviour change.
If the stress is high, the blood sugars go high. If you don't sleep well for a day, your blood sugar is up by 2-5 per cent the next morning. If you don't sleep well for a month, your blood sugars go up by 10 per cent.
The third thing to assess is the fitness profile. We found that 40 per cent of people with diabetes have knee pain, back pain and shoulder pain. They have poor muscle maintenance and poor flexibility…. And then we work on improving their fitness and decreasing their pain so that they can get moving and do exercises.
Once you address their nutrition, stress and sleep, their behaviour change along with their fitness, then the results are much more sustainable. And they may not even need to do very strict dieting. We are very much against keto diet plans and low-carb meals, because they are not sustainable. Indian people love to eat rice and chapati. They can decrease it. And we found that achieving the right balance is sustainable in the long run. Even reducing carbohydrates by 15-20 per cent, coupling it with a good exercise regime, management of stress and sleep, and using technology to understand the progress is the key to achieving diabetes remission. That is the therapy itself, which is a minimum of three to six months of therapy, ideally 12 months.
Could you explain how you are using technology to assess the progress?
Giving someone a general diet plan doesn't always work. But if I can show you the data of how your meals work, and what happens in your body after each meal, then you will be able to make the choices yourself. So, we developed a technology called PGR―personalised glycaemic response. We believe that every person has a different response to blood sugar with the same food.
We made India's largest food database. So, our food database has 37,000 Indian food items. It is used by different firms to understand nutrition at a very deep level. Then we did experiments on a lot of people to find out what happens in their bodies when they eat certain food. And we found that within the same house where people eat the same food, blood sugars are rising at different levels. This means if everybody's body is very different and their blood sugar response is very different, they should get a very personalised diet plan using technology.
My blood sugars rise with wheat, but my wife's blood sugars do not rise with wheat so much. Her’s rise with rice. And now we have so many patients whose blood sugars rise with millet. We have two patients whose blood sugars are rising with ragi. Somebody's is rising with jowar. We have these case studies on record. So, our idea is that there is no single diet that fits all. It's how our genes are. And if we can use technology to understand what are the real culprits for your blood sugar rising, and ask you to reduce the quantities of only those without giving you a generalised diet, it works well. And one can track this on our app.
The continuous glucose monitor (CGM) sensor will give a real-time reading on my mobile phone. And on mobile, people can either click a picture of or type in what they are eating. We have a system that calculates the calories, carbohydrates, protein, fats and fibres and their relationship to blood sugars. And then our application will calculate what was healthy and what was not. And once you are showing this data to the patient, they automatically understand before eating what is going to happen. Then they make better choices.
How does this sensor work?
The sensor has a microneedle in it, which goes below the skin. You can wear it for 14 days. And then there is an enzyme called glucose peroxidase within the needle, which interacts with the fluid under the skin every 15 minutes. And then it sends out a signal, which is translated and goes into an algorithm, which is then reflected on the app as the blood sugar value.
What was the motivation behind this startup?
I lost two of my first cousins to diabetes. My dad has had diabetes for 35 years. He had a heart attack. He struggled with it. So, when I was diagnosed with pre-diabetes, my blood sugars were going up and down, and a couple of times I fainted in the gym because of the fluctuation of blood sugars. At that time, I decided that I am not going to get diabetes. I got together with all of my friends, and we started building technologies where I could understand my own health. And when I saw the improvement in my own health; my friends, who were doctors, told me they would send some of their patients who needed more support than just tablets. That's how our journey started.