Five years ago this month, Scripps Health's Chief Academic Officer Dr. Eric Topol began a speaking tour about the potential of digital health at a mobile industry event in Las Vegas. One of his presentation's key slides, which would become a fixture of his talks for the next two years, listed the top ten opportunities for digital health. In April 2009 MobiHealthNews called these Topol's Top Ten Targets for Wireless Medicine. They included: Alzheimer's, asthma, breast cancer, COPD, depression, diabetes, heart failure, hypertension, obesity, and sleep disorders.

In an effort to reflect a bit on progress made since Topol first took framed the digital health discussion, MobiHealthNews caught up with Dr. Topol to discuss how he might rework that list if he had a chance to do so today and how well he thought the list stood the test of time. The MobiHealthNews team also reviewed our archives from the intervening years and put together a high level review featuring a sample of digital health activity relevant to each of Topol's ten targets.

"The idea back then was what if we could have sensors and digital technology take fresh, novel approaches to these very important chronic conditions that affected tens of millions of Americans -- the only ones that weren't, like heart failure, Alzheimer's, and breast cancer, obviously are very important and also growing," Topol told MobiHealthNews in a recent interview. "What's happened in the five years since is that every one of those has had significant efforts to apply digital technologies and mobile devices to them."

Topol says that in hindsight he underestimated digital health's immediate opportunities. 

"In fact, I had underestimated the field. While in some ways we haven't gotten a final solution for any of them, so much has been done for each -- most of which I had not envisioned at the time," Topol said. "Plus the field has blossomed well beyond the sensor side of it. Back then, I was mainly thinking about sensors, but it's really exploded in other ways too."

While each of the targets he pointed digital health entrepreneurs toward in 2009 have received considerable attention, Topol says that digital health hasn't yet gone too far beyond point solutions.

"The problem still today, I would say, is integrating the information from multiple data sources -- that's a major issue still," he said. "That is, if you just take an example like depression and have a sensor that captures data that includes tone of voice, inflection, ... blood pressure, heart rate, along with galvanic skin response, heart rate variability, movement, activity, posture, and breathing -- if you had all of those and could process it all, you could come up with incredible quantitative tracking for state of mind and depression. You could do that. But none of them have yet folded them all together. What we have now is a lot of siloed activity."

Topol said that's true for many of the digital health offerings targeting asthma today too.

"We have sensors that can pick up air quality, pollen count, oxygen saturation, microphones that can sense lung functions, even sensors for inhaled [nitrous oxide] and breath analyzers that detect would-be constituents for precipitators of an asthma attack. But we don't have that all folded together yet into a single functional system with the predictive analytics and learning we'd like to see. We are mainly missing the data platforms and data processing downstream."

In addition to pulling the data streams together and developing better analytics, Topol said that digital health still needs to make much more progress in validation, regulation approvals, and reimbursement policies.

Topol said that he really missed the mark in his heart failure prediction by leaving out arrhythmia monitoring, which ended up being one of the first digital health products to find its ways into consumers' hands thanks to AliveCor. He also admitted that he never would have predicted a digital health company developing a smart bra that could help predict breast cancer, but he did see a big opportunity for handheld ultrasound devices that at-risk women could use at home. Finally, Topol said he didn't appreciate how powerful the smartphone would become as a hub for conducting lab tests, for example, or for various imaging devices used in annual physical exams.

"The other thing that I didn't envision back then, that has really exploded since, is the other dimensions of the smartphone hub. For example, to do lab tests. That's going to be -- over the next five years -- remarkable, in terms of being able to do almost any lab test. All the routine labs could be run through the smartphone with a very simple microfluidic adapter -- any lab test could. Then there's all the ways you can do a physical exam through a smartphone now via mostly medical imaging, whether it is ears, eyes, you name it --  all through a smartphone."

Topol believes that one of the most important factors that will drive digital health forward in the next fives years will be recruiting data scientists into the field.

"I'm starting to get convinced that we need to find a way to attract data scientists to digital health," he said. "Too many of them are working at places like Twitter and Facebook and we need them here in healthcare and medicine." 

Alzheimer's

CNN reported, in 2009, that the number of people with dementia globally is estimated to nearly double every 20 years. At the time, MobiHealthNews posted a roundup of three companies with products available for people with Alzheimer's, a common form of dementia.

The list included Omnilink’s wireless tracking service for Alzheimer’s patients, which ran on a Qualcomm-powered handset, LoJack's tracking system aimed at Alzheimer’s patients who may wander off and have trouble finding their way back home again, and Healthsense’s eNeighbor remote monitoring system aims to help those taking care of friends and family with Alzheimer’s disease or dementia. All three companies still exist, but since 2009, many others have surfaced as well.

Another GPS-based tool to help people with Alzheimer's came in the form of a shoe from personal location services device manufacturer GTX. In 2011, the company launched the shoe, which was developed specifically for the purpose of tracking seniors with Alzheimer's, and it retailed for $299. The GPS-enabled shoe received FCC clearance in September 2011 and was powered by GTX’s partners Omnilink and the MedicAlert Foundation.

While these products offer patients a way to manage Alzheimer's, in recent years, other technologies have arisen that aim to sharpen an older person's brain who is at risk for the disease.

In August 2013, the CJE Senior Life (formerly Council for Jewish Elderly) and The Art Institute of Chicago launched an iPad app funded by Alzheimer’s Foundation of America, called Art in the Moment. The app is designed to encourage conversation and engagement in older adults with cognitive disabilities. Art in the Moment shows adults a series of well-known pieces of art arranged by themes, such as “Celebrations,” and then leads a discussion about the art pieces, in this case how different celebrations are depicted in art. Following this activity, the app offers caregivers and friends the opportunity to collaborate with the user on an art-making activity.

While the app was launched in the last year, the science behind the app is based on NYU Center of Excellence for Brain Aging and Dementia's evidence-based efficacy evaluation of MoMA’s educational program for adults with dementia, Meet Me at MoMA, which was published in 2008.

An even more recent initiative was developed in the form of a video game, and is meant to help researchers detect indications of Alzheimer’s in healthy individuals. The research team, called Akili Interactive Labs, partnered with Pfizer in January 2014 to conduct a study of Akili’s iOS-based game, Project Evo. To play the game, a user navigates an alien (chosen specifically because it is culture neutral but also relatable) down a course by tilting a smartphone or tablet back and forth. While navigating the alien, the user must also respond to targets by tapping the screen. Because it is high resolution, the app keeps track of movements every 30 milliseconds and can therefore monitor the user’s behavior and quickly adapt to the player.

Akili sees the Pfizer trial as a potential test run for eventually deploying the app as a tool to find early cases of Alzheimer’s.

Asthma

In 2009 Topol noted that asthma affected 20 million Americans. He also suggested that wireless can track the respiratory rate and peak flow so patients can use inhalers before an attack occurs.

In the last five years, plenty of digital health technologies have focused on asthma, in a much broader range of use cases than Topol's original prediction. There is at least one wireless enabled peak flow meter, but it's taken us nearly all that time to get there. MySpiroo debuted at a Polish startup festival a few weeks ago and is set to launch some time this year. The tiny meter connects to the smartphone via the headphone jack and collects GPS data as well as peak flow data. Creators Dr. Lukasz Koltowski and Peter Bajtala plan to create a home version and one for doctors.

There are other sensors besides peak flow monitors asthma sufferers can use to track their attacks. iSonea's Wheezometer is placed against the user's windpipe during breathing. The device has launched in Australia but is still awaiting FDA clearance for a US launch. AT&T also debuted its own connected asthma sensor, an air quality sensor called Asthma Triggers that measures for volatile organic compounds (VOCs)—a class of chemicals that asthmatics are particularly sensitive to—in the air. Even Ford has looked to asthma as one of the first mobile health use cases to incorporate into vehicles.

Most mobile health for asthma, however, has been more focused on sensors connected to smart inhalers. The most high profile company in this space is Propeller Health, formerly known as Asthmapolis, manufactures a sensor that affixes to a rescue inhaler and also includes GPS. Users can collect data on how, when, and where they need to use their inhaler and report that back to their physician -- together the patient and physician develop a better understanding of the patient's triggers. 

Propeller Health's technology has been adopted by a number of providers since its 2010 launch, including Dignity Health in California, Amerigroup in Florida, and the City of Louisville. More recently, the platform has shown up at the Sharp Rees-Stealy Medical Centers in San Diego and as part of a trial with Qualcomm and Zephyr at Rady Children’s Hospital.

Breast Cancer

Five years ago Topol said breast cancer affected 3 million Americans. He predicted that women would soon be able to use a wireless ultrasound device at home and send the scan to the doctor – without having to go in for a mammogram.

The at-home ultrasound has not really emerged yet -- due in part, perhaps, to the difficulty in getting over-the-counter clearance for such a thing from the FDA. There are several portable ultrasounds cleared by the FDA for use by physicians in rural clinics and house calls: GE's V-Scan, Mobisante's MobiUS TC1, and Teratech's Terason uSmart 3200T are three examples.

But in the world of breast cancer, a few other mobile health technologies have emerged. Because breast cancer, like most cancers, is most treatable when caught early, the two most prominent mobile technologies to emerge in this space have both focused on early detection. These technologies could replace the monthly breast self-exam, which research shows most women don't take and can easily miss small tumors even if they do.

Eclipse, a sensor device that tried to crowdfund last fall, is a handheld imaging device paired with imaging software that tracks changes in breast density over time, and also incorporates an element of social networking. Eclipse says the device, which uses what the company calls “transphotonic” technology – combining low-energy photons and light sensors, without the need for radiation – is as much as five times as sensitive as the human hand.

Meanwhile, First Warning Systems in Reno, Nevada is developing a bra-insert sensor to screen for breast cancer. The sensor, meant to be worn for 24-48 hours, finds cancer by detecting tiny metabolic temperature changes caused by cancerous cells in a tumor. The temperature readings are sent back to a global library where they’re run through a proprietary algorithm. Then the results are sent back to a user’s phone. In several smaller trials, the device has had a 74 percent correlation with mammography and may work better than a mammogram in patients in the early stages of cancer (when it is often undetected) or with dense breast tissue, a condition that affects over half of women.

Both Eclipse and First Warning are still pending FDA clearance. The other side of mobile health for supporting cancer patients, including breast cancer patients, is the rise of patient social networks and support communities, like PatientsLikeMe. The Henry Ford Center for Cancer Surgery launched an app last fall to answer questions cancer patients might have, and at the beginning of the year Akron Children's Hospital launched an app for survivors of childhood cancer. 

Chronic Obstructive Pulmonary Disorder (COPD)

Back in 2009 this affected 10 million Americans. Topol pointed to a few opportunities for COPD back then: Sensors could monitor FEV1, air quality and oximetry.

Chronic Obstructive Pulmonary Disorder, or COPD, is a is a chronic lung condition which manifests itself in occasional attacks of extreme shortness of breath, called exacerbations, which usually lead to a patient being hospitalized, as well as losing an average of three years of life expectancy per attack. But those attacks can be detected up to seven days beforehand and prevented with early treatment. The disease is likely up for more attention from the market in the coming years, since readmissions related to COPD will soon be added to the list of specific conditions for which the ACA will penalize hospitals.

Last year, AliveCor founder and CMO Dr. Dave Albert called out COPD as an area where doctors were overworked and could use the help of digital health. "We don’t have enough doctors, we don’t have enough nurses, to treat all of these cases of COPD,” Albert told MobiHealthNews last year.

Propeller Health partly changed its name from Asthmapolis to emphasize the company's intention to go beyond asthma -- into, initially, COPD. CEO David Van Sickle told MobiHealthNews the approach to COPD is less about geographic mapping than asthma, because environment is less of a factor in COPD exacerbations than in asthma attacks. Instead, the focus will be on adherence and early warning. Many other asthma startups could find themselves expanding into COPD as they become established.

In March 2013, AstraZeneca teamed up with mobile clinical trial company Exco InTouch to launch a telemedicine pilot for COPD patients in the UK. The pilot involved providing patients with an interactive app, through which Exco InTouch, AstraZeneca, and care providers could send patients educational materials and patients could track symptoms and treatments by filling out surveys. Patients could also use a BlueTooth-enabled inhaler, offered by AstraZeneca, to automatically report data. Exco would then send tailored text messages to support patients in the study.

A few months later, Futura mHealth teamed up with Temple University spinoff HGE Healthcare Solutions to build a smartphone app, called SmartScope, for monitoring COPD. SmartScope is an HTML5 app that has COPD patients fill out an eight-question survey once a day and sends that information back to their provider, who then assesses their likelihood of an attack based on their answers. Certain questions require the patient to use devices like a peak-flow meter or a thermometer. Bluetooth-enabled devices can take those measurements and put them in the app, but the devices are too expensive for most patients, so most use non-connected devices instead and enter data manually.

Depression

Topol estimated that 19 million Americans were affected by depression in 2009, and he suggested that digital health tools could monitor medication compliance, activity and communication to help identify signs of depression earlier for intervention.

One of the more promising companies working on depression is Ginger.io, which recently began offering a program called Mood Matters to anyone who is experiencing signs of depression. Ginger.io’s app passively monitors how a person is using their phone as well as other activities to help determine triggers for depression during their days.

Last year Oregon-based ORCAS launched an app called MoodHacker, a clinically tested app marketed to employers to offer to employees to help them self-manage bouts of depression. Users can track their mood on the app along with other factors like food and activity, to educate themselves about what things correlate to different moods. The app responds to the data with analysis and videos about depression. The app also connects to Fitbit devices to automatically report activity data to a dashboard.

A company called LinkedWellness is working with a New Zealand university to commercialize an immersive video game, called Sparx, that aims to help players rid him or herself of negative thoughts and aim to reach ‘hope’:

“Games like this involve self efficacy,” the company’s founder David Burt said. “The player develops his or her avatar and walks through the fantasy world shooting down negative, automatic thoughts which can cause and perpetuate depression [while] developing skills — skills that are sustainable. This is not taking a pill and waiting for something to happen to your brain.”

Gaming is popular among digital health companies with an eye on depression. Jane McGonical’s SuperBetter also addresses depression (among other conditions) via gamification and a racing game studied at the UCSF seemed to help seniors with depression and other issues.

A couple of insurance company-affiliated investors believe that AbilTo is one of the more promising digital health companies working on depression today. The startup recently received $6 million in a second round of funding led by BlueCross BlueShield Venture Partners and Sandbox Industries. AbilTo is focused on identifying and remotely treating mental health comorbidities that can negatively affect recovery from medical conditions or events such as cardiac events, diabetes, or breast cancer. The company works with health plans and employers, including Aetna and Costco, to identify the individuals in an employee population that are at the highest risk for these complications and are the most likely to be helped by treatment. Then those patients are invited to an eight-week video messaging program with a therapist and health coach. 

Diabetes

In 2009 this affected 21 million Americans. Topol suggested that sensors could could monitor blood glucose and hemoglobin.

Diabetes management has been, and continues to be, a key focus for mobile health for a number of reasons. It affects a huge number of people, and it requires diligent self-management to avoid hypoglycemis or hyperglycemic events. At this point, there are a number of smartphone-connected glucometers that allow people with diabetes to check their blood glucose levels, track and monitor them over time, and in some cases automatically alert family, physicians, or caregivers about a low reading. Smartphone-connected glucometers include Sanofi's IGBStar (developed with Agamatrix), LifeScan (a Johnson and Johnson subsidiary)'s OneTouch, the TelCare BGM, LabStyle Innovations' Dario, and a device from iHealth Labs, a subsidiary of China's Andon Health.

Another company, Glooko, is taking a different route, marketing a cable and app that turns many of the digital glucometers already on the market into smartphone-connected glucometers. Glooko has recently partnered with the Joslin Diabetes Center and with Samsung to be integrated into future generations of S Health. The company is also working on a wireless version of its offering.

But the potential for glucose monitoring is just the tip of the iceberg when it comes to diabetes management, which can also involve coaching and behavior change. One of the biggest names in that space is WellDoc. WellDoc’s flagship offering is BlueStar, an FDA-cleared mobile application and program for people with Type II diabetes that is prescribed by physicians and adjudicated through pharmacies just like pharmaceutical therapies. The program is supported by WellDoc’s Automated Expert Analytics System, which includes real-time motivational messages, behavioral coaching and educational content, delivered right to the patient’s mobile device. The program also provides patient’s physician with clinical decision support tools based on how they’re doing.

Other diabetes management efforts include a recently added diabetes-specific program from Weight Watchers, text message initiatives from Agile Health and Voxiva, and diabetes management app mySugr over in Europe. One high profile app, Glucose Buddy, was acquired by Azumio and incorporated into their suite of health and wellness apps. Cellnovo takes diabetes management one step further, incorporating an insulin pump into the system. Sanofi has released a popular app, GoMeals, which is a cooking app aimed at people with diabetes.

Omada Health, a Rock Health company, has a offers an online, mobile implementation of a 2002 NIH Diabetes Prevention Program (DPP) intervention that produced significant results for prediabetics. The landmark study found that the lifestyle intervention group, who participated in a 16-week course of intensive training in diet, physical activity, and behavior modification, reduced their risk of diabetes by 58 percent compared to the control group. A third subject group, taking weight loss drug metaformin, reduced their risk by 31 percent.

Like asthma, diabetes affects a significant number of children, and there are plenty of mobile health apps focused on helping kids manage their blood glucose as well. DiaPETic is a virtual pet game for teen girls to help them manage diabetes. Monster Mansion, from Ayogo, is for kids in school, and the company also makes Diabesties, a social app for college kids to remind each other to check their blood sugar. The Diabetes Hands Foundation also launched a mobile game, called HealthSeeker.

Many people in the diabetes space agree that the future of mobile health for diabetes will lie, to some degree, in continuous glucose monitoring. CGMs are already for sale, but largely not yet mobile connected, and not cheap or practical enough for widespread adoption. Google recently drew attention to this space with an announcement about glucose-sensing contact lenses, though it was met with widespread skepticism from within the industry. 

Heart Failure

Topol noted that heart failure affected 5 million Americans in 2009. He suggested at the time that wireless sensors could monitor cardiac pressures, fluids, weight and blood pressure.

Digital health tools and services for heart patients have had five productive years since Topol’s keynote. As Topol noted above, when he outlined opportunities for digital health to address heart failure in 2009, he missed a big one – heart arrhythmia monitoring has turned out to be a breakout digital health category.

San Francisco-based AliveCor is the first to offer up a smartphone-connected device with FDA clearance for over-the-counter use by patients to record their own electrocardiograms by placing their fingers on the device’s sensors. The device’s companion app can then transmit the recordings to various remote health practitioners for analysis or a user can share it with their own physician. Consumer pay $199 for the device then a nominal fee for each remote analysis conducted. AliveCor’s Heart Monitor device was first made available to physicians and other medical professionals, who could use them with their patients during exams or prescribe them to patients to take home.

iHealth Lab, Mega Electronics, and Cardiac Designs are a few examples of other companies that have developed smartphone-enabled ECG sensing devices that are in various stages of commercialization.

While most heart failure offerings include some kind of peripheral sensor device, Azumio is an example of one high-profile company that has created a heart rate sensing app by leveraging a smartphone’s camera sensor – no additional hardware required. Azumio’s popular Instant Heart Rate app also just appeared in one of Apple’s most recent television commercials. Its also being used for a massive study at UCSF called Health eHeart along with other well-known heart focused companies like AliveCor and iHealth.

Another major study focused on connected heart devices was published at the end of 2010. This one, led by The University of Southern California’s Chief of Cardiology and Executive Director of USC’s Center for Body Computing Dr. Leslie Saxon found that patients with wireless-enabled implanted cardiac devices had half the mortality rate of those who did not have connected devices. The landmark study followed more than 100,000 patients across the US who had cardiac resynchronization therapy (CRT) devices and implantable cardioverter-defibrillator (ICD) devices. The study examined survival rates among those patients with wireless-enabled devices and those with no wireless-enabled tracking.

Another smaller but more recent study showed how powerful mobile health apps could be for cardiac patients. The Mayo Clinic found that incorporating a smartphone app into cardiac rehabilitation can reduce emergency room visits and hospital readmissions by 40 percent. The study’s lead research concluded that these kinds of tools can help prevent cardiovascular disease in high risk groups.

In the study, which was funded by the BIRD Foundation and recently presented at the American College of Cardiology’s 63rd Annual Scientific Session in Washington, D.C., the Mayo Clinic designed an online and smartphone-based program for patients recovering from stent placement for a heart attack. Forty-four patients participated in the study — 25 used the application and a control group of 19 had regular cardiac rehabilitation without the app.

Patients used the app for three months, and it had two functions: tracking patient vital signs and providing educational content. For the former, patients tracked weight, blood pressure, blood sugar, physical activity and dietary levels. The educational content was aimed at showing patients things they could do to help them avoid a secondary heart event, such as eating more fish or adding exercise into their daily routine.

Other companies working to replace traditional Holter monitors with wearable devices that aim to go wherever the patient goes have also found some success in the past few years. Longtime wireless health company Cardionet – now called BioTelemetry – has started adding companion smartphone apps to its offering. Corventis, which originally focused on heart fluid monitoring, slightly pivoted to focus more on arrhythmia monitoring via its peel-and-stick sensors. The Mayo Clinic teamed up with Preventice to create yet another wearable patch sensor for heart monitoring, called BodyGuardian, which commercially launched in 2013. 

Hypertension

Companies have been developing wireless blood pressure monitoring devices for many years -- even before 2009. Some of the earliest companies in the space include A&D Medical, which has launched a number of Bluetooth-connected devices and blood pressure monitors over the years. Another pioneering company, MedApps, offered a FDA 510(k) cleared platform for managing various chronic conditions -- including hypertension. MedApps was later acquired by Alere and then rebranded as Alere Connect.

More direct-to-consumer, smartphone-enabled blood pressure monitoring devices began to enter the market in the years following Topol's 2009 speaking tour. Two big names in digital health emerged, in particular. Within six months of each other, in the first half of 2011, iHealth and Withings received FDA 510(k) clearance for their connected blood pressure cuffs. What was different about these devices, which have similar form factors to each other, is the companies also focused on the design of their products. In a Withings press release, the company wrote that its product offers a "modern way to measure and record blood pressure readings in the personal and professional arenas" because the company "combined advanced technology and sophisticated design to create a medical device that is visually attractive".

Another device called  QardioArm is working on developing a wireless blood pressure monitor that fits into a small colorful case that looks like it could carry a smartphone, notebook, or even a wallet.

Of course, while these devices were getting attention from hospitals and consumers who are accustomed to mobile technology, one startup wanted to bring wireless blood pressure devices to users who might not own a smartphone. At the end of 2012, Blip Care, the consumer-facing side of wireless monitoring company Carematix, launched two products on Indiegogo: a wireless weight scale and an FDA-cleared wireless blood pressure monitor. Both work over a WiFi connection instead of only Bluetooth and both are designed to natively track health data for two people in a household and send it to a family member or designated caregiver.

Interestingly, even though a plethora of companies have tried different approaches to wirelessly monitoring blood pressure, not as many have tackled continuous blood pressure monitoring, which is what Topol identified as a growth area on his list. Sotera Wireless (formerly Triage Wireless) had been talking about developing technology that does just that since 2009, but didn't get the system cleared with the FDA until October 2013. Sotera’s main product, called ViSi Mobile, monitors blood pressure, heart rate or pulse rate, electrocardiogram (ECG) or heart rhythm, blood oxygenation level, respiration rate and skin temperature from a wearable sensor system with a wristworn screen. The system is meant to cut down on the number of wires connected to a patient in a hospital bed. The product is also intended to help clinicians keep track of patients in the hospital or while patients are in transit.

Obesity

In 2009, when Topol outlined his list of targets, obesity was affecting the largest number of people on the list -- 80 million. Since then, obesity has grown to affect even more people. Topol pointed to wireless scales that can track weights and wireless sensors that can track calories and activity levels as two tools that could help overweight people lose weight and get healthier. Since then, another category for wireless tools has become popular as well, nutrition and fitness apps. Although these tools, especially the free apps, are very accessible, few of them specifically say they aim to take on the obesity problem.

Still, a recent study came out from The Vitality Group that found overweight or obese people in the incentive-based digital wellness program studied were likely to use an activity tracker, heart rate monitor, and smartphone to track their health. That population made up 67 percent of activity tracker users, 62 percent of heart rate monitor users, and 63 percent of smartphone users, although the study didn’t specify what percentage of users of the program overall were overweight or obese.

Two of the largest categories that digital health tools tackle for fixing America's obesity epidemic is adult obesity, which healthcare companies often link with type 2 diabetes, and childhood obesity.

For adult obesity, tools like Weight Watchers aim to help users track nutrition and eat healthier. Other apps, like Quantia's fitness coaching app DailyCoach focus on intensive blood glucose control and lifestyle intervention for diabetics. Daily Coach is intended specifically for those with diabetes (or at risk) and patients with cardiovascular conditions or obesity issues. It was designed based on input from a 1,000-patient study done from members on QuantiaCare, in which half of the respondents felt that exercise and weight loss were the most difficult issues in managing diabetes.

A new trend of passive tracking apps may not point to obesity as the problem they are trying to solve, but the nature of the apps, which are much less intensive than others in their category, also suggest that they are meant for those who want to transition from sedentary behavior to a more active lifestyle. Apps, such as Moves and Noom passively track activity using an accelerometer on the user's smartphone and show a history of the user's activity over time.

Another company, wellness app maker Six to Start received funding from the UK’s Department of Health and NHS in the fall of 2013 to launch its app, called the Walk. Unlike Six to Start's other app, Zombies, Run!, which is meant to encourage users to run often, the Walk was designed for people of all fitness levels. The game includes 65 episodes and 800 minutes of audio story and the difficulty of the game is adaptable and adjusts itself based on a learning algorithm. 

For children with obesity, there has been a push recently to bring health tools to gaming so that children are excited to be active and eat healthily. Zamzee, Sqord and GeoPalz are three companies trying to encourage children to stay active. In Zamzee’s system, kids wear a Zamzee Activity Monitor, a plastic tracker with a customizable skin. The device tracks their movement, not just steps, but intensity of activity, whether or not it fits into the “moderate or vigorous” categories considered to be most beneficial to kids.

Another system, GeoPalz, provides a pedometer, worn on the hip or shoe and shaped like, for instance, a lady bug or a soccer ball, and a web and mobile portal. With GeoPalz, kids read their steps taken off a screen on the pedometer and manually enter that number into a website, which converts the steps into points they can use to buy goods selected and priced by their parents. The third company, Sqord, offers a wristworn tracker which syncs wirelessly, and the company is focused on the social aspect at the classroom or neighborhood level. Competition is the main motivator in Sqord’s platform, rather than rewards.

A recent study from the Journal of the American Medical Association (JAMA) Pediatrics lends even more weight to the theory that gaming techniques could be a good way to encourage children to stay active. The study found overweight and obese children lost weight and demonstrated a significant increase in physical activity after using a 16-week weight management program that incorporates active video gaming.

Sleep disorders 

Topol said this affected 15 million Americans back in 2009. He said at the time that sensors could monitor each of the phases of sleep for quality of rest, detect apnea and track vital signs.

It's been something of a rocky road for the sleep health market in digital health, since it was the source of what we consider to be the space's first big flop:  Zeo, the consumer sleep tracking company that went out of business a year ago. But in recent years it's rallied and become a major area of innovation.

MobiHealthNews has written a small handful of technologies aimed specifically at clinical sleep disorders. One is NovaSom, a cellular-enabled sleep test that launched in January 2012, after raising $35 million in the fall of 2011. Another, way back in 2009, was a clinical sleep sensor from CardioNet called SomNet, which had the potential to identify patients with a high likelihood of sleep disorders by measuring cyclic variation of heart rate (CVHR), a rhythm that is caused by repeated arousals from sleep because of the disorders. The offering doesn't appear to be available any longer. Competitor LifeWatch's smartphone-based home sleep testing offering NiteWatch, on the other hand, appears to be alive and well.

But most of the digital sleep market we’ve covered looks more like Zeo. Most of these are over the counter, app-enabled devices not meant specifically for sleep disorder diagnosis, but for more general sleep health monitoring.

Since Zeo shut down, new contenders in the sleep tracking space have emerged. Beddit, a company tracking sleep with sensors that strap to the user’s bed, had a successful Indiegogo campaign and began selling its product in December. Another company, IntelliClinic, raised $400,000 for a smart sleep mask called NeuroOn, meant to measure and improve the user’s sleep. In January, SleepRate launched an app-based sleep system using cognitive behavioral strategies licensed from Stanford University’s School of Medicine, Psychiatry, and Behavioral Sciences. Finally, sleep tracker maker Bam Labs teamed up with smart bed maker Sleep Number to create an $8,000 bed with a tablet interface.

Activity tracker companies, too have been earnestly getting into the sleep game, starting with Lark, a tracker that was competing in the sleep space back while Zeo was around. Fitbit, Jawbone, and Basis have all touted their sleep-tracking features. In fact, shortly before it was acquired by Intel, Basis added a new advanced sleep analysis feature for its wristworn, multisensor health tracker: “With advanced sleep analysis we are able to do REM sleep, which nobody else can do, and which is what your mind needs to consolidate memories,” a company spokesperson told MobiHealthNews. “[We can do] deep sleep, which your body needs to recover. As well as things like toss and turn, sleep score, interruptions, benchmarking against where you have been and where you are headed.”

And at CES this year, Withings announced a whole new multi-device system, called Aura, for tracking sleep and facilitating sleep behavior change. Aura is offering a different approach than what most sleep tracking systems offer – it has no wearable component. Instead, the system consists of a sensor placed in the user’s bed and a bedside device that serves as both lamp and alarm clock. The system is controlled via a smartphone app.