This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.
Over the past year at Covenant HealthCare in Saginaw, employees living with Type 2 diabetes have participated in a pilot program that develops personalized diets for them based on the unique population of microbes found in their digestive systems.
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Erik Fielbrandt.The project, labeled "Precision Nutrition" and developed by San Francisco-based company DayTwo, uses artificial intelligence (AI), genomic analysis, registered dietitians, a personalized nutrition app, and patients' health care providers to precisely develop diets that control patients' individual blood sugar levels.
"We have 5,000 employees and a high number of employees with Type 2 diabetes. We had diabetes education and some other programs that were not being utilized, so we thought this would be a great option," says Erik Fielbrandt, Covenant HealthCare human resources manager.
The Precision Nutrition pilot started in March 2020. The 18 Covenant HealthCare employees who participated reported having more energy, fewer sleep problems, less hunger, and – in spite of being in the midst of a pandemic – felt less stressed. Their A1C tests (which measure average blood sugar) dropped by an average of 1.6 points and they lost an average of 18 pounds over the course of the pilot.
"Employees who participated have been commenting on how easy the process was, that it didn't feel like extra work," Fielbrandt says.
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Dr. Catherine Baase.The results have Fielbrandt planning on expanding the program to employees diagnosed with both Type 2 diabetes and prediabetes. Covenant HealthCare came to host one of the first two Precision Nutrition pilots in the country through its connection to the Michigan Health Improvement Alliance (MiHIA) and its work with the Transforming Health Regionally in a Vibrant Economy (THRIVE) initiative. The THRIVE initiative is a portfolio of interventions implemented with the Great Lakes Bay Regional Alliance and a variety of community partners in the broader Great Lakes Bay region.
"Our food emphasis is an exciting space," says Dr. Catherine Baase, MiHIA board chair. "This is not the normal practice of how disease is managed in this community or other communities around the country. We are seeking transformative change."
DayTwo developed Precision Nutrition for Metabolic Disease with research partners at the Mayo Clinic, Weizmann Institute of Science, Joslin Diabetes Center, Tufts University, University of California San Francisco, The Microbiome Center, and Janssen Pharmaceutical company. Using an at-home collection kit, patients mail a stool sample to DayTwo's lab in Huntsville, Ala. DayTwo's clinicians analyze the samples to determine each patient's specific gut microbiomes.
The human digestive tract is up to 30 feet long in adults, stretching from the mouth, esophagus, and the stomach down into the small intestine and large intestine. While saliva and stomach acid help break down food initially, digestive organs — liver, pancreas, and gallbladder — add secretions to further aid the process. However, more help is needed to complete healthy digestion. This is where the gut microbiome comes in.
Trillions of bacteria, fungi, and other microbes aid digestion, benefit the immune system, and otherwise contribute to health. In other words, a large metropolis occupies the mid-section and every resident has an important role to play. Each human being's unique gut microbiome helps predict their glycemic response to specific foods and food combinations. High microbial diversity and richness positively correlate with better health.
"That stool sample lets us analyze the bacteria in the gut, up to 3,000 strains," says Josh Stevens, president of DayTwo. "We learned in the original research that everyone's gut bacteria is different."
By referencing a scoring system that rates thousands of foods and food combinations based on the individual's microbiome sample and DNA sequencing, the clinicians apply an algorithm to predict the foods that will cause blood sugar to spike.
"There is no best diet for humans. The one-size-fits-all diet is faulty as a principle. The response to food is highly personal. Two different people can eat the same food and have different results," Stevens says. "If this is knowable in advance, you don't have to guess or use legacy models that are inaccurate. We can profile a person through a stool sample, feed it through the model, and know how they will respond. We can match food to people in a way that has never been done before."
Along with their sample, patients send in a completed questionnaire about their current A1C levels and diet habits. After getting results, DayTwo personalizes the app to help patients tweak their existing diets, rather than eliminate favorite foods, and suggest foods they are not in the habit of eating. When those favorite foods are identified as culprits in unhealthy blood sugar levels, the app directs users on how to identify other foods that can be eaten along with the problem food to keep those levels in a healthy range. For example, oatmeal might be identified as a food that causes a specific patient's blood sugar levels to rise. But by applying the microbiome analysis, the app lets the patient know that if they add walnuts to their oatmeal, they can keep eating it.
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Covenant HealthCare employees use the DayTwo Precision Nutrition app."We don't seek to change someone's eating behaviors radically. It's a diet of addition, not elimination," Stevens says. "Now, people can know in advance what their glucose score will be with pre-meal glucose monitoring. This eliminates the need for lancets."
Those familiar with Type 2 diabetes have no great affection for lancets, which are used to poke the thumb for routine blood samples after meals. In addition to inflicting pain, they can be costly. Stevens notes that another goal of the Precision Nutrition approach is to reduce the amounts of medications that patients need, which can also save them money.
"The success with the employers involved has been rapid and brought a call from some Michigan Medicaid providers," Stevens says. "They said, 'We see what you're doing and we'd like to see if we can apply it to Medicaid.'"
As a result, DayTwo has adopted a protocol change and will be working with food security partners in Michigan, as well as existing social services like SNAP and Double Up Food Bucks.
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Covenant HealthCare employees use the DayTwo Precision Nutrition app.Stevens believes that managing Type 2 diabetes and prediabetes is only the beginning of what AI enhanced gut microbiome analysis can do to support people in achieving better health. Meanwhile, the 18 Covenant HealthCare employees continue their journey to better health, ideal weight, and easier diabetes management.
"We are very pleased that we took the leap," Fielbrandt says. "One participant told me they were very thankful that they made a connection with a dietitian [through the program]. It was a relationship, a friendship that they built as they met weekly to go through their food plan. When that employee went to their physician for routine a check-up, the doctor told them, 'I don't know what you're doing, but keep on doing it.'"
A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.
Photos courtesy of DayTwo, except Catherine Baase photo courtesy of MiHIA and Erik Fielbrandt photo courtesy of Covenant HealthCare.