“More data, better diagnosis” – Founder & CEO of FoodMarble (Interview)
“More data, better diagnosis” – Interview with Founder & CEO of FoodMarble, Aonghus Shortt
We are back with the next season of Scope Forward Show where you’ll get to meet innovators and leaders who are reimagining the healthcare system.
The next phase of GI depends on innovators such as Aonghus and FoodMarble. Why? Because the industry is shifting from under our feet. Four trends are influencing GI: exponential technologies, consolidation, big brothers (such as hospitals, insurances) and changes in patient behavior.
FoodMarble, a tiny device that analyzes digestive disorders such as IBS and SIBO, comes squarely in the middle of these trends. After selling 30,000 devices, what do they know about patients with IBS that a private practice does not? How can this be a new revenue-generating ancillary opportunity?
The story of its growth is also interesting. An engineer gets an idea after seeing his girl friend suffer. Ideates and develops the device in Ireland and China. Raises $6 million and sells globally – more than 2/3rd in the US. It’s indicative of how the next phase of innovation would happen.
Aonghus says, with “more data”, you can come up with a “better diagnosis”. True.
Welcome to the evolving world of data-driven GI.
Don’t miss this one.
The Transcribed Interview:
Praveen Suthrum: Aonghus you’re the CEO and founder of FoodMarble which is a breath analyzing device that I’m excited to learn about. I warmly welcome you to The Scope Forward Show.
Aonghus Shortt: Thanks very much, Praveen. I’ve always loved Scope Forward Show. Just really informative and just delighted to be invited.
Praveen Suthrum: Aonghus, you are a PhD in engineering in a completely different field, and you’re a data scientist. How does somebody with your background get into a field like gastroenterology?
Aonghus Shortt: It’s a good question. It was actually my wife while my girlfriend at the time. She has IBS, and she was struggling. She was having a really difficult time. She’d been to different types of clinicians between primary care, she’d been to a number of gastroenterologists. She tried enough medications. She, of course, had a number of procedures, and she didn’t find anything they were very worried about. So kind of a really common story where people end up with a diagnosis of IBS. And I just started doing some research to see because I had access to the literature. So at that time, breath analysis had been used for quite some time because of large benchtop devices. But I could see the low FODMAP diet was emerging from the literature. And this was kind of an approach where if you can identify which foods ferment rapidly into gases in the gut and reduced down the consumption of those foods, that you could feel a lot better. And it was remarkable for me because I could see that in those early trials of Low FODMAP diet and as many as three or four people were seeing significant improvement, people at least tend to feel better. So they were using breath analysis in that research. So it kind of triggered me to think, okay, can I build one of these devices for Grace? And when she’d eat it, she’d see sometimes very significant rises in the breath hydrogen be measured. That was quite a good signal in terms of maybe this food should limit in her diet. It’s a pretty cool way if she was able to start personalizing what she could and condition. I guess that was sort of the inspiration for what we’re doing today.
Praveen Suthrum: That’s an amazing backstory. So how did you get started?
Aonghus Shortt: I started working on the original prototypes back in 2014. The accelerator program is at the start of 2016. We spent a couple of years developing the device and just getting it up to a level where it was performing really well because it is really challenging to measure these breath gases at the concentration levels. We need to measure them out on the breath. Yeah, there was a lot of product development that went in and just even learning from users using the device, giving feedback, letting us know and kind of us being able to build up that app guided process as well with their users. That took a while, but it’s really beneficial for us I think.
Praveen Suthrum: From my understanding, why did you choose to focus on hydrogen as a gas, like for the lay man, if you can explain why hydrogen in particular?
Aonghus Shortt: Yeah. There’s a few gases that are relevant on the breath. And so hydrogen is probably the primary gas. So whenever if you eat something, essentially, it’s not absorbed or it’s not fully digested, and it gets as far as microbes that can break it down in the gut. So that might be the small intestine, but usually the large intestine. If you get that undigested food to that point, it starts to be fermented by the bacteria or the different microbes in the gut, and that’s producing hydrogen, carbon dioxide And lots of other different metabolites. Hydrogen is the kind of primary gas that’s produced. Some of the hydrogen can be turned into methane, which is another gas that’s often present on the breath. Some of it can be turned into hydrogen sulfide as well. There is a couple of other gasses on there. For a first generation device, we want you to measure hydrogen because, first of all, it is the main gas of interest. But then also, when it comes to people being able to identify what foods they can and can’t eat, hydrogen is very responsive to the food that people are eating. If you’re not digesting the food effectively, you’ll often see very significant increases in hydrogen levels. And if you’re not seeing it, that’s a good indicator that this food might be actually okay for the person. So that was the first one. But in our second generation device, we are measuring methane, and we should be able to release an update on that device where we’re also measuring hydrogen sulfide on the breath. So in our sensing array, we have the capability to measure all three gasses in our second-generation device.
Praveen Suthrum: What is in the device that listens to the signal of hydrogen? How exactly does it sense?
Aonghus Shortt: Inside the device there’s a sensing canal. So the person is exhaling into the device, and there’s a sensing array inside of there. So multiple sensors which are measuring effectively. There’s a signal that’s generated by the sensors. It’s measuring the electrical resistance of process sensors. So whenever the molecule of interest comes in contact with the sensor, it kind of temporarily attaches to the sensor, and then it kind of detaches it again. So you’re having all of these reactions happening on the surface of the sensors while they’re exposed to the sensors. So we get a signal. Then, in effect, we’re getting multiple signals that are coming from the sensing array. And then there’s all sorts of different kinds of models we’re using to be able to translate that into concentration levels that we can show to the clinician and show to the patient.
Praveen Suthrum: Aonghus I’d love to see the device if you have it with you. I’d love to see how it looks. And if you can show it to us.
Aonghus Shortt: Yeah, sure. So I’ve actually got this is actually the second generation medical device which is coming up. This is med AIRE 2. So if you can see here. So this is a mouse piece at the front which you can click off, and you can wash the on and off button at the top. And so you can see the canal here. So you’re breathing in here and the breath comes out the other end and you can see as well. There’s a USB Port on the side. So that’s for charging the battery.
Praveen Suthrum: And it communicates via Bluetooth?
Aonghus Shortt: Yeah, exactly. So it communicates with the phone over Bluetooth and then the readings can be uploaded to our cloud servers. So then the clinician is able to see the results through the dashboard at that point.
Praveen Suthrum: Sounds so fascinating. Now can you share some numbers? How far have you come?
Aonghus Shortt: Yeah. So we’ve sold over 30,000 devices so far, so most of those are direct to consumers. So initially we started offering the device direct to consumer at the end of 2018 through our website. More recently, in the middle of last year, we started selling a medical so our first medical device, it’s an FDA class one device which we call Med AIRE. So that’s now available in the US. In terms of other numbers, we’re 25 people based over in Dublin, but we’re often in the US, we’ve raised over $6 million of VC funding. And yeah, we’ve seen a steady growth. So last year, we saw our sales double compared to the previous year. And again this year, we’re seeing really good growth as well. So there’s certainly a lot of interest from consumers and also from clinicians. And often what happens is a consumer buys a device, they’re gathering data, and they come into their gastroenterologist. And probably many of the people on the show might have had this experience. I guess about a year ago or so we decided, okay, we need to be able to build a system where we can provide a dashboard to the clinicians to see the results. And also we’re making it possible by having a medical device. The clinician can use that. And from a kind of considerable revenue point of view, it’s something that they can add to their practice and it can be a source of revenue as well.
Praveen Suthrum: Can you talk a little bit more about that? How could a clinician earn money by partnering with you? And how could it be a source of revenue for them?
Aonghus Shortt: Yeah. So basically the way we do it is that if a clinician gets set up with us, it’s been possible for them to order devices that get sent to their patients. So we can send them directly or we can send them a bulk number of units that they can have to hand because sometimes the clinician wants to be able to give the device directly to the patient if they’re coming into their office. In this instance, then the clinician is also able to avail reimbursement. So there’s reimbursement for the breath test. For breath tests that have been done traditionally. So it’s the same reimbursement codes. And something we’re also doing more and more is where the device has been used from a remote physiologic monitoring perspective. So that’s an RPM idea is something that’s getting increasingly because these are conditions like IBS, SIBO, functional constipation. These are conditions where it really makes sense to track the patient over a period of time. So clinically, if you’re measuring, for example, for functional constipation, measuring methane levels in the brain is very relevant because constipation tends to correlate with methane levels in a lot of patients. But yes, there’s different models that can be applied, and it really depends on what the clinician wants to do. But fundamentally, there’s a dashboard for the clinician to be able to review the results from the patient, and so we can guide the actual patient through the procedure of doing breath tests. So that could be SIBO breath tests or tests for different food intolerances or as I said, remote monitoring. So we keep it really easy for the clinician and for staff to be able to set up patients and to be able to interact with the patient. It just makes it a lot easier for a clinician to be able to do breath testing and facilitate that from the home.
Praveen Suthrum: Does this come under the same category as other remote patient monitoring devices, such as blood pressure cuff or you measure diabetes and you send that to the clinician, would it come under the same category?
Aonghus Shortt: Yeah, exactly. So from a Reimbursement perspective, it’s the exact same code.
Praveen Suthrum: Yes from a Reimbursement standpoint?
Aonghus Shortt: Yeah. Also, it’s a very similar concept as well. So you’re tracking data that’s relevant to the course of treatment. For example, if a patient so initially they might be diagnosed, the GI might diagnose them with SIBO. So if they did conventional SIBO breath test, which is a kind of a fasting morning breath test, and that can be done remotely using our device if they determined that, okay, this patient appears to have SIBO, and in most cases, they proceed to treating with vaxamin, which is an antibiotic, like during the course of treatment and after treatment, you’re able to monitor the levels of hydrogen and methane in the patient. And that’s really relevant because, well, first of all, you want to see, did the treatment work and is in the course required. But then also after the patient has been treated successfully, in about half the cases, SIBO tends to return. So for some clinicians, they might be interested in being able to monitor the patient to see, do the symptoms return, do they need to do another course of treatment, or what’s the best next approach for this patient, because for a lot of these conditions, you need to try different things. So you might like in SIBO, for example, you want to identify what is the underlying cause and what can bring the patient to a resolution, because you might be testing placebo and you clear it with antibiotics. If you don’t identify and resolve under lik cause, they may still continue to have symptoms. So, for example, you might have where a patient has very slow motility, so the food is passing very slowly through the gut, and sometimes maybe using a pro kinetic agent or something like that might be beneficial. But if you’re able to track their fermentation levels in real time over a period of time, that could be really beneficial in terms of treatment.
Praveen Suthrum: I’m really curious about that. So do you write into the EHR? I’m getting into a little bit of detail now, but how does the clinician I think what I’m trying to figure out are two things. One is from your end, one is from a clinicians end. If you’re providing a dashboard, or if you’re writing, let’s say into the EHR, whatever, how can I get a longitudinal view of a patient’s condition? One. Second is how can I get a population view if 30,000 people have used the device? What have you learned from it? These are two questions mixed into one.
Aonghus Shortt: They’re both really good questions. So, first of all, from the perspective of how does the clinician monitor results? So in the dashboard, they can see charts of the patient’s data over time, so they could be looking at their breath readings, they could be looking at their intake of fermentable carbohydrates. So what the patient is eating, they could be looking at their symptom levels. Fuel tracking can be very relevant, especially if you’re talking about functional constipation or IBS. So they can see that data over time and they can look at it just at a specific day, or they can look at over a week or a month or over a longer period of time. And we also try and make it possible. You can also see the trend in the data. So we try and make it easy for the GI to see whether the levels tend to be going down or maybe they’ve started to go up again. So there are some of the key things that they’re looking for. But it’s something we’re building on all the time. So you mentioned the population level data. So something we want to get into the dashboard is where the gastroenterologist is able to compare the results of this patient against the broader population or different kind of cohorts of patients. So that’s something we’re looking into, because what we found, which is kind of remarkable, is different individuals are in terms of their breath readings. When we’ve done clinical trials or what we’ve been involved in different studies, it’s just a huge range in terms of people’s daily patterns and their longer term patterns. So some people their levels go up and down quite often during the day. Some people it’s a slower progression, and a lot of that seems to link to how quickly or slowly people digest food.
Praveen Suthrum: Is there a role of stress here? I’m just curious. So do you see a correlation? If people are more stressed? Does the condition flare up and do you sense it in your device?
Aonghus Shortt: We do invite the patients and the users to be able to record their stress levels. Certainly stress is a factor in digestion. It’s something that there’s probably a two way correlation there. Your other symptoms can provoke stress and then where stress can provoke your symptoms. We’ve definitely seen a certain amount of that in the data and to provide assistance to people as well, to be able to try and manage that side of things. And in the future, we’re hoping to partner with other app based technologies, for example, which can help from that perspective as well.
Praveen Suthrum: Now you have the benefit of more than one clinical study, isn’t that right?
Aonghus Shortt: Yeah. So we’ve done a number of studies validating the device itself and then more recently, looking at interesting ways of using the data.
Praveen Suthrum: So coming back to the business aspect of it, are you in touch with insurance companies? What are they saying? The US?
Aonghus Shortt: Yeah. From a business point of view, this is something that we want to develop because we haven’t had any discussions so far with payers. But this is an area where you’ve got like, IBS is the number one diagnosis in gastroenterology. You’re looking at different cohorts of patients, like, say, for example, IBSC, which is IBS that’s constipation predominant. I was looking at numbers just before the call where the average was an extra $4,000 per patient per year, which isn’t as much as some other conditions. When you’re looking at the amount of people that are affected, it becomes a very big number. It is a huge cost for payers. And we think of the different drugs that are used. They can be expensive. And so I suppose from a payer perspective, we can offer a tool that you can save a lot of money. And because value based care is coming, and we think we’re very consistent with that as well.
Praveen Suthrum: So you’ve raised $6 million, you’ve sold 30,000 devices, and two thirds of that is in the US. What happens next, short term and long term? What are your growth plans?
Aonghus Shortt: Yeah. So there’s some really interesting things that we’re looking at with some of our research collaborators. We’re doing a clinical trial at the moment, for example, over in Johns Hopkins, and it’s looking at where you’re using breath readings instead of kind of looking purely at a single snapshot, fast eating morning breath test, if you’re gathering data over a period of time from the home as a patient. So if you’re recording your meals, you’re taking breath tests just during the day. So if you’re taking breath tests after you eat, well, first of all, that’s quite convenient for the person because they’re measuring in the home in a sort of more conventional sort of way. You’re getting to capture how does somebody actually respond to food when it comes to actual diagnosis and guiding the course of treatment becomes especially interesting because what we found in our trial is that we were looking in particular at seeing if somebody would respond well to rifaxman, which is a drug that’s approved for IBSD. We found that this approach seemed to be much more effective than the conventional test. So instead of replacing kind of single snapshot testing with where you’re gathering data over a period of time seems to be very powerful, mainly because the digestive tractors antidepressant trial disk knows there’s a lot of variability. There are a lot of factors that affect your digestion. So if you’re able to capture more data, you should be able to do a better diagnosis.
Praveen Suthrum: Do you see yourself branching off into other disease conditions, or would you stick with IBS and similar conditions?
Aonghus Shortt: Primarily, we’re very much focused on disorders of the gut, and we think that you’re seeing increase in evidence that where the microbiome and the gut is affecting broader health as well. So we will be very focused around the GI tract. That’s a pretty broad scope. So IBS is certainly very important to us. SIBO, functional constipation. These are some of the key kind of target areas. But we do think that what we’re doing could be relevant in other areas as well. So we’re doing a study actually in IBD patients, which is very interesting, and we will probably do more in respect of IBD. But yeah, so there’s a lot more we can do because fundamentally when you’re looking at breath, it’s something that can be gathered very easily. You can gather it over time longitudinally. The actual equipment for doing it is accessible from a cost point of view. So we think there’s a lot of potential. And say, for example, with the trial at Johns Hopkins, we’re applying machine learning to the data, and then it becomes even more exciting. So, yeah, I think that there’s a broad range of things that we can do. But yeah, our focus right now is really on somebody’s kind of really common but hard to manage GI disorders.
Praveen Suthrum: Are you raising more money? What happens from a fundraising standpoint?
Aonghus Shortt: Yes, we’re doing around at the moment. And so you’re very interested to speak to anyone who’s investing at the early stage, really with a focus on US investors as well, because from a healthcare perspective, our complete focus is on the US. And, yeah, we’d love to hear from anyone who might be interested.
Praveen Suthrum: Excellent. Is there anything else that you want to share before we close?
Aonghus Shortt: I think for us we do see a big gap where there’s a lot of people who have some of these functional gastrointestinal disorders. Right now, there’s not that much for those patients. We just want to sit in that gap and to be able to provide something that’s really convenient for the gastroenterologist and their staff and something from a practical perspective can be a revenue generator also taking breath and these measurements combining with machine learning for example, there’s just so much that can be done with that. Looking forward we just want to keep expanding what’s possible using the technology.
Praveen Suthrum: Is there a vision that you have for the future of GI? Everything happens like you think it should? What does that look like? What does such a future look like?
Aonghus Shortt: The way it should be for patients who are coming in and it could be something like half of patients coming into gastroenterology but have conditions that would be relevant to what we’re doing. So for those patients coming in if we can give them the technology where they can go home, gather data over a period of time and use that to manage treatment. For example, if they were to take over the counter supplements like identifying which are helping them if they were to take different medications help the clinician choose which would be most beneficial. It could be just purely food related so deciding whether this patient is a good candidate for example a low FODMAP diet or maybe another type of diet that might be more suitable for the patient. If you’re able to guide the patient over a period of time through that process remotely it’s something that will cost a lot less money it’s something that will be much more effective for the patient and for the clinician as well. Just the satisfaction of being able to treat the patient really effectively because these are really hard to manage patients because they’re really complex conditions.
Praveen Suthrum: Aonghus Shortt thank you so much for joining us today on The Scope Forward Show. I’m excited about what you’re building. Always admire and respect innovators. What you’re doing is fantastic. I wish you great success, you and your team.
Aonghus Shortt: Thank you once again, thanks Praveen.