Abe Kiani, MD, a practicing anesthesiologist in Loma Linda, California and VP of Medical Affairs for Cercacor, joined me at the 2016 CES conference to talk about their product, Ember, a non-invasive hemoglobin tracking system for athletes.

The technology behind the Ember is the same as the one sold by Masimo and used in hospitals to non-invasively track hemoglobin levels. Masimo is a “brother company” to Cercacor—in fact, it was founded and is run by Abe’s brother, Joe E. Kiani.

 

Elite athletes and hemoglobin

Elite athletes have known about the performance-enhancing benefits of optimizing hemoglobin levels for years. Prior to the advent of blood doping and the use of erythropoietin (aka EPO), elite athletes used to train at altitude where the lower oxygen levels could naturally stimulate the production of red blood cells.

Because there is uncertainty about the duration of time each athlete needs to remain at altitude, there was a need to find an easy, non-invasive way to track the effects of altitude training on hemoglobin levels. That is what Cercacor was designed to do.

 

Watch the video to learn more:

I asked Abe about less savory uses for the tracker, such as monitoring of blood doping and EPO use. He indicated it is their hope that when providing elite athletes with an easy, non-invasive way to monitor “natural self-doping” via altitude training and diet optimization, athletes will find it easier to do the right thing. We certainly hope so!

Patricia Salber MD, MBA (@docweighsin)
Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.

3 COMMENTS

  1. I’m going to go out on a limb here, and assume that the Ember device is Masimo’s non-invasive hemoglobin technology repackaged into a consumer device. Masimo’s FDA submission states that SpHb has been validated in a range of 8 to 17 g/dL with accuracy of ±1.0 g/dL at one standard deviation. A clinical study summary on Masimo’s website claims precision of 0.95 g/dl at one standard deviation. For the statistically uninitiated, the “one standard deviation” part mean is that those accuracy and precision levels will be seen in 68.2% of people. For 31.8% of people, the accuracy and precision will be will be WORSE.

    The sports medical community has been studying the the subject of altitude training for many decades. Christopher J Gore et. al. performed a meta-analysis of 17 such studies (“Altitude training and hemoglobin mass from the optimized carbon monoxide rebreathing method determined by a meta-analysis” – one may google it), concluding that the median change in hemoglobin mass is 1% per 100 hours. We could therefore expect that for a 2 week training camp at altitude, the median change in total hemoglobin for an individual starting at 15 g/dl would be 0.45 g/dl.

    This situation is akin to trying to measure, for example, an change in body temperature of 0.5 degrees with a digital thermometer that can only measure body temperature as a whole number (97, 98, 99, 100, 101… degrees). It tells you NOTHING. It’s highly doubtful that the Ember device would be of any use for tracking one’s response to altitude training.

    Unless the Ember device is a major improvement over the Masimo SpHB technology, I gotta call BS on this one!

    • As far as I understand it, you are correct, the Ember device is based on Masimo’s non-invasive hemoglobin technology. Thank you for your thoughtful and very interesting analysis of the science. Since I am not an expert on either non-invasive hemoglobin measurement or high altitude training, I will refer this to Dr. Kiani to respond.

    • First we would like to thank you for your thoughtful comments. We apologize for the length of this response. We thought we could take this opportunity to not only address some of the questions but further educate the readers about Ember as well.

      We understand that what the medical and athletic community have known for quite some time is that hemoglobin naturally increases over time in response to altitude. However, that increase, its timing, when it plateaus, and when it returns to normal once back at sea level vary among individuals. In fact, studies have shown that levels of erythropoietin, the hormone that increases the production of red blood cells and hemoglobin (called erythropoiesis), not only vary in amount between persons exposed to altitude but also in extent of erythropoiesis (Friedmann, et al., British Journal of Sports Medicine, 2005). Further discussion of this topic can also be found on our website http://elevation.cercacor.com. All this variation means that there is no “one size fits all” regimen for altitude training. Ember was designed to help the athlete tailor their training by giving them a quick and painless assessment of their hemoglobin trends, keeping in mind the individual variation.

      As is stated on our website, the technology used in Ember is also licensed to Masimo Corporation. Unlike Masimo’s products, Ember is NOT a medical device and is not intended for this use. It utilizes the second generation of the Rainbow technology platform for measuring hemoglobin which has a specified accuracy of 1.0 g/dL at one standard deviation. This means that about 68% of the hemoglobin values measured on a properly used Ember device should fall within +/- 1 g/dl of properly calibrated and used laboratory reference methods for measuring hemoglobin concentration (http://accuracy.cercacor.com). Of course, these reference methods also have known error. However, Ember has a trend accuracy of 0.7 g/dL at one standard deviation. This refers to its ability to detect changes in hemoglobin values when compared against a proper invasive laboratory reference. We believe the trend accuracy to be a more relevant measurement to an athlete looking to detect hemoglobin changes in response to altitude and exercise regimens. Additionally, since Ember is noninvasive, athletes can take as many measurements as they want thereby improving the resolution of the trend. Let’s use the same meta-analysis study referenced here by the commenter as an example below to illustrate this further (Altitude training and hemoglobin mass from the optimized carbon monoxide rebreathing method determined by a meta-analysis. Christopher Gore et.al, 2013).

      This study reviews previous studies looking at measuring hemoglobin MASS using the carbon monoxide rebreathing method. Ember measures hemoglobin CONCENTRATION not mass and is calibrated as such. Therefore it is expected that fluid shifts from dehydration, over hydration, physiologic changes, body position, etc. can influence concentrations and results will vary from day to day, hour to hour and even with a change in body position from one measurement to the next. This is true of any instrument, including laboratory instruments utilizing invasive blood draws, which measure hemoglobin concentration. That is why we suggest testing in a consistent fashion (ex. first of day) over multiple days and weeks to establish trends, knowing these variations exists. Furthermore, the method of measuring hemoglobin mass (carbon monoxide rebreathing) is not practical for most people given the time, lab set up required and cost. It is also not a routinely ordered test. Hemoglobin concentration measurements, on the other hand, are a routinely ordered lab test.

      While the meta-analysis concluded that a beneficial increase in hemoglobin could be seen in as little as two weeks, they also showed a much more robust response to altitude with increasing time spent. Looking at table 2 from the study, the estimated increase in hemoglobin mass expected upon exposure to altitude for 504-672 hours (3-4 weeks) is 6.48 %. Using the commenter’s own example of an individual starting at a hemoglobin of 15 g/dL, this 6.48 % increase in hemoglobin mass, corresponds to an increase of 0.97 g/dL hemoglobin concentration, assuming concentration is constant. Therefore it would be expected, based on the meta-analysis presented here, that the hemoglobin of an athlete training at altitude for 3 to 4 weeks would increase effectively by 1 g/dl. This falls within the resolution of the device given Ember’s accuracy and the ability of the user to test daily.

      We hope that the preceding helps clear up any questions posted here. We direct anyone interested in more detail to visit our website, http://www.cercacor.com, to learn more about hemoglobin and Ember. Additionally, we’d also like to mention that several elite athletes have been using Ember and have personally found it very useful. Ultimately, the success of Ember relies on people finding it useful. We hope they do. Thank you.

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