Proceedings of a Workshop—in Brief

Developing Wearable Technologies to Advance Understanding of Precision Environmental Health

Proceedings of a Workshop—in Brief

The rapid proliferation of wearable devices that gather data on physical activity and physiology has become commonplace across various sectors of society. Concurrently, the development of advanced wearables and sensors capable of detecting a multitude of compounds presents new opportunities for monitoring environmental exposure risks. Wearable technologies are additionally showing promise in disease prediction, detection, and management, thereby offering potential advancements in the interdisciplinary fields of both environmental health and biomedicine.

To gain insight into this burgeoning field, on June 1 and 2, 2023, the National Academies of Sciences, Engineering, and Medicine organized a 2-day virtual workshop titled Developing Wearable Technologies to Advance Understanding of Precision Environmental Health. Experts from government, industry, and academia convened to discuss emerging applications and the latest advances in wearable technologies. The workshop aimed to explore the potential of wearables in capturing, monitoring, and predicting environmental exposures and risks to inform precision environmental health.

The workshop was organized under the purview of the Standing Committee on the Use of Emerging Science for Environmental Health Decisions (ESEHD) of the National Academies.¹ This standing committee aims to explore cutting-edge scientific advances that can make the work of scientists and decision makers “more accurate, precise, feasible, and make the … biggest impact on human health,” as stated by the ESEHD co-chair Kristen Malecki (University of Illinois at Chicago). Although wearable technologies have advanced rapidly in everyday life, their potential applications in interdisciplinary research and health are beginning to be explored.

Another overarching aim of the workshop was to connect environmental health scientists with representatives of the broader biomedical community. “By collaborating across disciplines and … embracing the potential of wearables, I’m convinced that we can revolutionize our understanding of how different environmental exposures can influence human health and well-being,” posited Rick Woychik (National Institute of Environmental Health Sciences), during his opening remarks. The wide range of real-time environmental and physiological data of wearables can open doors to new possibilities in research and health monitoring especially with innovations in artificial intelligence (AI) and machine learning (ML).

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During the workshop, speakers and panelists underscored the significance of interdisciplinary collaboration in leveraging wearable technology to bridge the gap between environmental health and biomedical research. Several participants highlighted the importance of collaboration among experts in various fields, including environmental health, infectious and noncommunicable diseases, and biomedicine, in order to enhance research and response to individual and cumulative exposures. The discussions revolved around the diverse stakeholders and expertise that could contribute to these collaborations and also addressed the barriers hindering effective partnerships. The workshop also explored opportunities to strengthen collaborative efforts in order to effectively combat current and emerging health threats.

This Proceedings of a Workshop—in Brief provides the rapporteurs’ high-level summary of the workshop discussion. Additional details can be found in materials and videos available online.² Statements from workshop participants should not be viewed as consensus conclusions or recommendations of the National Academies. The views contained in this proceedings are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies.

MONITORING ENVIRONMENTAL EXPOSURES AND HEALTH

Advancements in wearable devices, such as chemical samplers and sensors, have revolutionized the field of environmental monitoring, enabling precise detection and analysis of hazardous exposures and their impact on human health. In her keynote address, Cristina E. Davis (University of California, Davis), who leads the development of chemical samplers and sensors, explained their broad range of applications. One sampler detects compounds that emanate from the body in exhaled breath. This exhalation produces an aerosol containing thousands of molecules from the interior lining of the lung, which are in equilibrium with circulating capillary beds and therefore “mimic the compounds that you see in blood, but at lower concentrations,” Davis said.

In a pilot study, Davis explained how small aerosols captured by an exhaled breath condensate (EBC) sampler in teenagers with well-controlled asthma could be distinguished from healthy controls.^3,4,5 The EBC sampler has the potential to reveal how individual patients respond to particular drugs, informing a personalized medication regimen.

The group is also developing technology to capture volatile organic compounds (VOCs) released from the skin or breath. Davis and colleagues used a mobile sampler that collects exhaled VOCs to distinguish COVID-19-infected patients from uninfected controls.^6,7 On the environmental science side, her group is developing devices to capture a person’s cumulative environmental exposure over the course of daily life and coupling real-time chemical sensors with wearable devices that monitor physiological states, such as temperature, activity, and blood oxygenation.⁸ Davis’s environmental sensor, which can detect VOCs down to the 100-part-per-billion range, has been deployed on drones to monitor air quality during wildfires.⁹ She suggested that in the future environmental and breath VOC sensors could be used in community-based participatory research (CBPR) to measure their own exposure to volatile toxins in their day-to-day life, as well as during disasters.

The integration of wearable technology illustrates examples of collective efforts to address challenges in health care and environmental sciences, holding significant promise for precision environmental health

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with the goal to bolster data-driven, decision-making processes and foster a deeper understanding of the complex interplay between human health and the environment.

CAPTURING, MONITORING, AND PREDICTING ENVIRONMENTAL EXPOSURES, HAZARDS, AND HEALTH RISKS

The following speakers described their use of diverse tools and technologies to detect and predict environmental exposures and health risks to inform precision environmental health. Sameer Halai (Wehealth), Bijan Najafi (Baylor College of Medicine), and Natalie Johnson (Texas A&M University) emphasized the significance of incorporating diverse technologies to account for environmental factors in real-time models.

Worldwide Contact Tracing with Privacy Protection

In today’s interconnected world, the potential of smartphones as wearable tracking devices becomes increasingly evident, offering unprecedented capabilities for monitoring and tracing various aspects of people’s daily lives. The Wehealth app was developed in 2020 to provide contact tracing for COVID-19 exposures. Halai said that the underlying technology was also adopted by Google and Apple and made available to all smartphones worldwide. Halai described anonymous contact tracing, where phones broadcast and detect random exchanges of coded communication, known as keys, with participating phones nearby. If a phone owner tests positive, they can choose to share their keys from the past 2 weeks to a public server, notifying other phones of an exposure risk without revealing the source. Wehealth is now extending the protocol by adding small sensors, wearables, and stationary Bluetooth beacons to its network, to communicate infection risk more rapidly and efficiently while still preserving privacy.

Halai noted that Wehealth can adapt its protocol for monitoring a wide range of environmental exposure risks and can target particular areas or individuals in need of mitigation. The app can be updated in real time and uses a system of AI combined with human review to translate all of the information into many languages. Both Halai and Najafi expounded on leveraging cutting-edge, realtime wearable technology to monitor and promptly detect immediate exposures.

Wellbuilt for Wellbeing: How Office Design Affects Workers’ Health

With roughly 90 percent of people’s time spent indoors,¹⁰ and a significant portion of that time spent in office buildings, “we are increasing transforming into an indoor species,” postulated Najafi. Buildings “are only truly high performing if they also enhance the health and well-being and performance of those who inhabit them,”¹¹ but the relationship between building design and health outcomes can be difficult to parse due to the interconnectedness of health metrics. For example, high stress at work is related to low physical activity afterward, which can lead to poor-quality sleep and increased stress the following day.^12,13 To address these complex reciprocal associations, Najafi and an interdisciplinary group of collaborators employed sensors to capture a broad range of environmental and physiological data.¹⁴ In the study, four federal buildings were equipped with wearable sensors to monitor office workers’ stress, posture, physical activity, and sleep.

The study found individuals working in an open-bench floor plan had significantly higher physical activity and reduced stress at the office and engaged in more physical activity after work than those working in cubicles or private offices.¹⁵ Additionally, those working in humidity levels outside a relatively narrow comfort zone experienced greater physiological stress at the office and worse sleep quality at home.¹⁶ Najafi highlighted how sensors allowed his group to precisely measure the

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impact of a broad range of exposures on workers’ stress, physical activity, and quality of life, which paralleled Johnson’s discussion on the utilization of silicone wristbands to detect such environmental exposures, described in the section below.

Silicone Wristbands as Personal Passive Samplers

Air pollution is a top environmental cause of disease and death¹⁷ with distinct windows of vulnerability over the human life span, including among neonates and very young children, stated Johnson. On average, increased exposure of pregnant women to fine particles is associated with a decrease in birthweight of 20 grams,¹⁸ though individual studies vary considerably. Furthermore, low birthweight is more closely associated with maternal exposure to polycyclic aromatic hydrocarbons (PAH) than to PM_2.5.¹⁹ This highlights the importance of quantifying personal exposure to a range of organic chemicals in air pollution as personal dosimeters to track exposure to PAH.²⁰ Johnson recruited 17 healthy women in their third trimester in the McAllen-Edinburg-Mission area of the Rio Grande Valley, which has elevated rates of prematurity and childhood asthma. Each woman carried a backpack fitted with two active air samplers, a GPS device, and a silicone wristband for 24 hours on 3 nonconsecutive days.²¹ Similarly to Najafi, Johnson mentioned people’s predilection to remain indoors for long periods of time, noting monitoring is important in both indoor and outdoor environments.

Johnson highlighted the utility of silicone wristbands in assessing long-term inhalation exposures, due to their affordability, user-friendliness, and capacity to capture small molecular weight semi-volatile PAHs. Additionally, these bands are being employed to monitor the environmental exposure of pets, serving as valuable indicators for human exposure, and hold potential for applications in equal justice communities and environmental disaster response.

USING WEARABLES TO ADVANCE RESEARCH FOR DYNAMIC AND REAL-TIME MEASUREMENTS OF ENVIRONMENTAL EXPOSURES

Researchers are harnessing the capabilities of wearable technologies to capture, monitor, and anticipate realtime environmental exposures, hazards, and risks, thus informing precision health initiatives. Speakers Ana Rappold (U.S. Environmental Protection Agency [EPA]), Kevin Lanza (UTHealth Houston School of Public Health), and David Noren and Sara Mariani (Philips)²² explored the transformative capabilities of wearable technologies in detecting and monitoring real-time environmental exposures.

SmokeSense: Using Phone Apps and Wearables to Encourage Protective Behaviors

Rappold posited that the popularity of wearable technologies is because of their capacity to measure the immediate changes in the environmental conditions on a personally relevant scale. “When we observe changes in the environment [on a personal scale],” she said, “we start building the rationale for behavioral change.” However, in the absence of a clear message on how to behave, people tend not to change their actions, even when this carries an increased health risk.

EPA’s SmokeSense project began in 2017 with the aim of developing communication strategies that could influence people to take health-protective actions when they were exposed to wildfire smoke.²³ The SmokeSense app provides real-time information on wildfire smoke, such as reported physical and behavioral responses to smoke and the reported location of wildfires, with more than 50,000 users. Rappold explained during the initial study phase, participants perceived smoke as a greater health risk to others than to themselves, resulting in delayed behavior change. To address this, a new phase called SmokeSense Level Up is being prepared to provide

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personally relevant data and evidence of the benefits of behavior modification. This includes the establishment of a digital community that leverages social and behavioral science principles, allowing individuals to observe others’ reactions to smoky conditions and receive rewards for adopting protective measures.

In their discussions, both Rappold and Lanza underscored that understanding the impact of environmental factors on physical activity levels, such as extreme heat and air pollution, is crucial, as wearables provide an opportunity to track these exposures in relation to individual behaviors and health outcomes.

Wearable Technologies to Assess the Environment–Physical Activity Relationship in Children

Extreme heat has emerged as a leading cause of weather-related fatalities in the United States, disproportionately affecting low-income communities and communities of color, according to Lanza. His research involved CBPR techniques to map temperatures in Austin, Texas, revealing concentrated high temperatures in a low-income Latino community. Similarly, physical activity disparities exist, with less than 20 percent of Texas fourth graders meeting recommended physical activity guidelines, and this number is even lower for Black and Latino children.²⁴

Through the Green Schoolyards Project,²⁵ Lanza investigated the impact of temperature and shade on physical activity in schoolyards serving primarily economically disadvantaged Latino households. Lanza measured air temperatures by installing sensors at fixed sites throughout study parks and used GIS to measure shade from trees and artificial shade structures in parks. Students wore elastic belts with an accelerometer and GPS device, tracking their physical activity in time and space during recess. Lanza found that as temperatures rose, children decreased physical activity and sought shade. Conversely, children in the school with the highest amount of tree canopy were more physically active than those in schools with the lowest amount.²⁶ Lanza suggested incorporating tree shade in physical activity spaces, with future research exploring the relationship among children’s summertime physical activity, air temperature, particulate matter, and VOCs in space and time, utilizing wearable belts with multiple sensors to track exposures. Lanza highlighted the potential of wearables to link exposure data with socioeconomic and built environment data, emphasizing their role as either barriers or facilitators to physical activity engagement.

EXPLORING WEARABLE APPLICATIONS IN BIOMEDICAL RESEARCH

Exploring the expanding landscape of wearable applications in various research domains, such as disease monitoring, interventions, and biomedicine, was a key focus of the workshop. Shruthi Mahalingaiah (Harvard University), Lauren Cheung (Apple and Stanford University), Jessilyn Dunn (Duke University), David Armstrong (Keck School of Medicine of the University of Southern California [USC]), and Veena Misra (North Carolina State University) shared insights on the latest advancements in biomedical technology and highlighted the diverse array of wearable devices being developed for effective disease management. Notably, the data derived from wearables, along with other health-related sources, hold potential for training ML algorithms and constructing predictive models in disease prognosis, diagnostics, and treatment. Mahalingaiah, Cheung, Dunn, Armstrong, and Misra note these developments mark significant strides in harnessing the power of wearables to revolutionize health care practices and pave the way for precision medicine approaches.

Using Wearables for Precision Health: The Apple Women’s Health Study

The Apple Women’s Health Study (AWHS) exemplifies how wearable technologies can advance precision environmental health, as highlighted by Mahalingaiah and Cheung during their joint presentation. AWHS aims to explore the relationship among the menstrual cycle, lifestyle, and demographic factors through survey-based data and sensor-based data from iPhone and Apple Watch through the Research app. This long-term data collection capability facilitates monitoring of exposures and outcomes over extended periods.

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Cheung emphasized how Apple Watch and iPhone sensors can measure various indicators of both internal physiology and the external environment. To maintain data privacy, when iPhone is locked with a passcode, Touch ID, or Face ID, all health and fitness data in the Health app are encrypted on the device. Cheung and Mahalingaiah encouraged researchers to utilize ResearchKit and CareKit, free open-source tools for developing apps that leverage data from Apple devices to support medical research and care. Apple’s Investigator Support Program grants researchers access to Apple Watch devices and technical support teams, with one project investigating the impact of wildfire smoke on firefighters’ cardiovascular health.

The Digital Physiome: Wearables for Early Disease Detection

Dunn discussed the digital physiome²⁷ and how digital biomarkers from wearables correlated with signs, symptoms, and clinical indicators of disease. These biomarkers involve the transformation of digitally collected data into powerful indicators of health outcomes.

In the field of infectious disease, Dunn studied individuals with respiratory infections to determine how digital measurements from wearables correlated with indicators of infection.²⁸ These measurements could distinguish infected from uninfected individuals and predict the trajectory of illness prior to symptom onset.²⁹ Additionally, digital biomarker data may provide an early indicator of prediabetes, said Dunn, noting that 90 percent of people with prediabetes are unaware they have it. She found that smart watches were comparable to continuous glucose monitors in their ability to estimate a person’s A1C level, which is an indicator of glycemic health.³⁰ Similar to Mahalingaiah, Dunn is also using wearables to measure the cardiovascular effects from the exposure or proximity to wildfires. Dunn outlined the resources stored on the Digital Biomarker Discovery Pipeline,^31,32 which includes open-source data, code, algorithms, and educational materials.

Combining Wearables and Other Technologies to Eliminate Amputation in Diabetes

Every second someone develops a diabetic foot ulcer, and every 20 seconds someone with diabetes has an amputation. This burden falls disproportionately on individuals of color.³³ Armstrong emphasized the importance of addressing the imbalance of activity and pressure in the feet of diabetics with neuropathy, describing how they “wear a hole in their foot like they wear a hole in a sock.” To confront this issue, collaborative efforts between engineers and clinicians—illustrated by Armstrong’s role as the director of USC’s National Science Foundation (NSF)-funded Center to Stream Healthcare in Place—utilize wearables with the objective of maximizing hospital-free and activity-rich days. These multidisciplinary initiatives have resulted in advancements including smart bandages, direct drug delivery systems, and e-stimulation techniques.³⁴

One strategy suggested by Armstrong involves a smart boot equipped with gyroscopic gait detection and direct feedback. To extend ulcer-free days in wound remission, Armstrong is dosing patients’ activity levels with electronics.^35,36 Smart shoes and insoles, presently being developed, contain miniature shock absorbers that can adjust pressure across the foot.^37,38,39 Wearables

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can also be integrated with devices that are injected or implanted into the patient,⁴⁰ and a smart blood vessel can be paired with a smartphone for continuous blood flow monitoring.⁴¹ Armstrong acknowledged the largest obstacle in facilitating remote treatment for ulcer prevention is to “make all of these things communicate.” Looking forward, the future of wearables in health care is connected to overcoming the challenge of seamless communication between these devices and systems, fostering a connected and intelligent environment for individuals in extended care facilities.

Self-Powered Wearable Systems for Personal Monitoring of Health and Environment

Misra noted that continuous and long-term monitoring of a wide array of health and environmental information is essential to detect and understand the impact of toxins on our well-being. She highlighted the work of the NSF-funded ASSIST Center, a collaborative effort aiming to create self-powered wearable systems. These innovative wearables harvest and store power from the human body while minimizing energy consumption for sensing, computing, and communication.

ASSIST wearables are being used to study a range of diseases, many of which are related to environmental exposure. For a study on ozone exposure and asthma, Misra’s team built a wearable device that continuously monitored environmental ozone and VOCs along with cardiorespiratory and activity metrics. Healthy individuals experienced decreased lung function and lower heart rate variability following exposure to low-level ozone, suggesting that the effect would be much more adverse in people with asthma. Available devices include a reconfigurable wristband and chest patch, ECG shirt and armband, a biophotonic ring, implantable/injectable devices, and a metabolic tracker that samples sweat or interstitial fluid, with new sensors under development, including a “skin watch” that can analyze VOCs coming out of the skin.

UNDERSTANDING HOW TECHNOLOGY ADOPTION, IMPLEMENTATION, COMMUNICATION, AND TRAINING FACTOR IN TO ADVANCING BIOMEDICAL AND ENVIRONMENTAL HEALTH RESEARCH

Exploring the intersection of technology adoption, implementation, communication, and training in the realm of biomedical and environmental health research, panelists provided valuable insights into the challenges and opportunities that arise when embracing new tools. Throughout their discussions, Nita Farahany (Duke University), Ritika Chaturvedi (USC), Shekhar Bhansali (Florida International University), Tiffany Powell-Wiley (National Institutes of Health), and Deborah Prince (UL Standards & Engagement) emphasized the significance of addressing concerns surrounding data privacy, cognitive liberty, data equity, workforce development, community engagement, and user safety.

Wearables and the Brain

Investments are being made into the development of sensors that can read and interpret brain activity. The ability to gain insight into one’s own mind offers great potential, said Farahany. The widespread use of brain sensors could vastly increase the data available for studying and addressing the leading causes of neurological disease and suffering. However, as large tech companies develop the capability to embed brain sensors into everyday devices, concerns about privacy and oversight arise, particularly considering business models that rely on the ability to collect and sell user data. These data can possibly be used to “produce new varieties of commodification, monetization, and control.” Farahany posited that humans’ “brains are truly [the] last fortress of privacy,” noting that brain sensors have the potential to be exploited for monitoring participants.

Farahany emphasized the importance of establishing a right to cognitive liberty, or the right to self-determination over our brains and mental experiences, ensuring that the collection and sharing of brain data empowers individuals rather than disempowers them, while also recognizing the heightened sensitivity of wearables that capture such data and implementing safeguards against intrusive privacy risks. By combining these efforts, she suggested, researchers can foster an

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inclusive and ethically responsible approach to advancing both biomedical and environmental health research.

Improving Equity in Digital Health Study Cohorts: The American Life in Realtime Project

Addressing the importance of equitable representation in digital health study cohorts, Chaturvedi emphasized the significance of overcoming methodological biases that have perpetuated underrepresentation of minoritized populations in biomedical research using consumer wearables. This underrepresentation, driven by practices like relying on convenience samples of easy-to-reach populations and “bring-your-own-device” (BYOD) designs, has resulted in demographic and socioeconomic disparities across various factors. USC’s Understanding America Study⁴² found that only 22 percent of U.S. adults are self-motivated wearable device owners, and that they are significantly more female, White, educated, and higher earning than the general U.S. population. “Consequently,” said Chaturvedi, “excluding non-owners from digital health studies results in demographic and socioeconomic disparities across almost all factors.”

As health care relies increasingly on big data analyzed by ML and AI, benchmark datasets that can test, train, and validate these models in an equitable and rigorous manner are urgently needed, said Chaturvedi.⁴³ The American Life in Realtime (ALiR) project was developed to ensure inclusive and accurate representation of marginalized populations in datasets used for life science research and medical decision making.⁴⁴ The ALiR cohort is largely representative of the general population both socioeconomically and health-wise, and the dataset includes a wide array of sociodemographic and health measures. ALiR modeled and predicted COVID-19 infection based on the retrieved biometric data from participants provided with Fitbit devices. Chaturvedi found a model trained on ALiR data was more effective at predicting infection in males, minoritized populations, or lower-educated groups (who are commonly underrepresented in current studies) than a model trained on BYOD data “demonstrat[ing] the need for representative sampling for equitable model performance in AI machine learning,” said Chaturvedi.

Education and Training for Emerging Sciences

Recognizing the role of interdisciplinary training, Bhansali emphasized the importance of fostering collaboration among students from various fields in biosensor and environmental sensor work. Undergraduate and graduate curricula, he explained, need to adapt to meet the evolving demands of emerging sciences, as the future workforce will require a diverse skill set. Institutions like Florida International University (FIU) and the University of Southern Florida (USF) have expanded course offerings and increased opportunities for undergraduate research. External funding for NSFIGERT and Bridge to the Doctorate national training grants and fellowships have exceeded FIU and USF’s initial investment by a factor of 10 and supported more than 200 minoritized students, representing a significant return on investment, Bhansali posited. It was critical, he said, for students in different fields to interact directly with one another. However, Bhansali acknowledged the challenge of attracting talented individuals despite the significant contributions of interdisciplinary electromechanical research in recent years. Looking ahead, bridging the gap between disciplines and cultivating excitement in emerging sciences will be important considerations for fostering education and training in this rapidly evolving field.

Using Digital Technology to Promote Cardiovascular Health Equity

In health care, digital health technology holds promise for addressing disparities, as mentioned by Powell-Wiley. However, concerns about privacy, data confidentiality, and discrimination can impact trust in the health care system and limit the willingness to use technology. One way to overcome this barrier is by engaging communities directly as partners in the process of developing interventions.⁴⁵ Powell-Wiley described a partnership among researchers and community members that used digital technology to design an intervention to promote cardiovascular health equity in areas of Washington,

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DC, with the highest rates of obesity and cardiovascular disease. A community advisory board met quarterly to provide feedback on each step of the design process⁴⁶ and helped tailor the intervention to the community, recruit participants, and disseminate findings back to the community. The group identified physical activity as a particular target for intervention and demonstrated the feasibility of using wearable devices to promote this intervention.^47,48

The efficacy trial, called the Step It Up Physical Activity Intervention, is currently under way; it is a sequential multiple-assignment randomized trial that uses a smartphone app and wearable physical activity tracker to promote physical activity for Black women living in target areas. Each version of the app was tested by community members and revised based on their feedback. By engaging the community and refining the app based on their input, this approach showcases the potential of community-engaged research in tailoring digital health interventions to address health disparities. Moreover, it enhances understanding of the influence of social determinants on chronic disease disparities, potentially facilitating the development of more equitable interventions and algorithms.

Developing Safety Standards for Virtual Reality, Augmented Reality, and Mixed Reality Equipment

When it comes to wearables that offer virtual reality (VR), augmented reality (AR), or mixed reality (MR), “how do you know that they are safe?” asked Prince. She specifically described UL 8400, a safety standard that was published in April 2023 for addressing the risks posed by VR, AR, and MR devices.⁴⁹ This standard is used in conjunction with other consumer electronics standards that handle baseline concerns of safety, fire, and shock. Hardware is divided into three categories: non-see-through, denoting total optical occlusion; video see-through, which allows some video to pass through the cameras; and optical see-through, which maintains most of the user’s vision. The standard covers see-through visual functions, including use cases that may impact visibility; flicker that could induce biological effects like seizure; potential damage to skin, eyes, and cervical spine; cleaning; mechanical robustness; spatial perception; safety instructions; and safety during use. Warning and labeling are done through a risk assessment that includes basic health and safety information. Due to insufficient data relevant to children, the current standard is designed for users over the age of 12; However, Prince noted that UL 8400 is under continuous maintenance, requirements will be refined as more data become available, and the standard will be advanced in scope—or new standards developed—as the technology continues to expand.

Data Security, Privacy, and Trust

During the panel discussion, Farahany, Chaturvedi, Bhansali, Powell-Wiley, and Prince considered the challenge of collecting, storing, and maintaining the privacy of massive amounts of data, including a lifetime’s worth of information on personal health, GPS locations, and relationships among cohort members. This “raises significant challenges over the long haul,” said Farahany. For long-term longitudinal datasets, Farahany suggested efforts to secure data against misuse. It is likely important to proactively explore “what the potential risks of discrimination and misuse of those data are, and by which actors, and then to put into place rights and remedies to protect against that,” posited Farahany.

Regarding the question of trust, Chaturvedi noted that the primary barrier to wearable ownership in the underserved populations she studies is not distrust related to data privacy, but rather access and knowledge regarding the benefits of wearables. Providing free wearables and education reduces most of those barriers, and privacy concerns could be alleviated by establishing trusting relationships. Powell-Wiley concurred. Her study populations are interested in using mobile apps for health-related issues, and the main barrier is accessing

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the wearable and learning how to couple it with the phone. The feedback from these groups has been positive: “the populations we work with … are really excited about being a part of these types of studies and having [them] focus on African American women,” she said.

DISCUSSING RESEARCH GAPS, LIMITATIONS, AND FUTURE DIRECTIONS FOR WEARABLES IN ENVIRONMENTAL HEALTH AND BIOMEDICAL RESEARCH

Exploring the frontiers of wearable technology in environmental health and biomedical research, panelists Joseph Wang (University of California, San Diego) and Edward Ramos (Scripps Research and CareEvolution) shared their insights on the future directions of wearable technologies. In an engaging group discussion, Wang and Ramos delved into the current limitations of wearables while emphasizing their transformative potential in clinical trials, paving the way for possibilities and advancements in the field.

Wearable Sensors: Examples of Major Gaps and Challenges

Wang has made significant strides in developing mobile and wearable electrochemical sensors for detecting environmental chemical hazards and toxic metals. However, he emphasized that the most notable success story thus far has been the miniaturization of glucose analyzers for diabetes treatment, leading to wearable continuous glucose monitors (CGMs). Drawing inspiration from CGMs, Wang aims to create noninvasive, real-time wearable chemical sensors capable of providing continuous profiles of environmental hazards and immediate user alerts. His work focuses on monitoring biomolecules, drugs, toxic metals, and more through sweat, saliva, tears, interstitial fluid, and the surrounding environment. Key challenges arise in terms of engineering, measurement accuracy, limited scope, stability of enzymes, adaptation of laboratory assays for on-body use, safety of reagents, energy generation, data security, scalability, and regulatory considerations.

Innovations in Clinical Trial Study Design

Adding to Wang’s discussion on innovation, Ramos noted how wearable technology offers a new paradigm for clinical research. In a traditional clinical trial model, the physical facility is centralized, and the patient cohort is typically recruited from the surrounding population, which can limit the study to a demographic that is not sufficiently representative to fully address the research questions. The COVID-19 pandemic “catalyzed a paradigm shift … [toward] the decentralization of clinical trials,” said Ramos.⁵⁰ Combining decentralization with digital data collection presents new opportunities as the potential study population is expanded to “anyone anywhere.” In the Digital Trials Center at Scripps Research,⁵¹ Ramos and colleagues conduct remote studies with participants self-collected biological samples to address a wide range of questions relating to sleep medicine, precision nutrition, maternal health, and infectious disease. According to Ramos, this work has established a strong proof of concept that can be readily applied and adapted to advance environmental science and public health research.

Diversity, Desensitization, and the Meaning of Interdisciplinary Research

During the panelist discussion, Wang and Ramos further explored the challenges and opportunities surrounding diversity, equity, inclusion, and accessibility in the field of wearables for precision environmental health and medical care delivery. The paradigm shift toward a decentralized digital clinical research model is exciting, but Ramos emphasized the need to prioritize underrepresented and underserved populations, avoiding the risk of building infrastructure that caters primarily to the majority. This likely involves addressing gaps in service, trust issues, and data security, as Farahany, Chaturvedi, and Powell-Wiley previously mentioned, while effectively communicating the capabilities of these new technologies. Wang finds hope in the diverse representation among his students and postdocs, as he develops devices for civilians and soldiers, ensuring equal access for all.

Wang and Ramos further discussed the potential challenge of information overload and desensitization caused by ubiquitous sensor use. Wang’s devices are designed to alert users to sudden dangerous exposures, remaining silent when levels are within normal limits, and Ramos provides participants with their data and

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insights, engaging them through personalized feedback. Both Wang and Ramos noted that overcoming barriers to interdisciplinary collaboration is important for the future of wearables. Ramos expanded the notion of interdisciplinary to include a diverse advisory team representing various societal roles, aiming to extract valuable insights for public health.

Addressing Gaps in Wearable Technology

During the workshop, many of the panelists noted that advancements in wearable technology show promise, but there remains a notable gap in performance, reliability, and scope that may benefit from a multidisciplinary approach. This challenge extends to other environmental sensing devices, with Misra highlighting the need to ensure sample delivery and prevent contamination during long-term monitoring. To enhance wearables for research purposes, Lanza suggested incorporating features such as data logging, storage, and offloading capabilities, along with low-cost, research-grade products tested for accuracy.

Interoperability emerges as another key challenge in leveraging wearable technologies for biomedical research, as highlighted by Armstrong. Ensuring platform-agnostic technologies that enable seamless communication and actionable information delivery to clinicians and patients is important. Additionally, timing exposure within the relevant biological time window is a complex task, as mentioned by Mahalingaiah. Remote clinical trials introduce concerns regarding data reliability and accuracy, an aspect acknowledged by Ramos. Collecting environmental and digital biomarker data alongside patient surveys that assess mental states is valuable, although the validity of self-reported measures and physiological data could be carefully considered to distinguish meaningful signals from potential inaccuracies. Wang also underscored the significant investment and market-driven progress witnessed in continuous glucose monitoring, emphasizing the challenges associated with adapting such technology to other metabolites within the relatively limited environmental market.

CLOSING REMARKS

Over the course of 2 days, experts from diverse fields covered a range of topics relating to the innovative field of wearable technologies for precision environmental health and medicine. During her closing remarks, Rima Habre (USC), Workshop Planning Committee Chair, summarized the 2-day discussions, and further posited how novel methods and technological advancements in wearables research can be combined to develop ML/AI algorithms, further informing precision health research.

Wearable devices have the potential for long-term, even lifetime, data collection, which presents opportunities for discovery, along with concerns about privacy, most pointedly in the realm of brain sensors. Establishment of a right to cognitive liberty and restrictions on data use were suggested, and multiple participants noted that addressing questions of equity can improve data quality and outcomes. Nevertheless, considerable technological hurdles remain in the effort to move analytical processes from bench to body. Looking forward, outreach and interdisciplinary training are areas of focus for wearables, both important in attracting and preparing the next generation of scientists who are dedicated to advancing the interconnected field of environmental health and biomedicine.

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Natalie Armstrong, Carol Berkower, and Lyly Luhachack as a factual summary of what occurred at the workshop. The statements recorded here are those of the individual workshop participants and do not necessarily represent the views of all workshop participants, the workshop planning committee, the Standing Committee on the Use of Emerging Science for Environmental Health Decisions, or the National Academies of Sciences, Engineering, and Medicine.

WORKSHOP PLANNING COMMITTEE Rima Habre (Chair), University of Southern California; Paloma Beamer, University of Arizona; Yuxia Cui, National Institute of Environmental Health Sciences; Jennifer Horney, University of Delaware; Amy Wagoner Johnson, University of Illinois at Urbana-Champaign; Tiffani Bailey Lash, National Institute of Biomedical Imaging and Bioengineering; Akane Sano, Rice University; Treye Thomas, U.S. Consumer Product Safety Commission (independent consultant)

REVIEWERS To ensure that this Proceedings of a Workshop—in Brief meets institutional standards for quality and objectivity, it was reviewed by Kevin Lanza, UTHealth Houston School of Public Health. The review comments and draft manuscript remain confidential to protect the integrity of the process. We also thank staff member Blake Reichmuth for reading and providing helpful comments on this manuscript.

SPONSOR This workshop was supported by the National Institute of Environmental Health Sciences (Contract No. HHSN263201800029I/Order No. HHSN26300003).

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. Developing Wearable Technologies to Advance Understanding of Precision Environmental Health: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. http://doi.org/10.17226/27178.

Division on Earth and Life Studies Copyright 2023 by the National Academy of Sciences. All rights reserved.