I caught this article in Time magazine yesterday about people that do not have diabetes using continuous glucose monitoring systems (like Dexcom) to monitor their glucose levels and make tweaks to their diets and routines.
From the article:
Using a CGM, even when it’s medically necessary, is not cheap. Parts of the device have to be replaced every couple of weeks or months and it’s estimated that CGMs cost $5–10 per day, or around $3,000 a year. For people with type 1 diabetes, that can be covered by insurance. But people without the disease must either convince a doctor to prescribe one or purchase them online on sites like eBay. Even if a doctor prescribes one, it’s highly unlikely insurance would cover it for someone without diabetes.
I know many people with diabetes that wish they had better access to this technology, so I found it sort of surprising to see that there are people that don’t have diabetes that are paying out-of-pocket (and in some cases doing so illegally by not having the required prescription) to get access to the data. Is this as surprising to you as it was to me?
Wow - very much so. I wore a dexcom sensor once. It was a very boring experience. It also made me sad to see how flat and in range my line was when it takes so much effort to try and keep Caleb’s between the lines and how often we bounce beyond them. It’s fascinating to me that people without diabetes have a purpose for this.
It doesn’t surprise me at all since there’s so much talk in health circles about blood sugar & insulin spikes caused by various foods. Honestly, that talk usually annoys me because for the vast majority of people, their own pancreas is perfectly capable of taking care of it.
My biggest hope from the article is that this trend will bring an affordable CGM to market. I was happy to see this:
As Gizmodo reported in February, the company Sano Intelligence is planning to release a CGM for the general public. The device may be released in beta later this year.
It doesn’t surprise me at all that various types of professional and amateur athletes would be interested in using CGMs (I know some professional sports teams use CGMs to monitor the effects of diet in athletes, like Manchester United). Of course, pro athletes (or their teams) can easily afford such tech.
“Low-insulin” diets are becoming quite the medically-supported rage in the US for weight loss. These are similar to ketogenic, or Atkins-type diets (low carb, high protein or fat). There are medical specialist board certifications in the US (Internal Medicine-Endocrinology, Diabetes, and Metabolism from ABME and Obesity Medicine from the American Board of Obesity Medicine) that involve nutritional and non-surgical approaches to weight loss and metabolic disorders that are actively promoting low-carb diets. Since these medically-supervised diet techniques involve minimizing insulin production in order to minimize storage of fats, a CGM could be very useful (for those who could afford it).
I’m only aware of the new metabolic specialists because I’ve been under the care of one to manage my diabetes until I can see an endocrinologist (we don’t have any in town) later this spring. While I’m not obese, and my doctor is more used to dealing with Type 2s, the low-insulin eating plan has been working quite well for me so far! My only issues have been undesirable weight loss and some low-energy issues around working out. And I really wish I could afford a CGM even though I’m not yet on insulin
After living 24/7 with the CGM near-real time BG data flow for the last eight years, I’ve come to appreciate the incredible educational effect this can exert on a motivated individual. I think a sufficiently motivated average non-diabetic person may be learn a great deal about how the standard American diet (high fat, high carb, highly processed foods) impacts their blood sugar. I suspect that the quality of blood sugar metabolism ranges a fair amount in the non-D population. The feedback that a CGM gives could be put to good use in the right hands.
Can you imagine how effective a CGM would be for someone with impaired fasting glucose or other such Pre-Pre-Diabetes disorders? For those at high risk of Type 2 but who haven’t crossed that threshold yet, I can imagine that having access to CGM data would be an incredibly powerful tool to make the difficult life changes necessary to avoid full-blown T2. And considering how poor (and expensive) the outcomes are for Type 2s in the US, it would seem to me that insurance companies would jump at an opportunity to head off the litany of issues that come along with progression.
I agree. As long as the person doesn’t deny the reality of his/her situation and takes the data to heart, I think some people could pivot to better food/exercise habits and avert the apparent imminent slide into T2D. It certainly would have attracted my attention since I’m easily engaged with math and data health measures. My Fitbit motivates me to walk more.
As to any enlightened policy changes by insurance managers and their narrow focus on a single bottom line, I don’t hold out much hope. I think most commercial insurance companies believe that they won’t have to pay for the more costly consequences of status quo BG management. I’m sure they’re happy to dump the 65+ age group happily onto Medicare. They have little incentive to trade short term costs for longer term profitability.
I think it’s a great idea for almost anyone to wear a CGM – at least for a short while. There’s information potentially there – even if just confirmation that you’re doing great – that can’t really be obtained any other way. I do find it surprising, though, that an significant number of people would actually do it! I have spoken with several PWD who tell me about how their one or two tests a day indicate “improvement” or some degree of “success” – yet that isn’t reflected in their symptoms or A1c. This is not surprising to me. at all, but even when I explain to these folks why they’re seeing such discrepancies, they rarely really “get it.” I’ve suggested that they ask their doctors for a 1-week “trial” of a CGM so they can see what’s really happening – and universally these folks have said something to the effect of “No way! I don’t want to go around with something attached to me!!”
An accessible and cost effective cgm would become the best possible screening tool for pre-diabetes, diabetes, hypoglycemia, gestational diabetes using real life, real time data… And a tool to adjust diet by. Given the epidemic that is diabetes this will be a phenomenal step forward.
In the hands of a motivated person it could be life changing. How many pwd only get 1 or 2 strips a day. No more blind management.
from peter attia, who happened to strike up a conversation with the guy sitting next to him on his flight- the CEO of Dexcom:
"And that’s the least amazing part of CGM. I’m not sure I’m at liberty to discuss the next generation of CGM. Admittedly, not too many people want to wear the device I wear, but in two years, well, that’s when it will get amazing.
And that’s just the tip of the iceberg when it comes to why this device is adding insights and actionable data at a geometric rate. In two years this device will evolve into something everyone can wear."
scroll down to near the end of his post- he has his CGM data:
There is so much inaccurate information about diabetes that I think CGMs for non-diabetics will geometrically increase the stupidity.
This reminds me of a truism for musicians: If you have good rhythm, you don’t need a metronome. If you have bad rhythm, a metronome will just confuse you.
If you have good BG levels, you don’t need a CGM. If you have bad BG levels, a CGM will just confuse you! (The reason for this is a technical term: diabetes).
a CGM might pick up some prolonged spikes/dips that an A1c would not be reflective of. I had to do my own version of a CGM by buying a cheap meter from wal-mart. that’s when i picked up bg abnormalities. my fasting glucose was and has always been 85-90 and I am not overweight. both parents type 2, though. i may be going hypoglycemic in the middle of the night and that may be a factor in my hot flashes. i have been too lazy to set my alarm at night to use my glucose meter to check, however. and my hot flashes have decreased in frequency due to other trial/error interventions.
It sort of does surprise me, and it sort of doesn’t. I can certainly see the obvious attraction for athletes, weight loss, etc. But given the cost, I am a bit nonplussed at how widespread the practice is.
And yes, one part of me does harbor some resentment that people in the general population can use it for fine tuning whereas someone like me, who could get enormous value from it, can’t access the technology at all.
Someone said earlier that wide enough use might bring costs down. That would be nice. In fact, it would be a life saver for some percentage of the population.
Thank-you for that link to the Peter Attia article. He uses the Dexcom CGM, though he is not diabetic. He found that the A1c calculated by the Dexcom Clarity program (currently suspended) to be much lower than his lab A1c. I share that characteristic and I’ve seen explanations of this phenomena based on the lifespan variability of red blood cells across the population. Here’s the section that caught my eye:
Below is a printout of my last 14 days. As you can see my measured average glucose was 92 mg/dL, which imputes an A1C of 4.8%. At some point I may write about the dozen insights gleaned from CGM (and I think I mention a few in the podcasts), but here’s one: measured A1C is probably directionally valuable (you know, the difference between, say, 5% and 9%), but that’s about it. If your RBC (red blood cells) live longer than 90 days—mine live much longer since I have beta thal trait—your A1C will artificially reflect a higher average glucose. Conversely, if your RBC are large, the opposite occurs. (For those wondering, MCV, which is part of a standard CBC, shows you RBC size).
My A1C in standard blood tests routinely measures 5.5% to 6.0% (courtesy of my tiny RBCs), which poses a problem when applying for life insurance (prediabetic is defined as 5.7% to 6.4%). But with CGM, which is calibrated 2-3 times daily, my imputed A1C, which is much more reliable, varies from 4.6 to 4.9%. Big difference, huh?
This is the first time I’ve seen mention of “beta thal trait” in reference to red blood cells. This is also the first time that red blood cell size is related to red blood cell longevity. Interesting, now I have a few more search terms to play with.
Since CGM monitoring is an area where I am largely ignorant due to inexperience, I presume that Dexcom Clarity was an algorithm of some kind, whereas a lab test is an actual real world measurement (which, aside from all other considerations, has been around longer and had more time to mature). Personally I always trust empirical data over any calculation no matter how sophisticated. Just sayin’.
Though the main point of my previous comment was to be funny, a CGM in the hands of a non-diabetic person could lead to all kinds of stupidity:
Generalizing from their data that because THEIR BG appears to act in a stable manner-- everyone’s can and should.
Micro-managing BG could become hypochondriac heaven: CGM can be an obsession that makes a little bit of sense for us (because passing out and dying generally ruins your day if you’re a Type 1). But for people who are prone to overreacting for little or no reason, it could just add another level of crazy to their lives AND ours.
I agree with this, in general. As an example, I know that most labs will calculate LDL cholesterol using the numbers it actually measures for other lipid subfractions and then performs some arithmetic to calculate an LDL value. There are specialty labs that use an MRI process to actually count the LDL cholesterol. I prefer the actual measurement in this case to the calculated number if a treatment decision hangs in the balance.
But it’s more complicated when you examine things more closely. This comparison of the estimated average A1c calculated by the Clarity program to the lab measured A1c, however, does not support the general rule you state. The lab empirically measures the percentage of hemoglobin that is glycosylated (sugar attached). I am not disputing that measurement, merely the further interpretation of what that means given the presence of abnormal populations
The A1c test makes a fundamental assumption that the person’s hemoglobin is normal. By normal, I mean a person without any hemoglobinopathies, and thus dependable hemoglobin longevity. There are significant slices of the general population who exhibit measurable hemoglobin abnormalities that impair the accuracy of this empirically measured number.
I do see your point. Lab A1c testing is in a sense an indirect measurement as well, since it measures BG at one remove. Sigh. You pays your money and you takes your choice.
