“If you’re over 65 and have
diabetes, you should have a DEXCOM,” a guy in a white coat exhorts the viewer
in a TV ad. Have you ever thought about a Continuous Glucose Monitor (CGM)?
You’re supposed to assume the huckster is a doctor, not an actor shilling for
the maker of this CGM. You’re also supposed to believe that his spiel is guided
by “best medical practice.” But is using a CGM “best medical practice”? In an
ideal world?
Just a day earlier I had read
that the American College of Physicians (ACP) concluded that “home monitoring
of blood glucose does not benefit blood glucose control.” In this case the ACP
was denigrating the finger-stick home monitoring that I do every
morning. How could they, with such
conclusiveness, dis this practice, with no
conditions or no exceptions? I know home monitoring has helped me
a lot with my blood
glucose control.
The Dexcom CGM TV ad also lacks
nuance. The huckster does say “every
65yr old diabetic should have a CGM.” Unfortunately, Medicare (and
supplemental) insurance will only cover the cost of a CGM and its ongoing
supplies, for some diabetics. Coverage is qualified and severely limited.
It is only “for diabetics who use insulin to control their blood glucose,” and, more specifically, ONLY
for diabetics who take insulin with
every meal.” The small print at the bottom of the screen reads
“patients must meet coverage criteria.”
CGM’s are attached to your body
and connected via a small skin prick which monitors your interstitial fluid
every 5 minutes 24/7. The DEXCOM CGM sends downloadable readings and/or audible
alarms to your phone or your caregiver’s phone. So, contrary to what the ACP
said, CGMs are certainly a type of “home monitoring of blood glucose” that DOES benefit blood glucose
self-management (BGSM). Quid erat
demonstratum (QED).
So, as much as I would like to have a CGM to monitor and help me control my blood glucose, I am very happy that now CGMs are covered for type 1
diabetics and insulin-dependent type 2s who inject mealtime insulin.
Of course, I would argue that there SHOULD and WOULD be NO insulin dependent type 2s if
diet rather than pharmacology
was considered “best medical practice” -- by the medical establishment or
just by the patient!
Insulin is a dangerous drug, especially in the hands of a patient who
injects it multiple times a day every day and who has to know a great
deal about carbohydrates and the
insulinogenic properties of some proteins…and estimate portion size and other variables. It’s complicated and
risky. That’s why 1) doctors prefer to err by under dosing, with consequent
higher blood sugars and A1c’s and 2) patients sometimes under dose insulin, because overdosing on insulin can
(and sometimes does) lead
to hypos (hypoglycemia), coma and death!
The irony is that once a type 2 patient has learned so much
about carbs and insulinogenic proteins, they could just as easily eat
low carb, even VERY low carb, and dispense
altogether with the need to inject
insulin!
But what about the finger stick?
How does it benefit me? With a daily Fasting Blood Glucose (FBG), I am reminded
that I
control my type 2 diabetes by diet. If I ever cheat, my FBG will
invariably be in the prediabetic range (100-125mg/dl) the next day. If not, it
could be anywhere from 65 to 99mg/dl, depending on how many days in a row I was
“good.” My FBG is also an indicator of what my A1c will be at my next doctor’s
visit.
Years ago, when I was still
learning about which foods elevated my blood glucose, testing before a meal and
1-hour after taught me about my insulin resistance. Everyone’s
different, depending on where you are on your journey. Thus, it was a useful aide to me in the learning process
for self-management
of my type 2 diabetes.
For most type 2s that I know, or for
“pre-diabetics” or folks who are just overweight and in cahoots with their
doctor about their metabolic state (“denial is not a river”), BGSM is a way for
patients
to take responsibility for their health. But if that’s not you, your doctor
will be happy to track your A1c and say nothing (except maybe “lose weight”)
until you are diagnosed. Then, as Tom Hanks was told by his doctor, he’ll say,
“Congratulations, you've graduated,” and he’ll
write you a prescription. What else can he do?
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