Retrospective #479: “If you’re over 65 and have diabetes…”

“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 using 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?

For context, 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.

Now, back to the CGM. The Dexcom CGM TV ad is very misleading. The huckster says “every 65yr old diabetic should have a CGM.” Unfortunately, he doesn’t say that 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.” They cover their ass with small print at the bottom of the screen: “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 demonstrandum (QED).

So, as much as I personally 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 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, expensive hospitalizations 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” (didn’t cheat). My FBG is also a reliable 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 the severity of your Insulin Resistance. 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”), Blood Glucose Self Management (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 a certifiable type 2 diabetic. 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?