Sunday, August 16, 2020

CGM for Newbies

When I was diagnosed with type 2 diabetes in 1996, I lusted for affordable access to more test strips so I could learn more about which foods made my blood glucose (BG) levels go up.

My insurance would pay for only 3 strips a day, so if I wanted to do a detailed study of something, with a graph, I had to not test at all for several days or a week and stockpile the strips. I suppose I shouldn't complain. Previous generations didn't have BG meters at all; they had to test urine, which showed only what their glucose levels had been several hours earlier.

But now there are so many ways one can see what one's BG levels are, including continuous glucose monitors (CGMs), which measure BG every 5 minutes or so and even show the results as graphs.
But these gizmos aren't cheap. Most insurance plans will cover the CGMs for people with type 1 diabetes, but not for type 2 until your beta cells have degenerated to the point that your C-peptide levels indicate that you're producing almost no insulin.

 But it's now being discussed whether CGMs should be supported for type 2s. Some people think it's not cost-effective. But I've always thought people with type 2 should be given CGMs soon after diagnosis, as most people have no real understanding of what types of food make BGs go up. In fact, many don't even know what a carbohydrate is. Perhaps right away wouldn't make sense, as getting a diagnosis of type 2 is usually a shock, the patient's head is spinning, and learning to deal with a CGM might just be a burden. At first it might be better just to follow whatever the doctor or nurse or dietician suggests.

But after a few weeks, the patient should be ready to learn more. For example, the patient might learn that the "healthy" breakfast of cereal and skim milk suggested by a dietician still supporting low-fat diets for people with diabetes made the BG soar. Then the patient could try various other foods to look for something that kept BG steadier and was also tasty and satisfying for that patient.

Because of the cost, the CGM might not need to be a permanent part of the patient's regimen. As the patient learned what worked, finger-stick tests could be used to confirm what the patient had already learned.

One program, United Health Group's Level2, is offering CGMs to patients enrolled in a United Health insurance. They say that "Level2 is provided at no additional cost to eligible members as part of their covered health insurance plan." The program also includes personal coaching and a Fitbit to track activity. But you have to have been diagosed in the previous 24 months to be eligible. There are also some other restrictions.

I would have killed (well, maybe not literally) for a program like that when I was diagnosed.

Other diabetes programs offer not CGMs but unlimited test strips along with coaching. Examples are Virta Health, which promotes low-carb diets, OneDrop, and Livongo. They all charge monthly fees, sometimes considerable, but employers or health insurance will sometimes pay those fees. Other sites like MySugr and Dario offer unlimited strips with or without coaching.

Today, on Medicare I don't qualify for a free CGM because I don't use mealtime insulin, and I no longer lust after unlimited strips. I test fasting BG just to make sure I'm not totally out of control, but otherwise I test only if I have a new food or some unusual exercise or get sick. But I occasionally buy a Libre CGM for $63 for two weeks as a spot check in case some food I thought was fine and so didn't think to test actually sends me way up, or if there's something I want to test.

The technology has certainly improved since I was diagnosed, and I'm pleased that newbies have a lot of support if they know where to get it. I hope they do get this support. Good control from the beginning reduces the probability of complications, and that reduces the overall cost of treatment. A CGM is a lot cheaper than new legs or a kidney transplant.

I wonder what's next.