Routine glucose monitoring may be unnecessary for people with Type 2 diabetes(nytimes.com)
nytimes.com
Routine glucose monitoring may be unnecessary for people with Type 2 diabetes
https://www.nytimes.com/2019/03/11/upshot/a-diabetes-home-test-can-be-a-waste-of-time-of-money.html
60 comments
I'm glad you found something that works for you, but this is massively over-complicated for almost everyone.
Constant glucose tracking is interesting, but completely unnecessary. EDIT - For most healthy individuals.
It's like my father-in-law who obsesses over vitamins while he ignores being ~40 pounds overweight - he needs to simply eat less & move more, not keep reading articles until he uncovers some magic combination of micronutrients.
Beef spikes insulin just as much as rice does. Acute insulin spikes are not bad, and can be very beneficial. Chronically elevated insulin is not good, but it's almost always simple to address that - just eat less, less often.
But people seem to prefer to focus on complicating easy things instead of consistently doing simple but difficult things.
Constant glucose tracking is interesting, but completely unnecessary. EDIT - For most healthy individuals.
It's like my father-in-law who obsesses over vitamins while he ignores being ~40 pounds overweight - he needs to simply eat less & move more, not keep reading articles until he uncovers some magic combination of micronutrients.
Beef spikes insulin just as much as rice does. Acute insulin spikes are not bad, and can be very beneficial. Chronically elevated insulin is not good, but it's almost always simple to address that - just eat less, less often.
But people seem to prefer to focus on complicating easy things instead of consistently doing simple but difficult things.
As a type 1 diabetic, I can tell you beef does not spike blood glucose and resulting insulin response just as much as rice as does. Protein usually takes about half the dosage for the same amount of grams (ie 10g of carbs / 5g of protein), and it does it more slowly. For many type 1 diabetics on non low-carb diets, protein is eaten in small enough amounts with large enough amounts of carbs that you usually don't factor it into your dosage.
Your point is valid, I should have specified "in most healthy individuals".
https://watermark.silverchair.com/1264.pdf?token=AQECAHi208B....
https://watermark.silverchair.com/1264.pdf?token=AQECAHi208B....
There is absolutely no way beef spikes insulin as much as rice does. Beef has zero carbohydrates and while some protein does convert to glucose, it is a slow process and thus the insulin response will still be much less than if one consumed the equivalent of carbohydrate in rice. This is further slowed by digesting the fat in the beef.
""Between 50–60% of protein becomes glucose and enters the bloodstream about 3–4 hours after eaten." Perhaps 50–60% of protein goes through the process of gluconeogenesis in the liver, but virtually none of this glucose enters into the general circulation."
http://journal.diabetes.org/diabetesspectrum/00v13n3/pg132.h...
""Between 50–60% of protein becomes glucose and enters the bloodstream about 3–4 hours after eaten." Perhaps 50–60% of protein goes through the process of gluconeogenesis in the liver, but virtually none of this glucose enters into the general circulation."
http://journal.diabetes.org/diabetesspectrum/00v13n3/pg132.h...
Are you suggesting that insulin only responds to carbohydrate intake? I understand insulin plays an important role in shuttling all macronutrients from the GI tract into tissues, even if that action is somewhat different for fats, proteins, and carbs. (ie insulin binds to fat cells to reduce fat mobilization in a fed state)
Here you can see while its not the exact same, the insulin scores of beef & rice (brown especially) are very close to each other. Definitely much closer than most popular culture advice would suggest.
But it should also be said that this is for healthy individuals.
https://watermark.silverchair.com/1264.pdf?token=AQECAHi208B....
Here you can see while its not the exact same, the insulin scores of beef & rice (brown especially) are very close to each other. Definitely much closer than most popular culture advice would suggest.
But it should also be said that this is for healthy individuals.
https://watermark.silverchair.com/1264.pdf?token=AQECAHi208B....
For healthy individuals - I agree 100%.
Beef spikes insulin as much as rice? Well not for me (and I suspect most people). I can eat a steak without raising my blood glucose at all - one bowl of rice and it jumps 100mg/dl.
There's not a lot of good data on glucose spikes. It's a discussion I've had with my endocrinologist a number of times. He suspects it's not bad for occasional incidents as long as A1C isn't affected but again it's not been studied yet.
Sure, eat less. It's that easy - I guess the 90% of people overweight are just stupid.
You last statement is very true however. People and doctors want to do the simple thing. For doctors it's meds and then when they don't work well enough it's insulin and then more and more insulin.
That's a hamster wheel that people need to get off.
Beef spikes insulin as much as rice? Well not for me (and I suspect most people). I can eat a steak without raising my blood glucose at all - one bowl of rice and it jumps 100mg/dl.
There's not a lot of good data on glucose spikes. It's a discussion I've had with my endocrinologist a number of times. He suspects it's not bad for occasional incidents as long as A1C isn't affected but again it's not been studied yet.
Sure, eat less. It's that easy - I guess the 90% of people overweight are just stupid.
You last statement is very true however. People and doctors want to do the simple thing. For doctors it's meds and then when they don't work well enough it's insulin and then more and more insulin.
That's a hamster wheel that people need to get off.
I appreciate you sharing your thoughts with your doctor. I should have presented it as: “in this linked experiment, beef rose circulating insulin about as much as brown rice did”.
Oh and I didn’t mean to suggest fat people are lazy, eating less is simple, but not easy at all. That’s why I think people tend to end up complicating the easy stuff (and I agree meds can be an example of that) instead of doing the simple but difficult stuff.
Oh and I didn’t mean to suggest fat people are lazy, eating less is simple, but not easy at all. That’s why I think people tend to end up complicating the easy stuff (and I agree meds can be an example of that) instead of doing the simple but difficult stuff.
There might be other insights that can be gathered from the data that a CGM provides though. Even for healthy individuals.
>Beef spikes insulin just as much as rice does.
Citation?
Citation?
The NYTimes article isn't about continuous glucose monitoring.
Data drives me to do better.
This is the point. If you don't use the additional info somehow -- like eating or exercising differently based on info like BG fingersticks -- merely adding more info achieves zero.
That should be the takeaway lesson from this study. Just because some people stuck their fingers and gathered BG numbers three times a day does not mean they acted on that info to change their health. Until health pros make this clear to patients, that they need to actually use this info to adapt their lifestyle on a daily basis, there's simply no point in gathering daily info like this. And certainly not at a frequency of 3 or 4 times a day.
Once you've dialed in your lifestyle into regular eating and exercise habits, repeatedly gathering daily numbers is redundant overkill. Gathering BG numbers no more than one day a week should suffice, just to confirm you remain homeostatic.
Gathering info, by itself, changes nothing.
(BTW, I've had T2D for 15 years now. So I've walked the walk.)
That should be the takeaway lesson from this study. Just because some people stuck their fingers and gathered BG numbers three times a day does not mean they acted on that info to change their health. Until health pros make this clear to patients, that they need to actually use this info to adapt their lifestyle on a daily basis, there's simply no point in gathering daily info like this. And certainly not at a frequency of 3 or 4 times a day.
Once you've dialed in your lifestyle into regular eating and exercise habits, repeatedly gathering daily numbers is redundant overkill. Gathering BG numbers no more than one day a week should suffice, just to confirm you remain homeostatic.
Gathering info, by itself, changes nothing.
(BTW, I've had T2D for 15 years now. So I've walked the walk.)
Unless it misleads you. One can "lose" 2 lbs...by weighing before drinking water after a run. Did you really lose 2 lbs?
If you're allowing a single data point to have that much power over what or how you think, you've already lost. Especially if you decide to ignore context like "I just lost water by running and I haven't had anything to drink yet", or even important variables like time of day. The number by itself is meaningless. Data (as in a ton of data points) with context can be incredibly useful. Don't blame the tool if you don't learn how to use it properly.
Oh to be blessed with decent analytical intelligence. Not everyone is, however.
Weight loss isn't really a good analogy. It's much more about trends over time than any individual data point.
When we're talking about diabetics and blood sugar, one data point could be the difference between life and death.
When we're talking about diabetics and blood sugar, one data point could be the difference between life and death.
If you're misled by thinking you lost 2 pounds when instead you just lost some water, you are missing some pretty essential data.
Off-topic: but as someone who's not officially type 2 diabetic but would like to be proactive about measuring their sugar level (I've had my A1c at pre-diabetes levels in the past), what options do I have to secure a CGM?
I've asked my physician but he said he won't be able to prescribe one that's covered by insurance. The DEXCOM website doesn't have a clear MSRP for folks like me.
I've asked my physician but he said he won't be able to prescribe one that's covered by insurance. The DEXCOM website doesn't have a clear MSRP for folks like me.
14 day freestyle libre is $130ish but you can find coupons online that push it down to around $80. Dexcom is in the hundreds per month.
Does a 14 Day FreeStyle Libre cost $130ish per month, or is $130ish a one time fee that one can use 14 Day FreeStyle Libre forever afterwards?
The device has a 14 day lifespan.
Interesting. So it’s fairly inexpensive to get one if you just want to gather data for a short period and get insights about the patterns.
Can you order them over the counter in Canada?
Edit: yes, you can: https://libre.myfreestyle.ca/
$97 CAD for a new sensor, not bad. That’s about $73 USD
Can you order them over the counter in Canada?
Edit: yes, you can: https://libre.myfreestyle.ca/
$97 CAD for a new sensor, not bad. That’s about $73 USD
Ha I've been trying to find one for forever. Can't even find cheap non-fda approved clones from alibaba/aliexpress. Would love to hear if anyone has made some headwind on this. It seems odd that only diabetics are allowed access to the tools that enable CGM. Blood glucose is an important marker of health, diabetic or not.
On the other hand, you can get a normal blood glucose monitor with 100 test strips for under 20$ there. I did this to control my keto diet, and just measured my fasted blood glucose levels in the morning.
The FreeStyle Libre is a way cheaper option (and also way easier to gain access to for those of us in the UK under the NHS). Strictly speaking is not a CGM, as you have to manually scan the sensor to retrieve the last eight hours of data. However, there are devices sold by smaller manufacturers such as the MiaoMiao [1] or Blucon [2]. You mount these devices on top of the sensor (I have heard that wig glue is a good choice to attach it), which then reads the data via NFC and sends it out via Bluetooth to whatever “smart“ device that you may own. Effectively turning your FreeStyle Libre into a “CGM lite”, albeit with lover accuracy than a Dexcom.
[1]: https://miaomiao.cool
[2]: https://www.ambrosiasys.com/our-products/blucon
A word on accuracy, as a type 1 diabetic I have not pricked my fingers once since I got onto the FreeStyle Libre almost six months ago and I am achieving excellent control of my day-to-day levels. Take from this single data point what you may, but I want to offer it as a counter weight to the “need for calibration” I heard before I received the device.
I am currently holding off on getting a MiaoMiao2 until mid-November just to avoid the first few batches of the device that may or may not have manufacturing issues (simply being cautious, I have no evidence). Having easy access to continuous historical data changed my life as a type 1 diabetic, imagine having pain-free and instant access to your levels when you are on the go, stressed out, sick, or just as you wake up in the middle of the night. Then add to this being able to look back eight hours in time to adjust your mental model when things go wrong. It is a matter of night and day. Now I am hoping that turning it all live will make things even better.
[1]: https://miaomiao.cool
[2]: https://www.ambrosiasys.com/our-products/blucon
A word on accuracy, as a type 1 diabetic I have not pricked my fingers once since I got onto the FreeStyle Libre almost six months ago and I am achieving excellent control of my day-to-day levels. Take from this single data point what you may, but I want to offer it as a counter weight to the “need for calibration” I heard before I received the device.
I am currently holding off on getting a MiaoMiao2 until mid-November just to avoid the first few batches of the device that may or may not have manufacturing issues (simply being cautious, I have no evidence). Having easy access to continuous historical data changed my life as a type 1 diabetic, imagine having pain-free and instant access to your levels when you are on the go, stressed out, sick, or just as you wake up in the middle of the night. Then add to this being able to look back eight hours in time to adjust your mental model when things go wrong. It is a matter of night and day. Now I am hoping that turning it all live will make things even better.
Fellow T1D in the UK Here. I'm coming towards the end of my 'trial period' with my FreeStyle Libra and I am shocked at how much I have been able to take control of my glucose levels. I have never had particularly bad control - but finger pricking 4 times a day is like using your phone light in a pitch-black forest. There are so few data points that it is nearly impossible to identify patterns. The sheer amount of data that you have access to with the sensor is amazing. You've gone from 4 data points a day to a minimum of 96 (if you are scanning once every 8 hours). Within a few weeks I had adjusted my basal insulin dose resulting in much more stable blood sugar during sleep which has gone a long way to improve my general health and wellbeing.
One other aspect of the FreeStyle Libre that I was not expecting was a feeling of accountability. When I was just finger-pricking I could essentially hide high blood sugars. Say I had eaten some sweets or something, and forgotten to take my insulin, I could sort of hide from the responsibility of that high reading by just taking my insulin when I remembered and testing in a few hours - my Consultant would never know. However, now I am aware that my sensor is going to read that high sugar, and that makes me feel accountable for it - so I have seen my insulin taking get more consistent, and this has resulted in less hyperglycemia and hypoglycemia (as a result of mistiming the insulin and whatever I have eaten).
On your point about accuracy - I have found it to be a little out in the extreme highs or lows - for example there have been a number of times when my sensor has given me a reading of, say, 2.4. However when finger-pricking I might be 3.9 or 4. Now this could be because the reading is about 15 minutes behind, and since that moment my liver has pumped out some glycogen. But I have had similar accuracy issues when high - say above 18. Having said that, to me this is not a problem, and the accuracy between 4 and 18 is pretty spot on (apart from one sensor that went bananas and was reading at least 15 above what I was for about a week).
One other aspect of the FreeStyle Libre that I was not expecting was a feeling of accountability. When I was just finger-pricking I could essentially hide high blood sugars. Say I had eaten some sweets or something, and forgotten to take my insulin, I could sort of hide from the responsibility of that high reading by just taking my insulin when I remembered and testing in a few hours - my Consultant would never know. However, now I am aware that my sensor is going to read that high sugar, and that makes me feel accountable for it - so I have seen my insulin taking get more consistent, and this has resulted in less hyperglycemia and hypoglycemia (as a result of mistiming the insulin and whatever I have eaten).
On your point about accuracy - I have found it to be a little out in the extreme highs or lows - for example there have been a number of times when my sensor has given me a reading of, say, 2.4. However when finger-pricking I might be 3.9 or 4. Now this could be because the reading is about 15 minutes behind, and since that moment my liver has pumped out some glycogen. But I have had similar accuracy issues when high - say above 18. Having said that, to me this is not a problem, and the accuracy between 4 and 18 is pretty spot on (apart from one sensor that went bananas and was reading at least 15 above what I was for about a week).
Using the freestyle libre. however, i am still doing finger pricks, when i need to figure out my current blood sugar level
and i don't have the time to wait 10 minutes, since the libre has a 10 minute lag.
Kroger, Walmart, and CVS all have identical monitors for around $10, strips are 25 for $12ish.
Unfortunately they are keyed at the end so each stores strips only fit their own device.
Unfortunately they are keyed at the end so each stores strips only fit their own device.
What country is this? I just order freestyle libre online you don't need any doctors receipt for this.
Not an the option for US afaik.
US requires a prescription because it's classified as medical device "class 3"
Isn't that interesting - the UK regulates medicines pretty closely, but I've just tried and I can go straight to the web site and buy one here, no questions asked.
Here in Canada you can buy them at WalMart: https://www.walmart.ca/en/health/home-health-care/diabetes-c...
For those of you interested. Intensive Dietary Management of Type 2 Diabetes has been shown to be very effective at treating and often curing Type 2. Dr. Jason Fung runs the program up in Canada and has written a couple books about it.
My partner recently was declared cured of Type 2 by his very surprised endocrinologist after focusing on dietary management and fasting. His A1C is lower than mine now...
The Diabetes Code: ISBN 9781925548891
My partner recently was declared cured of Type 2 by his very surprised endocrinologist after focusing on dietary management and fasting. His A1C is lower than mine now...
The Diabetes Code: ISBN 9781925548891
Do you know of any results besides those 3 people recounted in this paper?
https://casereports.bmj.com/content/casereports/2018/bcr-201...
https://casereports.bmj.com/content/casereports/2018/bcr-201...
Another anecdotal report but when I diagnosed with T2 early this year I went into overdrive testing after waking up, before bed, and 2 hours after every meal. My doctors said it was excessive but better than the alternative. I gradually learned how to eat without spiking my glucose and now that my a1c is down to 5.4 I've eliminated testing almost completely.
My A1c was awful before I started finger pricking and continued to be so until I started using a CGM. I have dropped to pre-diabetic levels now. I think the problem is the method. I can see why the study came to this conclusion using finger-pricking but having an easier method of checking would probably change the outcome of the study.
Concur. I was diagnosed with T2 about 3 weeks ago. I’ve been on a CGM for about two weeks. It’s been invaluable. Also much less uncomfortable since I’m not tearing my fingertips up.
May I ask what you guys are using?
I've seen the freestyle libre but it still seems like a costly option that most probably couldn't afford.
I've seen the freestyle libre but it still seems like a costly option that most probably couldn't afford.
I started out with a Dexcom but this insurance year they decided they weren't going to cover it because T2D doesn't have a benefit (allegedly). Maybe as a result of this study? I switched over to the Libre and I'm paying $85 out of pocket every month which is worth the ROI. The Dexcom is way more expensive.
Alas, the Dexcom is more accurate and has better calibration, but the Libre if far better covered by insurance options. Self-hackers have to pony up.
Where's the evidence of this statement? It's well known that blood glucose monitors get a wide latitude for accuracy from the FDA anyways so real accuracy would be very difficult to determine.
Why would real accuracy be difficult to determine? Clinicians get to test these on their patient populations and validate against other high accuracy methods (point-in-time serum draws). For instance, Dr. Peter Attia says he gets a useful fraction of his clinic to use CGMs (as well as personal use), and over years sees a strong signal.
There are many other Drs that have gone on record.
There are many other Drs that have gone on record.
Anecdotally - I helped a T1 diabetic friend set up Loop using a Dexcom G5 and then a G6. Over the course of many months of use, the G6 has proved MUCH more reliable and accurate than the G5, which resulted in far better Looping. The Loop community as a group seem to confirm this increased accuracy.
The Libre.
It is somewhat costly ($38 every 2 weeks) but for me it's worth it.
It is somewhat costly ($38 every 2 weeks) but for me it's worth it.
Rather interesting, it just occurred to me that I don't remember what Type 2 diabetic patients that I have worked with in the past did for their blood sugar monitoring. For the most part, I think very few of them monitored daily. Most of their blood sugar testing (fasting blood glucose, hemoglobin a1c) were done at clinic visits.
The only times I can remember daily glucose monitoring was for the insulin dependent (as they need regular monitoring to make sure they are using the right amount of insulin), or those who we were trying to track to give the doctor more information on how to treat, but also to push the patients into making lifestyle changes (not eat that sugary meal in the morning if their blood sugar is already high when they wake up, for example).
Glad to see that the evidence suggests no different in A1c outcomes regardless of what is done.
The only times I can remember daily glucose monitoring was for the insulin dependent (as they need regular monitoring to make sure they are using the right amount of insulin), or those who we were trying to track to give the doctor more information on how to treat, but also to push the patients into making lifestyle changes (not eat that sugary meal in the morning if their blood sugar is already high when they wake up, for example).
Glad to see that the evidence suggests no different in A1c outcomes regardless of what is done.
The article says:
> Of course, there are exceptions. When patients are acutely ill, or changing regimens, or finding that their blood sugar is not well controlled, testing may be appropriate.
So about the regimens: unless the patient eats the same every week (same ingredients, same quantities) without any significant variation, it’s still the way to go IMHO. General guidelines can be followed by the patient but usually they don’t have that much nutrition knowledge to judge if a new food is going to hurt them (besides the most obvious sugary stuff). There are exceptions and all that.
I supported a member of my family who’s gone from pre-diabetic to dangerous levels of A1c (well beyond “need insulin”, more like “go to the ER right now”) and the regular pricking helped a lot to know what could still be eaten (full keto wasn’t an option).
And even this story has a happy end: no insulin and very minimal pre-diabetes medication. Regular pricking still happens when significant (usually healthy) changes in diet happen and it helped to detect what should be avoided. And luckily it’s affordable.
Disclaimer: not a doctor, just a nutrition freak.
> Of course, there are exceptions. When patients are acutely ill, or changing regimens, or finding that their blood sugar is not well controlled, testing may be appropriate.
So about the regimens: unless the patient eats the same every week (same ingredients, same quantities) without any significant variation, it’s still the way to go IMHO. General guidelines can be followed by the patient but usually they don’t have that much nutrition knowledge to judge if a new food is going to hurt them (besides the most obvious sugary stuff). There are exceptions and all that.
I supported a member of my family who’s gone from pre-diabetic to dangerous levels of A1c (well beyond “need insulin”, more like “go to the ER right now”) and the regular pricking helped a lot to know what could still be eaten (full keto wasn’t an option).
And even this story has a happy end: no insulin and very minimal pre-diabetes medication. Regular pricking still happens when significant (usually healthy) changes in diet happen and it helped to detect what should be avoided. And luckily it’s affordable.
Disclaimer: not a doctor, just a nutrition freak.
> finding that their blood sugar is not well controlled
Isn't this everyone with diabetes? Hell of an exception.
Isn't this everyone with diabetes? Hell of an exception.
I believe they mean that the insulin+metformin+diet regimen isn’t keeping sugar in a reasonable range.
They still recommended that anyone on insulin monitor blood sugar, so this refers to people not on insulin...
Thanks, I didn’t read completely.
Interesting aside, I was just reading about a potential link between BPA and Type 2 diabetes: https://www.smh.com.au/national/exposure-to-chemical-in-plas...
"The link held even after the scientists adjusted for food intake, weight and physical activity."
Is there anything BPA can't do? ;)
"The link held even after the scientists adjusted for food intake, weight and physical activity."
Is there anything BPA can't do? ;)
Is there any metric besides A1C for "type 2 diabetes"? A few years ago, I went to a doctor and my A1C was 8 something (among other issues...). I ate low-carb a couple months, and the doctor was impressed my A1C went down to 5.1 or whatever. I sorta wonder if it's a https://en.wikipedia.org/wiki/Goodhart%27s_law thing..
I know someone who works at a clinic that serves diabetics without health insurance who cannot afford routine glucose monitoring. A majority of the patients show up with A1C of 10 or higher, often much higher. If uncorrected, this is tragic. A finding that most people will not find a way to comply effectively with a plan to scientifically manage T2D is not, to me, a convincing reason to make scientific management less available to all.
Yep. But the key issue is that patients need to be helped into diets that will be lower in carbs and provide more effective A1C control. I think the fact that you can see what happens to your glucose after every bite of food you take is a powerful incentive to improve your diet.
No meds are going to reduct A1C of 10 or higher to even moderately high levels of 8 or so without serious dietary changes.
I personally got my A1C down from 11 to 5.4 in 5 months with diet, exercise and meds but from my doctors own comments and my research the meds (Metformin and Victoza) really only contribute maybe 1.5 point reduction. If I have an A1C of 9.5 instead of 11 it's not going to make much difference. But at 5.4 I'm essentially normal.
No meds are going to reduct A1C of 10 or higher to even moderately high levels of 8 or so without serious dietary changes.
I personally got my A1C down from 11 to 5.4 in 5 months with diet, exercise and meds but from my doctors own comments and my research the meds (Metformin and Victoza) really only contribute maybe 1.5 point reduction. If I have an A1C of 9.5 instead of 11 it's not going to make much difference. But at 5.4 I'm essentially normal.
I agree completely. What the double-digit A1c people need first is to understand where they are headed, which the test substantiates if the practitioner has the nerve to spell it out. What to do about it is a different part of the problem. I am paywalled out of the article, but the word 'routine' is grievously vague to me. It could mean anything from an annual A1c to quarterly A1c's, with glucose monitoring anywhere from hourly to never.
http://archive.is/Fhlt9
Since diabetes are heart diseases are tightly coupled it's prudent to monitor blood pressure everyday
Since diabetes are heart diseases are tightly coupled it's prudent to monitor blood pressure everyday
It's no different to me than frequent weighings. I'm sure some people don't need or want the feedback but for me it's essential.
And using a CGM (I use 14 day Lifestyle) I can get readings whenever I want and also get data like trends that I can't get from finger sticks. I can see my blood glucose overnight for example which helps me tailor my meds and food to avoid the common overnight glucose rise that's pretty common.
So sorry NYTimes article but I'm going to disagree. I don't think enough people are encouraged to use CGM for example so that some real data can be extracted on diet compliance.