Diabetes management is, at its heart, blood sugar management. The continuous glucose monitor (CGM) is the best tool yet invented for tracking and understanding blood sugar changes.
While many Americans with type 1 diabetes now have ready access to the technology, the situation is very different for the more than 30 million with type 2. Insurers have been reluctant to cover the cost of the device, especially for patients that do not use insulin.
Thomas Grace, MD, wants to change that:
“It seems ridiculous to me that people with type 1 have very good access to this technology, but that people with type 2, who also struggle with glucose management, don’t.”
“My big push is to get everyone with diabetes access to CGM, regardless of type of diabetes.”
Dr. Grace is the medical director of Ohio’s Blanchard Valley Diabetes Center, and he’s embarked on a grand experiment to prove his point. With help from Dexcom, one of the leading CGM manufacturers, Grace has distributed hundreds of CGMs to people with type 2 diabetes that do not use insulin — the patient group least likely to be prescribed a CGM.
It’s very much a real-world experiment. Participants receive only minimal training and are left to utilize the CGM data in any way that they wish. The intent is to measure the effect of the CGM alone, without any coaching to guide patients’ experiences.
How’s it going? “I’m flabbergasted at how awesome the results look,” Grace shares.
A “Lifestyle Modification Tool”
The CGM is a small device worn on the body that measures blood sugar 24 hours per day. A Bluetooth transmitter sends the data to a smartphone or a dedicated receiver device.
It’s a huge leap forward from the method that most people with diabetes still use to measure their blood sugar — stabbing the fingertip with a lancet, and inserting the drop of blood into a dedicated meter. The old process is both cumbersome and painful, and many people with diabetes frankly prefer to avoid it. Even those that meet their doctors’ expectations — the American Diabetes Association recommends that insulin users “should check at least four times a day” — have a very incomplete understanding of how their blood sugar behaves throughout the day.
A CGM, by contrast, gives a complete picture. Users can see their blood sugar level at any time of day, even overnight, and can easily see the glycemic effect of food and exercise choices.
Grace, who has type 1 diabetes and uses a CGM himself, describes the CGM as “a lifestyle modification tool.” As he explained it, clinicians can advise healthy lifestyle changes “until we’re blue in the face,” but if patients aren’t regularly monitoring their blood sugar, they won’t actually see the effect of those changes.
“We can tell patients, ‘Don’t drink regular sodas, don’t eat a billion carbs,’ but it’s not until they can see that their blood sugar goes up to 400 mg/dL that they’re like, ‘Oh yeah, this is why I shouldn’t do that!’ That’s the power that this tool provides.”
“It helps people figure out what they should be doing with the disease of diabetes.”
Grace has already completed one small study, published in January 2022. This trial gave CGMs to 38 adults with type 2 diabetes from his clinic. The volunteers had an average age of 55, an average BMI of 35.6, and an average A1C of 10.1 percent, far above the targets set by diabetes authorities. Fewer than half used basal insulin, and none used rapid meal-time insulin.
Six months of CGM use appeared to result in enormous changes: an average A1C reduction of 3.0 percent (from 10.1 percent down to 7.1 percent).
The impressive scale of the results may be partially explained by how much room for improvement these patients had: “Some of these patients weren’t taking their medications until the CGM showed them that the medications worked,” Grace told Diabetes Daily.
One participant was so enthusiastic about his experience that he offered his own money to help Grace repeat the effort with a much larger scope. Dexcom stepped in to donate sensors, though it should be noted that their heavy involvement in the study (and obvious interest in positive results) may provoke some skepticism.
The Community Glucose Monitoring Project
Grace’s new effort, dubbed the Community Glucose Monitoring Project, is taking place right now. This larger experiment, which has enrolled hundreds of Ohio residents, differs significantly from Grace’s earlier efforts in a major way — this time, he’s not using his own patients.
Instead, family doctors in the surrounding area refer eligible diabetes patients to the health department, which distributes CGM supplies. Study participants are given minimal training with the technology, and are not instructed to check in with their clinicians any more than usual. To put it simply, they’re given only the bare minimum of support. Grace wants to show that people with diabetes do not require coaching and hand-holding to get the most out of their CGMs.
“They’re kind of left on their own.”
“The CGM takes the responsibility out of the hands of the physician and puts it into the hands of the patients. And these patients are eager to take care of their diabetes when they have access to their glucose readings.”
Grace revealed some of the earliest data at a recent conference: the first 31 patients to complete six months of CGM use enjoyed a drop in A1C of 2.8 percent. He couldn’t divulge any more, but promised Diabetes Daily that the other early numbers “are very similar, if not better” than the results of the first trial.
We can expect more data in June, at the American Diabetes Association’s annual scientific conference. In the meantime, Grace is considering how to maximize the impact of his findings so as to best strengthen the argument in favor of CGM use in type 2 diabetes.
Will Insurance Pay?
The big question isn’t whether or not CGM technology is potentially helpful for people with type 2 diabetes. The question is whether or not health insurance companies, including government programs like Medicare and Medicaid, can be convinced that it’s worth paying for.
CGMs are not cheap (at this writing, a month’s worth of Dexcom G7 sensors can be purchased over-the-counter from Amazon for $178), but that cost could easily pay for itself if it delays or prevents treatment for severe diabetes outcomes, such as advanced kidney disease. CGM technology is also much less expensive than the new advanced drugs, like semaglutide (Ozempic), currently taking the diabetes world by storm.
Several years ago, the use of the CGM was mostly limited to people with type 1 diabetes, a condition that entails a very high risk of dangerous hypoglycemia (low blood sugar). CGMs can sense low blood sugar and sound an alarm, alerting the user to take action. It’s a feature that can save lives. People with 2 diabetes tend to have less hypoglycemia and therefore less need for such alarms. It’s one major reason that insurers have been slow to pay for the devices for this group.
Not all experts agree that people with type 2 stand to benefit from the use of CGM technology. In 2020, for example, the American Family Physician published an editorial arguing that CGM use was pointless and excessive in most patients with type 2: “there are no patient-oriented benefits to justify its great expense and additional hassles for patients and physicians.” But newer studies have strengthened the case.
Insurance coverage is now expanding for CGM devices for type 2, with the technology more accessible to groups with higher risks of hypoglycemia. Patients that employ “intensive” insulin management now have fairly robust coverage for CGM devices in the United States. Those that use only slower-acting basal insulin are less likely to have coverage, though that is changing. Finally, people with diabetes that do not use insulin at all are only rarely prescribed CGMs at this time, a situation that Grace dearly wants to change.
“This may not be a lifesaving tool for them, as it is for me. But they learn! They learn about what they’re eating, they learn what happens when they take their medications, they learn the benefits of physical activity.”
The results of Grace’s experiments have only strengthened his belief that CGM can be a game-changing technology for people with diabetes that do not need insulin.
“I used to think that CGM was really important. Now, I think it’s the most important thing for getting diabetes under control.”
“When you have CGM, you no longer have to fight diabetes. You live with it.”