
Routine glucose monitoring may be unnecessary for people with Type 2 diabetes - signor_bosco
https://www.nytimes.com/2019/03/11/upshot/a-diabetes-home-test-can-be-a-waste-of-time-of-money.html
======
SpikeDad
It wasn't for me. Individual anecdotal stories aren't evidence but without
consistent feedback it's easy to get back into poor habits. When I eat a
Twizzler and see my blood glucose spike at 180-200 FOR 1 TWIZZLER then it's
the feedback I need.

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.

~~~
jp555
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.

~~~
friedegg
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.

~~~
jp555
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=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAlowggJWBgkqhkiG9w0BBwagggJHMIICQwIBADCCAjwGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMuFO-
SV_7okpNmLHhAgEQgIICDWztyhmOsY057_KpYdVzU3p15v1M_ZE5Ml_XBAE2FZtygnMHfpOqqFFDLo5jmo8eAz_fCn93UBQJl77W3Cf-k8txFwzdz8BB_R1FBWw5h3nkJfFYfCPnKif-j2GmYwLEPW-
KxOKD1aYk925gwRxJZYXXKoCryEvvC7iwyPxuokjFAEp2-S6lflTJrh6DBvGP0AMidJc3BUv7Q6v9XrU6P7guJT5juHvLDuHg4lJ-
RQNEFXAHvv9U3sVDZww5ICVOlLyMpyTc0ZBaQm7EtNQ4wMauiJfbfjXFIcalSuweT1qGdLDaOTOEnfvsIlMTQEwIY310a98VtmLKOabtjXnhXHrPzt_t3iKCsUu6R9gb3PcrjO1csejtJrtPiUQ19SOpGH92WeLID6C918WNeIMXBXIN6kGaqvZ7lO2Migd0LyC0iIS1TJk9jqnGaSbpWMYA10-0KiJX9xldO-3kdOcaKHWn7Hh1iFRzMeDkjvqXtIV5l-gnJj8DNUAIokkwEi09w2RSnwOxbkLh_KMou_EQVbwRg6Qrk6ZNqjKevXBF6a0HxeE6ubKKKsjgcFpm6lkA-
BMAJfXrQihC3c168BoJwuM9WI1y_g_FMpeKFLxgMNjNFxHYu_JR6M6ILlW1bQqEF5da8ewZn2XvocACK9vHN3apQOvUwQYGMuf4JQaEdJ7LeikzHN2bkrALpyZqAw#page=1&.).

------
fizwhiz
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.

~~~
nikkwong
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.

~~~
ninjin
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](https://miaomiao.cool)

[2]: [https://www.ambrosiasys.com/our-
products/blucon](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.

~~~
trampypizza
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).

------
foxyv
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

~~~
James_Henry
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-2017-221854.full.pdf)

------
jwhite_nc
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.

~~~
TylerE
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.

~~~
uniacid
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.

~~~
jwhite_nc
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.

~~~
jeremyw
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.

~~~
SpikeDad
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.

~~~
jeremyw
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.

------
epmaybe
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.

------
known
[http://archive.is/Fhlt9](http://archive.is/Fhlt9)

Since diabetes are heart diseases are tightly coupled it's prudent to monitor
blood pressure everyday

------
outime
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.

~~~
darkerside
> finding that their blood sugar is not well controlled

Isn't this everyone with diabetes? Hell of an exception.

~~~
projektfu
I believe they mean that the insulin+metformin+diet regimen isn’t keeping
sugar in a reasonable range.

~~~
darkerside
They still recommended that anyone on insulin monitor blood sugar, so this
refers to people not on insulin...

~~~
projektfu
Thanks, I didn’t read completely.

------
nycbenf
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.

------
hnick
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...](https://www.smh.com.au/national/exposure-to-chemical-in-plastic-
linked-to-type-2-diabetes-study-finds-20191030-p535r3.html)

"The link held even after the scientists adjusted for food intake, weight and
physical activity."

Is there anything BPA can't do? ;)

------
kwoff
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](https://en.wikipedia.org/wiki/Goodhart%27s_law)
thing..

------
lucas_membrane
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.

~~~
SpikeDad
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.

~~~
lucas_membrane
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.

