The power of short-term glucose monitoring as an educational preventative

A 48-year-old woman with an A1C of 5.8 and a fasting blood sugar of 5.7 has just walked into the pharmacy after her doctor’s appointment. While filling her regular blood pressure medication, she asks you about her risk for diabetes as her sister was just diagnosed with type 2 diabetes and has now been prescribed metformin. This patient also struggles with her weight and she admits that her eating habits have been limited to frequently eating at restaurants and ordering fast food. What would you do for this patient? Would you consider offering a consultation on diabetes risk reduction? Would you suggest a referral to a dietician? Would the short-term use of a glucose monitor be a viable tool for patient education in this case?We know that being a woman who is over the age of 40, hypertensive, overweight, and with a diabetic first-degree relative are all risk factors for diabetes. In fact, 80-90% of type 2 diabetes patients are overweight or obese. Unfortunately, this is a patient profile we see with increasing frequency in community pharmacy.Could the offer of lifestyle education, delivered by a community pharmacist, and use of a continuous glucose monitor (CGM) prior to a possible diagnosis of diabetes or even prediabetes be something patients might appreciate being offered, even if they had to pay out of pocket for this service? The International Diabetes Federation estimates that 537 million adults suffer from diabetes worldwide and that this number is predicted to rise to 783 million by 2045.1 According to Health Canada, the incidence of both type 1 and type 2 diabetes is expected to rise (by threefold and by fourfold, respectively) in youth in the coming decades.2It is undeniable that CGMs have revolutionized diabetes care as we know it. These devices have improved the lives of millions of people globally, but do they have a place in preventative care for patients who have risk factors, yet do not have a diagnosis? Before proceeding, we must acknowledge that due to the lack of foresight when it comes to preventative medicine in our country, and therefore a lack of funding, this type of intervention, at present, may not be feasible for many of our patients. Diabetes in Canada remains entangled with health disparities, most often affecting individuals with a lower income and the socioeconomic disparities and environmental factors that dramatically increase one’s risk for diabetes should not be understated. However, considering our current reality, for those who are looking for a way to prevent disease and have the means to invest in their health, are we withholding a potentially lifesaving tool from our patients if we neglect to offer them the option of using a glucose monitor, even for just a short period of time?While writing this article I ran two public polls asking the following question: “Imagine you are at risk for type-2 diabetes. Should your healthcare provider offer you a continuous glucose monitor to help you (possibly) prevent diabetes and manage your sugars better prior to diagnosis (private pay) or offer this only after diagnosis to manage the disease (government-funded)?After 99 responses, both poll results were almost identical with 84.5% of respondents selecting “I would pay for prevention” over “After diagnosis.”The Hawthorne EffectThe Hawthorne effect, also known as the observer effect, refers to a phenomenon that occurs when a participant’s behavior changes as a result of being observed.In his recent book Outlive, Dr. Peter Attia believes he has witnessed a form of the Hawthorne effect in his own patients when they use a continuous glucose monitor for even just 1-2 months as part of his (private pay) longevity practice. In contrast to the traditional approach of relying solely on HbA1C, and fasting glucose values, Dr. Attia asks his patients to wear a CGM prior to a diabetes or even prediabetes diagnosis. The advantage here is that in this case the (healthy) patient is given real-time data as to how their body responds to different foods, and to different forms of exercise, as well as historical data that can be reviewed with their healthcare provider to help identify upward spikes and crashes that they would not otherwise have known how to manage.In the book, Dr. Attia notes that the use of CGMs does not have to be long-term to cause significant behavioral change. As previously mentioned, he generally uses this type of intervention for only one to two months in order for the patient to first understand what increases their glucose (month 1), and then adjust their behavior accordingly (month 2). Dr. Attia credits this phase of behavior modification as being largely due to the Hawthorne Effect. His patients, aware that their dietary choices are in some way being observed and recorded via their blood glucose meter, eventually begin to make choices that will keep their blood sugar steady, for example. This new awareness and change in behavior seems to last well beyond the time when patients stop using their CGM. “I find the Hawthorne effect persists, because they know what the bag of potato chips will do to their glucose levels,” he says.A personal accountAs biowearables and digital tracking devices become more widely available, a legitimate concern is whether the indiscriminate use of these technologies could lead to unnecessary anxiety among users. I was fortunate enough to be able to test out the Freestyle Libre 2 myself while writing this article. I noticed that after the first eight hours of obsessively checking my readings, I often forgot that I was wearing the device. In contrast to other devices like smart watches or fitness trackers, for example, I believe that having a CGM sensor out of sight on the back of the arm, rather than on the wrist, allowed me to go through the day often forgetting about it completely. I can certainly see, however, that for the general public, interpreting these readings without any form of education or follow-up from a healthcare provider could easily lead to confusion, and possible misinterpretation of the data, and yes, even anxiety.The need for diabetes preventionThough there is a paucity of research on CGM interventions for those without a prediabetes or diabetes diagnosis, we do have some data that appears to favour the use of real time glucose monitoring for those with a diagnosis when it comes to their ability to promote positive lifestyle modification.One small study (n=32) looked at whether the use of Flash Glucose Monitors in patients with prediabetes would be an acceptable and feasible way to encourage lifestyle change. Of the 32 participants, 26 participants either agreed (n=7) or strongly agreed (n=19) that “wearing sensors reminded [them] to stay healthy daily” and 25 participants expressed interest in using the CGMs once the study was over if given the opportunity to do so.3In a separate 12-week RCT study involving 126 participants with type-2 diabetes, the SEOUL (Self-Evaluation of Unhealthy Foods by Looking at postprandial glucose) algorithm explored whether intermittently scanned continuous glucose monitoring (isCGM) encouraged patients to make lifestyle changes, based on their post-prandial blood sugar levels. When compared to the standard of care, this study found significant improvements. In this case, A1C levels decreased by approximately 0.50%, indicating better overall blood sugar control, and participants lost an average of 1.5 kilograms, suggesting a positive impact on weight management.4These findings suggest that regularly monitoring post-prandial blood glucose levels by using isCGM, along with personalized dietary adjustments, can be effective in improving glycemic control and weight management for people with type 2 diabetes.5The true cost of ignoring diabetes preventionDiabetes Canada estimates that out-of-pocket costs for people diagnosed with type 2 diabetes can be as high as $10,014 per year in some areas of Canada.6In addition to the time, energy and expenses that patients will undoubtedly incur in managing diabetes, we know that patients with diabetes may develop heart disease as much as 15 years earlier than those without diabetes, and the risk of stroke, as well as hypertension, diabetic retinopathy, neuropathy, and nephropathy are all complications associated with this progressive disease. We also know that these patients are also more likely to struggle with mental health issues. These complications impose a considerable burden on both individuals and their families while further straining our already overwhelmed healthcare systems.The whole pictureThe lack of education and access to care when it comes to diabetes prevention continues to be incredibly challenging in many areas of Canada. It’s also important to note the data provided by CGMs are just one part of the clinical picture when it comes to diabetes.Dr. Brendan Byrne, co-founder and chief medical officer at LifestyleRx, a fully government-funded online platform that focuses on diabetes reversal for both diabetic and prediabetic patients in BC, Alberta and Ontario, is quick to note that although CGMs can be a powerful tool for both pre-diabetic and diabetic patients, “if you are not diabetic, CGMs may not give you the full story as they do not measure insulin response. You may have normal blood sugars on CGM and still be insulin resistant.” However, when it comes to data, Dr. Byrne also notes that “CGMs give you direct feedback that is impossible to match.”Dr. Fairuz Siraj PharmD, CDE noted that in terms of lifestyle, patients who have access to the appropriate education, combined with the use of a CGM would likely be more aware of how diet and exercise will affect their glycemic control and thus they will be able to make better choices to prevent diabetes, though he points out that not every patient who is at risk for diabetes will go on to develop diabetes.The opportunityIt has been reported that “as a result of the pandemic, digitisation took a seven-year leap ahead in the adoption of some products and services” in particular in the field of health care.7Throughout the pandemic, the public increasingly embraced routine health monitoring through apps to update their Covid-19 status, document their mental health, and utilize devices for tracking daily exercise levels. This marked a significant shift towards a digitally savvy, and proactive patient who recognizes the advantages that technology can offer when it comes to their health. Though governments and third-party payors may be slow to recognize the power of prevention when it comes to chronic disease, the tide has changed when it comes to the health- conscious consumer. Many of our patients are more focused than ever when it comes to being an active part of their healthcare plan. This includes embracing opportunities that allow them to prevent disease, improve their quality of life, and (hopefully) extend their health span (i.e., the number of years or decades a person is able to live well without disease).As the role of the community pharmacist further expands beyond the confines of the dispensary, the potential for pharmacists to offer evidence-based clinical consultations that focus on education and even possible prevention of chronic disease is likely to be welcomed by the public.For the motivated patient who is interested in prevention, the short-term use of CGMs, together with the personalized care, education, and follow-up of their local pharmacist could indeed prove to be an invaluable tool for the prevention of type 2 diabetes. Lindsay Dixon is a pharmacist, consultant, health content creator, and Public Health Ambassador for Heart Pharmacy Group in Victoria, BC. She is also the founder of Friendly Pharmacy 5 and CreateRx. ReferencesWhy Alphabet, Amazon and Apple are all working on diabetes tech: CNBCPublic Health - Framework for diabetes in CanadaFeasibility and Acceptability of Using Flash Glucose Monitoring System Sensors to Empower Lifestyle Changes in People With Prediabetes. PubMed.Effects of Patient-Driven Lifestyle Modification Using Intermittently Scanned Continuous Glucose Monitoring in Patients With Type 2 Diabetes: Results From the Randomized Open-label PDF Study. PubMed.The College of Family Physicians of Canada suggests that the effects of continuous glucose monitoring in diabetic patients may be of minimal clinical significance (type 1) and HbA1C effects (type 2) may be inconsistent.Diabetes and Diabetes-Related Out-of-Pocket Costs - Diabetes CanadaSensors and sensibility: the future of personal health - Financial Times - Partner Content by Abbott (ft.com)

The power of short-term glucose monitoring as an educational preventative

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