Shireen: In today’s episode, we are in conversation with Dr. Sara Mandy Reece, who discusses what continuous glucose monitoring or CGM is. And how does technologies revolutionizing diabetes management. Dr. Reece shares the benefits of CGM, how it defers from traditional blood sugar monitoring devices and much, much more. Stay tuned to learn more about this exciting technology and its potential to transform diabetes management.

Dr. Mandy Reece is a clinical pharmacist and educator with extensive experience in various avenues within the practice of pharmacy. She provides diabetes management and education services within a family medicine clinic in Gainesville, Georgia. Welcome, Dr. Reece.

Dr. Reece: Thank you. I’m excited to be here with you today.

Shireen: An absolute pleasure having you on. Dr. Reece. I want to dive right in, because I’m really excited about our topic today. I feel like there’s so many questions around it. You have just this extensive and diverse background within pharmacy. Can you share with us how your expertise in this field has given you this unique perspective on diabetes management and medication?

Dr. Reece: Yes, absolutely excited to share that. My journey, as I kind of call it with diabetes, began when I was working with an employer and training pharmacist to service coaches for people living with diabetes. And it really gave me early on the sort of boots on the ground, what’s it like to walk in the shoes of a person with diabetes.

And then the opportunity to work in public health. I was able to work with women with gestational diabetes in a safety net clinic and to provide education for persons with diabetes who were in a public health clinic. And now working in family medicine with diverse sort of population of folks with diabetes.

So, sort of seeing it all the way from employer folks who work for companies getting support for diabetes to public health, to family medicine where we see folks young and old and in between with diabetes.

Shireen: That is so fascinating. I do want to talk about one of this question that we get almost all the time around CGM or Continuous Glucose monitor.

Can you start by explaining what a CGM is and how it works? And also, I want to then get into how it is different from sort of some of the traditional glucose meters. But first let’s start with, what is this term that gets thrown around everywhere?

Dr. Reece: Yeah. And it’s a big long term. It’s because there can be kind of scary for folks when they first hear it.

Well, basically it’s a device that sits on the skin and there’s a little plastic sensor just underneath the skin. So, it’s not a needle, it’s just a little plastic piece with sensors and it’s sensing what the glucose is. In the interstitial fluid, which is between the skin and the bloods, kind of the layer above the blood and it’s sensing what the glucose is either every minute or every five minutes, depending on the device.

And then the sensor that sits on top will communicate with either a reader or an app on the phone to tell a person what their glucose trending. And what makes it different is it’s like taking a video. If you’ve ever been to an event, maybe in the springtime, you like to go to botanical gardens and you video the beautiful roses and the tulips and the daffodils and seeing all of it.

You capture all of that in the video. Which is very different than if you just take single snapshots with maybe the camera on your phone. And I like to compare blood glucose finger sticks you’re checking the glucose in the blood and you’re taking pictures, so you get snapshots in time of what the glucose is, but it doesn’t give you the full story.

And with continuous glucose monitors, because the values are coming in every minute to every five minutes, it’s telling a story about the trends in the glucose for that person living with diabetes.

Shireen: Now if I’m someone with diabetes and I’m used to pricking my fingers first thing in the morning because that’s what my doctor told me to do, and then again after a meal, how is what you are saying different from what my doctor told me to do with the traditional meter?

Dr. Reece: Sure. I describe it as the big difference is the work is being done for you in many senses, so you don’t have to remember to get up and prick your finger certain times, like the day as if thoughts by your healthcare professional. Rather, you’re wearing the sensor on either your arm or your abdominal area and the work is being done for you and the sensor is placed every 10 to 14 days, depending on the device, and the person changes it out.

Now, some devices do require a person to use a reader or scan, so there is some work in terms of, you got to remember to scan either with the reader or your phone app. Other devices, other continuous glucose monitors simply don’t require that. The information, the glucose data is being sent either to the receiver or to the app on the phone.

So, the person can simply open up their receiver to look at the screen, turn it on, or pull up the app and boom, you got the information there. Kind of like you go for a walk and you’re wearing some type of device, like a Fitbit. It’s going to track all sort of things that happen during that walk and you’re not really doing work for that to be captured. You’re just going to look at your device to see, oh my goodness, okay, I got all this good information.

Shireen: I absolutely love that. And I do want to go into what are the benefits of a CGM? So, you mentioned something about collecting information minute to, I believe the range you gave was between one minute to five minutes. Can you help us understand how, again, that is different from how we traditionally check our blood glucose?

Dr. Reece: Yeah, absolutely. So, where we traditionally check glucose, we get snapshots in time. So, let’s say I’m a person with type two diabetes and I check my blood sugar when I get up in the morning time and I can see, okay, kind of where am I at in this point in time, and I can see the impact of what happened overnight while I was sleeping.

As my liver was putting glucose out into my blood to maintain my blood sugar. Or I can see the impact that my meal or snack last night had. And then let’s say I checked two hours after dinner. And I check twice a day. So, when I’m checking two hours after dinner, I can see, okay, what impacted what I ate from that evening meal have on my blood sugar. With the continuous glucose monitor, I’m going to be able to see throughout the day the impact of all of my dietary choices on my glucose.

Also, maybe I am just not a big fan of going for walks, but I’ve agreed to do it because I know it’s good for me, but I’m not completely sold on it. And so, the information from the continuous glucose monitor can say, hey, guess what? I went for that walk and my glucose went down by 50. Wow, that’s great. Or you know, I had pizza at lunch because pizza’s important to me and I want to be able to have my pizza and I can see I had one slice and maybe I had a side salad.

And then I can see what happened to my glucose after I ate that because culturally depending on a person’s culture and foundational foods for their particular culture, living with diabetes doesn’t mean you have to cut foods out. So let me give you an example. So, if I was a person of Indian origin from the country, India, that is. And rice was a foundation to my diet, telling me that I could not eat rice when I’m diagnosed with diabetes would be stripping me of my cultural identity, and that’s just not acceptable.

What the continuous glucose monitored would allow me to do is my cultural foods that I eat. It can tell me which ones really work for me, which ones maybe don’t work for me as much. So, when I say that they don’t work for me as much. Maybe I need to change my combination of foods, how much I eat, and it really gives me that feedback in real time on what’s happening with my dietary choices, my medication, and my physical activity.

I’ve literally seen people and it worked with people. Who they were taking their medications, they were struggling with changing their dietary habits because they were long standing, and it was a real challenge in their A1C, which is an average of the glucose for the last three months as a percentage, we want it to be less than seven that’s kind of a general percentage.

But this person had an A1C of 11. Then they started wearing a continuous glucose monitor, getting feedback on what was happening with their dietary choices. We learned that he was actually having low blood sugar. And then overcorrecting because he got really scared, which is understandable.

And then he ended up with high blood sugars. So that’s an example of where lifestyle medication all comes together, and that CGM really gives the needed feedback for the big picture of what’s going on.

Shireen: Absolutely. Love that. And, going back a second to what you mentioned is I love the fact of when you spoke about the data side of it. To say, well, when you’re using the traditional sort of pricking your finger testing your blood glucose, Not only is there the hassle of doing that and remembering to do that and doing that consistently when time and again, pricking yourself who wants to prick themselves?

Absolutely no one. So not only are you having to do that, but you’re getting this snapshot of data that is just one data point. Versus what I’m hearing you say on the CGM side it is continuous CGM, continuous glucose monitor, it’s continuously sort of checking the glucose in your blood.

Every, like you said, even if it is five minutes. What I’m hearing you say then is if I’m eating something. Five minutes after or few minutes after that, immediately I can start seeing how that food I’m consuming, or the exercise I am doing is having an impact on my blood sugar. So, what we’re getting is a bunch of data points throughout the day. Without having to prick yourself.

Dr. Reece: Yes. So no longer, and I hear this time and time again as people will share with me and they say, I feel like a pin cushion, so no more feeling like I’m a pin cushion.

Shireen: I love that. And I also like the fact that it takes some of the guessing out, right? Like, how am I feeling? Is it, am I feeling kind of woozy because of this? And it just takes all of it out. So, you just quickly note your data with that five-minute lag or whatever few minutes lag that you have, and you quickly have that information.

Now I want to go back a second to the pricking part. How is it testing my blood sugar without pricking me? So, walk me through the logistics of how it works and exactly how. And then we’ll go into sort of how long it lasts and then changing it out and the longevity of a device as well.

Dr. Reece: Okay. Sure. Absolutely. So, depending on the device there is basically and I’ll kind of talk about some products specific cause I think it’s helpful and I’m going to mention ones that we use a good bit in primary care. That’s sort of commonly used by a lot of folks with diabetes, at least in primary care.

So, one is the Libre 2 and the Libre 3. And they’ve sort of made some minor sort of changes between the two devices in terms of the number of steps that basically it’s just uncapping the box, or it comes as a in a box. And basically, it’s taking off the top attaching a bottom piece to it

For the Libre 2 and for the Libre 3, it’s just uncapping and twisting it off, and then putting the applicator on the arm and then pressing down. That’s all that’s involved. And then what happens is what that uses a needle to get the sensor, which is just a little plastic cannula, just a little piece of plastic that has sensors attached to it underneath the skin

And then the applicator’s removed. So, the other weight. This is really kind of cute. I had somebody who just didn’t understand. They thought the big applicator, they were going to have to wear that the whole time. I’m like, no, no, no. It’s just used to apply it and then you’re going to have your sensor on your skin.

Dexcom, the G6 is different than the G7. So, the G6 has two parts to it. It has a sensor that sits on top of the skin and then a transmitter that sits on top of the sensor, which communicates with a receiver or with the app on the phone. And so that is applied to the abdominal area and it basically it’s a larger applicator and it just kind of peel back some of the paper, place the adhesive part of the applicator on the skin and then press the button and then the transmitter is placed on top of that.

The Dexcom G7 is applied to the arm and its actually kind of all in one, which is really nice. So, the sensor and a transmitter are all in one, and it’s similar to the FreeStyle Libre, in that it’s kind of like a twist top. So, you twist off the smaller applicator to take the base off. You apply it to the arm, and you press a button. And then the sensor is actually applied to the arm again using a needle. The plastic piece, the cannula with the sensors on it is put underneath the skin, but the needle’s removed.

 So that is one point I really want to emphasize. Nobody with a continuous glucose monitor is walking around with a needle and their arm because that’s one thing that folks sometimes will share.

They’re like, oh my gosh, I’m scared, and we have a needle in my arm. I’m like, no, no, no. You’re not going to have a needle in your arm. Folks are typically relieved when they hear that good news.

Shireen: And what I’ve also kept up with is seeing that some of them, in terms of like as they evolved, it seems like the more newer models don’t need that waving of the phone or the reader on top of the sensor itself. Now, it just syncs up on its own and just updates automatically in the app on your phone as well.

Dr. Reece: Yes. Absolutely. Yep.

Shireen: And so, one more step that is reduced for us. And then what happens from there. So, I keep it on my arm and then leave it on for how long?

Dr. Reece: So, for the Libre the FreeStyle Libre, or the 3, it’s 14 days. For Dexcom, it is 10 days for the sensor, for the Dexcom G6.

Just one clarification I want to provide is the sensor is changed out every day, and the transmitter, which sits on top of the sensor lasts three months. The all-in-one system with the Dexcom G7 with a sensor, a transmitter in one is changed out every 10 days.

Shireen: Gotcha. Okay, so far, so good. It is sounding great. And so now what I would like to understand from you is, why aren’t we all using CGMs? Like why isn’t it being given out like candy to everyone who at least has diabetes?

Dr. Reece: Yeah, absolutely. That’s a great question. Technically, I mean it’s, I will say they were FDA approved for use in persons with diabetes.

And so, they can be used for persons with diabetes. The barrier comes into at times is cost. Where a person financially can’t afford to pay for it. And many commercial plans, insurance plans. So, if a person works for, an employer and has a plan through their employer they will have coverage, certainly if they have type one diabetes for a continuous glucose monitor.

Often, but not always for type two if they’re on at least one dose of insulin per day we’re seeing pretty good coverage there. And then for Medicare patients, there is coverage for both the traditional Medicare as I kind call it, A and B. For those who have type one diabetes or if they have type two.

For the persons with type two, they have to be on one dose of insulin per day, or have something called problematic hypoglycemia, which is low blood sugar on at least two occurrences. Now, Medicare’s working out the details on the problematic hypoglycemia or low blood sugar, what they’re going to require in documentation.

Where it can get a little hairy is many folks will have Medicare Advantage plans, and there’s not always consistency with the Medicare Advantage plans in terms of coverage for continuous glucose monitors, particularly for those with type two. I think we’re going to see some changes with that now that Medicare A and B has changed to wear for type two at least one dose of insulin per day, or problematic hypoglycemia.

There’s another group of folks who have coverage through state Medicaid plans. Which varies from state to state in terms of getting coverage for continuous glucose monitors. This legislative session in Georgia, which is where I live, we worked with the American Diabetes Association on some legislation for a continuous glucose monitor for persons covered under Medicaid.

Meeting certain criteria especially type two because that’s the folks oftentimes with Medicaid that don’t get coverage. And to remove some of the barriers. We weren’t successful this legislative session, but we’re not giving up. So, each state is different in terms of their Medicaid requirements.

So, it really comes down to oftentimes, insurance coverage. What is covered; less so for type one, more so for type two. In terms of coverage for continuous glucose monitor, the least expensive on the market I will say is for folks with commercial insurance. The pre-sale Libre can be reduced to $75 per month. And then Dexcom’s come out with a new program as well to decrease the cost for copays.

There is an option for folks to get if we can’t get coverage for a personal continuous glucose monitor, which means the person with diabetes owns the system. There’s something called professional continuous glucose monitoring, which means the health system owns it and the person can wear it. Meet with a diabetes care and education specialist or another healthcare professional to have it placed on and then removed, and then talk about what did we see for those 10 or 14 days.

Shireen: Okay. But it would only be for the 10 to 14 days, or can I…?

Dr. Reece: Yes.

Shireen: Keep renewing the…okay.

Dr. Reece: Yes.

Shireen: Got it. Okay. All right. So, it’s not something that if I have type two diabetes, I can just go and talk to my doctor and get the prescription for it, I would have to actually have some of those associated complications or events that would then qualify me based on the insurance to then qualify for a CGM.

Dr. Reece: Now, one nuance is sometimes people are willing to pay more out of pocket because it means that much to them. So, in that case, if a person says I’m going to cut my budget here and there to squeeze in and make the money to make it happen to get the money. And certainly, their provider can write for it. Just knowing that the cost may be a bit more.

Shireen: And so, with that, and I do admire you sort of advocating for some of this access for, for CGM and hoping to see some of those changes because again, I think from my vantage point when I look at it, more data is great. And when you know more about your blood sugars, you can make more informed decisions.

And so, to me, the payoff would almost be immediate. So, it’s interesting to see that there’s still work to be done in order to get to where we would ideally need to get to. So, and which also takes me to the other part of the equation, which is to say, how is access to CGM accessible and equitable across communities, especially those of lower socioeconomic status and even older populations?

Dr. Reece:  I’ll start with the older population because we’ve seen a lot of progress in the older population in terms of access. And when I say access, coverage for the continuous glucose monitors. Historically when these devices were developed, it was recognized the need for them for persons with diabetes, to have them who had type one diabetes was recognized.

And so, coverage first came for that particular sort of subgroup of folks with diabetes and then Medicare slowly over time really began to see the value of it. So, we’re now folks with type two diabetes who have Medicare coverage, can now qualify for continuous glucose monitors without being on three to four injections of insulin per day.

Now, historically, for Medicare for persons with type two, they had to be on multiple daily injections of insulin, three or four. They had to be checking their blood sugar three times a day. They had to submit up blood glucose log to get the CGM covered. That’s changed. No longer is the requirement with Medicare to have multiple daily finger sticks that’s removed.

The insulin barrier has been removed in some sense. Particularly, if people have problematic low blood sugar and then the number of injections per day for those without problematic low blood sugar has decreased to one injection per day. So, it’s certainly access. It’s not perfect. It’s certainly not across the board for older adults, but it’s improved.

Now for lower income populations for persons with diabetes it’s certainly not accessible for every person. As I shared earlier, there’s differences, particularly if folks have Medicaid coverage. Some states have coverage, California does, but other states don’t have coverage. And so, it depends on what state you’re in.

And then also there are grant monies that are available that some of the federally qualified healthcare centers are getting to get access to CGMs grant money for persons who are being seen there. But it’s certainly not equitable across the board in terms of access. And so really trying to figure out who’s going to pay for all this. Because it’s like anything else in life. It’s money and money we got to get it from somewhere.

So, it’s a real challenge to figure out how do we get access for all the folks with diabetes to this technology.

Shireen: In the last 30 seconds here. One quick question that I would like to squeeze in is, are there any potential uses of CGMs to non-diabetic populations be it athletes or even individuals with prediabetes?

Dr. Reece: Yeah, so let me start with the pre-diabetes per piece of it. Absolutely! There is a place for CGM for pre-diabetes and the value is as folks are making lifestyle changes to see the decrease in their blood sugar as they’re making the changes. So, it’s certainly very helpful for that population as you’re making lifestyle changes to see the impact that those lifestyle changes have on their glucose. Absolutely.

Athletes. I’m not as sold on in terms of use. Now, depending on ability to pay for the devices, they can, and they are used by athletes. But the challenge with that is folks need to understand that if you don’t have diabetes or pre-diabetes. There it is normal to get low blood sugars during the night as a person without diabetes.

And so people need to understand sort of the nuances of the differences in what happens with the blood glucose and how the body responds, especially overnight. So, a lot of education needs to be done so folks can understand that before they start using these devices.

Shireen: Lovely, and I feel we could keep talking on and on about this. We’ve certainly gone over, and I do appreciate you hanging back Dr. Reece to answer some of my burning questions with CGMs. At this point though, I would like for our listeners to connect with you and just. Learn more about your work. How exactly can they do that?

Dr. Reece: Yeah, absolutely. I have an Instagram page Reese’s with a C diabetes. So, @reecespiecesdi. It’s ‘D-I’, that is my name for Instagram and Twitter. And then I have a blogging site, Reece’s Pieces in a Diabetes World, and I have a YouTube channel, Reece’s Pieces Diabetes.

Shireen: Absolutely love that. We’ll connect everything. We’ll have the links to everything in our show notes below this episode in the description box if you’re watching us on YouTube at this point. Dr. Reese, thank you so very much for your time, for walking us through and really helping break down this. The taking some of the mystery out of what exactly a CGM is.

So, I appreciate your time so much on that. And to our listeners, you know the drill at this point. Head over to our Facebook, our Instagram, find this podcast post and comment below, share with us if you are currently using a CGM and how it has helped you or not helped you. Be honest, share your experiences.

Again, just comment below. Go to Facebook, go to Instagram, find Yumlish on either of those. Find this podcast post and comment below the podcast post exactly how your CGM has made your life better or not so much, and if you would recommend it to others. So, we will find you there and we’ll continue the conversation.

Dr. Reece, thank you so very much again.

Dr. Reece: Thank you. My pleasure.

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