Today’s guest post is penned by William “Lee” Dubois, a Type 1 diabetic, diabetes educator, and fellow D-blogger at LifeAfterDx.
Wil has been called the “Godfather of Continuous Glucose Monitoring” because he was the 30th person in the whole United States to get “hooked up” to a CGM system when they became available five years ago; as far as anyone knows, he’s now the ultimate veteran, having continuously used a CGM longer than anyone else alive.
His latest book, on sale now, taps into his ‘godfather of CGM’ role. Titled Beyond Fingersticks: The Art of Control with Continuous Glucose Monitoring, it covers everything CGM from choosing alarm thresholds that really work, to successful calibration, to affording a system, to dealing with the volumes of data they create, to how to wear, travel, sleep with, and think about CGM. Even sex wearing CGM. Yep. Read all about it…
A Guest Post by William “Lee” Dubois
Because that’s the year the FDA approved the first Continuous Glucose Monitoring system (CGM) that provided real-time feedback to the user, revolutionizing diabetes care.
And since that time we’ve seen an explosion in CGM devices, their features, and their accuracy. And we’ve also seen a corresponding explosion in the love/hate relationship we D-folk have with this new technology. CGM is both loved and reviled. Both cursed and praised. But more than anything else, I believe CGM is misunderstood.
And I think I know why. But first, let’s review the basics.
In a nutshell, a CGM is a high-tech system for watching and tracking the changes in your blood sugar virtually all the time, day and night, night and day, with minimal input from you. CGM systems themselves are made up of three components that play together as a team. First, there’s a sensor that is inserted under the skin (don’t panic, it’s not as bad as it sounds). Second, there’s a small transmitter that sends signals from the first player on the team to the third player: a cell phone-sized monitor.
But what makes CGM unique, wonderful, and powerful, is not the gear, but the change of mindset it offers us. In fact, I’d argue that this change in how we can think about our diabetes isn’t so much an opportunity, but a necessity to get the most out of CGM — to get the most out of modern diabetes control.
Because if we step back in time and look at the technology of blood sugar monitoring, we can see how our history has set us up for some trouble.
In the Dark Ages of diabetes (oh, say, 80 years ago) the only way to test for elevated blood sugar was to taste urine. Eeeew… And it was a true or false quiz. Either there was sugar or there wasn’t. If there was sugar in the urine, then we knew there was sugar in the blood hours earlier.
Next came more sophisticated urine testing that let us see more or less how much sugar was in our urine. Three hours previously. Yikes.
Then, about 30 years ago, the wonderful and vexing fingerstick meter appeared on the scene, which let us know how much sugar was actually in our blood right at that moment. But there was a key piece of information missing.
This long history of only being able to look at static, fixed numbers caused us to adopt a static, fixed view of our blood sugar. But blood sugar is anything but static! It surges, ebbs and flows; it is dynamic, wild, and fluid.
Frequent fingerstick testing can give you some idea of this fluid motion of your blood sugar. Whether you are more or less heading upwards or downwards. But there is a realistic and financial limit to how many times per day you can test your blood sugar with fingersticks.
Enter CGM. It tests, at the very least, 288 times per day. If you were doing that with fingersticks you’d have to poke each of your ten fingers nearly 30 times each day. Oh yeah, and you wouldn’t get any sleep either. On the bright side, your diabetes control would be awesome because your fingers would be too sore to pick up anything to eat.
Today’s CGM systems can not only track our blood sugar virtually all the time without turning your fingers black-and-blue, but they can warn us of impending trouble. They can alert us when our sugar reaches unacceptably high or low levels. They can tell us if we are surging upwards rapidly, or spiraling downwards out of control. Some models can even peek briefly into the future and warn us of coming trouble before it comes to pass.
Moreover, the key value of CGM is being able to judge our blood sugar numbers in the context in which they exist. This is where the real power of CGM lies, in my book (both figuratively and literally). Let’s say your blood sugar is 123 mg/dL. Should you be happy?
Maybe so. Maybe not.
It depends on the context. A 123 first thing in the morning may be cause for celebration. A 123 a couple hours after a huge dose of insulin is the preview for an unfolding disaster that will leave you gulping glucose fluid, eating those nasty chalky tablets, or breaking into a Godiva Chocolate shop in the middle of the night.
The awesome power of CGM is that if you look at the face on the monitor you get not only a number that’s (in most cases) a pretty good ballpark figure for where your blood sugar stands, but you also get a “trace” — a line that shows you where you’ve been, and how fast there from where you were a short while ago.
It’s as easy as glancing at a wrist watch. In a second, you can get a sense of both your blood sugar number and its context. In short, a CGM is like a wristwatch for your blood sugar environment. But that’s only part of the story. In under a minute, you can make intelligent real-time decisions that will improve your diabetes control.
For example, just last night I ate a meal that was . . . ummm . . . less than healthy, at one of my favorite less-than-healthy restaurants. As I was leaving, my CGM warned me that I was high and going higher. Quickly.
I entered my current blood sugar into my insulin pump, but the pump’s opinion was that we had enough insulin in play to take care of the situation. But my pump was wrong.
What the pump didn’t know, that thanks to my CGM I did know, was that my blood sugar was going up like a rocket. The pump only knew my BG was 248 mg/dL and that I had X units of insulin coursing through my bloodstream. The pump had no view of the flow of the blood sugar reading. But the CGM was able to place that static 248 in context. That is the power of CGM — “continuous” gives context.
In this case, the context of my BG was bad and getting worse. Quickly. With that knowledge, I knew what I had to do. I had to take more insulin. Now. Or end up in the emergency room.
But real-time decision making is still only part of the story.
Every week you can download a CGM to your computer and “Monday Morning Quarterback” your real-time decisions. You can look at what worked and what didn’t work in your diabetes therapy, and you can learn from those success and failures to improve your control.
So CGM lifts us out of world of static views of blood sugar and drops us (kicking and screaming) into the churning waters of what is really taking place beneath our skins. From second to second, minute to minute, and week to week we can now look at our diabetes and our medications, our food and our exercise, in a whole new way.
To me the real revolution of CGM is that we now have a tool that matches our problem. Simply taking static “snapshots” of a moving, changing, dynamic environment can’t possibly work. We need a moving solution to a moving problem, and now we have one.
With fingerstick meters, and the urine testing that came before them, we could only see the rocks in the stream. With CGM we see the gurgling, flowing, tumbling waters of the stream itself.
“Beyond Fingersticks” is available for order at Red Blood Cells Books for $15.00.
btw, Wil works full-time as the Diabetes Coordinator for Pecos Valley Medical Center, a rural nonprofit clinic in one of the poorest counties in the United States, and is a tireless advocate for diabetes care and awareness. You can read about his amazing work here.