How to Start Using Continuous Glucose Monitoring in Your Practice

In the broad landscape of healthcare, a key focus is the successful management of metabolic disorders, a significant component of which is diabetes. Innovative technologies such as continuous glucose monitors (CGMs) are transforming our approach to managing these diseases. In fact, it is estimated that only 12% of American adults are metabolically healthy, even among those with a normal weight. This innovative technology offers patients and practitioners alike a new perspective on glucose management, illuminating the day-to-day nuances that could potentially lead to improved health outcomes.

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What is a Continuous Glucose Monitor?

A continuous glucose monitor, commonly referred to as a CGM, is a device that perpetually monitors blood glucose (sugar) levels, delivering real-time updates throughout the day and night. This is achieved through a sensor that is attached to your body, typically inserted just beneath the skin. The data from the CGM enables users to observe their glucose levels at any given moment while also reviewing how these levels fluctuate over several hours or even days. This continuous tracking and immediate access to glucose trends empower individuals to make more informed decisions regarding their dietary intake, physical activity, medication usage, and overall metabolic health management. Over time, CGMs have not only gained popularity but also improved in accuracy, rendering them a viable treatment strategy for individuals living with conditions such as diabetes or those interested in improving metabolic health (3,4).

How Does a Continuous Glucose Monitor Work?

A continuous glucose monitoring (CGM) system operates through a modest sensor positioned just under the skin, commonly on the abdomen or arm. The sensor monitors glucose levels in the interstitial fluid, which is the fluid found between cells. The sensor works around the clock by taking readings every five minutes to provide comprehensive glucose monitoring (3).

As per the device guidelines, the sensor needs periodic replacement. Typically, for most devices, users can replace sensors at home every 7 to 14 days. However, for certain long-term implantable CGM devices, the sensor change is managed by a healthcare provider during an in-office procedure. This happens a few times or less annually, depending on the specifics of the CGM device (5).

The data gathered by the sensor is transformed into an electrical signal that reflects the glucose concentration in your bloodstream. A small, connected transmitter wirelessly dispatches this data to a monitor, an insulin pump, or a digital device like a smartphone or tablet, thus enabling users to check their glucose readings in real-time (6).

It's essential to appreciate that CGMs are designed to detect patterns in glucose levels, like those that occur overnight or between meals. They are not intended to substitute standard blood glucose monitoring methods. Instead, they are meant to augment them by revealing shifts and patterns that could potentially be overlooked by conventional A1C tests and finger stick measurements (6).

How Do Integrative Medicine Practitioners Use Continuous Glucose Monitors in Practice?

CGMs offer healthcare practitioners a path towards a more tailored approach to caring for patients, particularly in relation to nutritional management and metabolic syndrome. Research has shed light on the significant differences in blood glucose responses in individuals who consumed identical meals. It's been observed that the fluctuation in glucose levels could be as much as 20% within an individual (this means your blood sugar level can go up and down by around 20%, even if you haven't changed anything about what you're eating or doing) and as much as 25% between different individuals, despite ingesting the same foods. These findings highlight the urgent need for dietary interventions that are custom-tailored to individual patients, especially in the management of metabolic syndrome and diabetes.

With the use of CGMs, practitioners receive a continuous stream of blood glucose data. This enables them to discern how particular foods impact each individual patient. Interpreting the insights provided by CGMs, healthcare providers can fine-tune dietary plans to fit the specific needs of their patients. Such individualized approaches facilitate the management of energy levels, symptom mitigation, and overall enhancement of health outcomes (8).

Apart from their utility in nutritional management, CGMs can be important components of remote health monitoring. These tools foster a stronger connection between patients and practitioners, heighten patient engagement in their own treatment, and afford practitioners a thorough understanding of patients' daily functioning. These technologies provide a wealth of data points, which could be key to recognizing the onset of an acute illness or monitoring chronic illness progression. Furthermore, they empower patients by granting them access to their personal health data, which in turn can promote healthier lifestyle decisions and proactive disease management (10).

Symptoms Patients Could Benefit From a Continuous Glucose Monitor

Patients demonstrating the following symptoms might benefit from a continuous glucose monitor (10,11):

• Frequent episodes of hypoglycemia or hyperglycemia
• Unexplained glucose variability
• Nocturnal hypoglycemia
• Hypoglycemia unawareness
• Desire to achieve improved/optimal metabolic health
• Desire to prevent chronic disease and/or increase health span
• A desire for general knowledge about how different foods affect personal glucose levels

How Much Do Continuous Glucose Monitors Cost?

Cost can be a determining factor when considering a CGM. A starter kit with replaceable sensors typically costs around $1,000 on average, while some CGM systems can amount to several thousand dollars annually. For example, the Dexcom G6 system has an average retail price of roughly $6,000 yearly or $500 monthly without insurance or discounts. This cost includes $437 for the receiver, $420 for a 30-day supply of sensors, and $300 for a transmitter that lasts 90 days.

There are more affordable options available too. The FreeStyle Libre 2 reader costs between $130 to $150 without insurance, and a month's supply of sensors costs about $130, totaling approximately $1,560 a year for sensors. Discounts are also available through coupons such as those offered by GoodRx, which may reduce the cost of systems like FreeStyle Libre 2 or the Dexcom G6 (12).

Whether health insurance covers CGMs depends on the specific plan. Many plans will cover some or all of the cost of diabetes equipment and supplies, including CGMs. Most people with commercial insurance can expect to pay $0 to $60 monthly for the FreeStyle Libre 2 sensors and around $65 per month for the reader, according to the manufacturer, Abbott. Medicare, Medicare Advantage plans, and most state Medicaid programs also typically cover CGMs, though the specifics can vary (12).

For those without diabetes, athletes or people seeking to prevent diabetes, CGMs may not be covered by insurance. Out-of-pocket costs for CGMs include a transmitter, reader, and sensors, typically ranging from $1,000 to $3,000 annually. Other necessary supplies such as adhesive skin patches, a blood glucose meter for calibration, and a smart device for real-time data could add to the total cost (12).

Various programs and discounts can reduce the burden of CGM costs. For instance, Dexcom offers a copay savings program, and companies such as GoodRx provide discounts that could lower the cost of certain CGMs. In some cases, it's also possible to use funds from a qualified Health Savings Account (HSA) or Flexible Spending Account (FSA) towards the costs of a CGM (12).

How Do Integrative Practitioners Prescribe Continuous Glucose Monitors?

Integrative practitioners prescribe CGMs based on a thorough assessment of the patient's medical history, current health status, and metabolic goals. They evaluate the patient's needs and potential benefits from the use of a CGM and then prescribe the monitor that suits the patient’s needs and lifestyle best. This decision may also take into account considerations such as the patient's comfort level with technology and their willingness and ability to respond to the real-time data provided by the CGM.

Common manufacturers of CGMs include Abbott (maker of the FreeStyle Libre System), Dexcom (maker of the G4 Platinum with Share, G5 Mobile, and G6 monitors), and Medtronic (maker of the Guardian Connect). These companies sell their products through various outlets, including direct sales, medical supply companies, and pharmacies. They might also be available through hospital or clinic networks, depending on the arrangements of the healthcare system. In many cases, a prescription for a CGM is filled at a pharmacy or a medical supply store, either physically or online. In some cases, the devices might be ordered directly from the manufacturer. Some online practitioners can order the device for patients and have the device mailed directly to the patient’s door.

Which Type of Integrative Practitioners Can Prescribe Continuous Glucose Monitors?

A wide range of healthcare professionals can prescribe CGMs, including Endocrinologists, Diabetes Educators, Nutritionists, Primary Care Practitioners, Nurse Practitioners, and more. The key consideration is the provider's familiarity and comfort with using and interpreting the given data. Online companies such as Levels Health and Veri (among others) offer patients options to receive a CGM from an online practitioner and have apps to help guide and decipher personal CGM results to provide suggestions on how to improve metabolic health.

How to Use Continuous Glucose Monitors to Personalize Functional Nutrition for Patients

Continuous glucose monitors hold great possibility in being able to help personalize functional nutrition for patients. CGMs provide insights into individual glycemic responses to different meals, offering valuable data for dietary planning. These responses can vary significantly between individuals due to a multitude of factors, including genetics, lifestyle, physical activity, body type, and the gut microbiome. Therefore, using a CGM can help in constructing a personalized diet plan that minimizes post-meal glucose spikes and promotes optimal metabolic health.

Another element of managing diabetes and personalizing nutrition involves monitoring glycemic variability. Large fluctuations in blood glucose levels can lead to harmful metabolic byproducts, inflammation, and activation of the stress hormone cascade. CGMs enable patients to identify and avoid foods or behaviors that cause these significant glucose fluctuations. By reducing glycemic variability, patients can potentially lower their risk of developing chronic diseases like cardiovascular disease and diabetes (19,20).

CGMs also play a significant role in managing fasting glucose levels. Keeping fasting glucose to the lower end of the "normal" range and reducing variability between readings is associated with better health outcomes. Continuous glucose monitoring can guide lifestyle and dietary adjustments to improve fasting glucose levels, even if those levels are within the normal range. Utilizing CGMs must be paired with patient education to promote self-management and behavior modification, principles central to diabetes care. Empowering patients to set their own self-management priorities can motivate them to initiate and maintain necessary behavior changes (18).

Frequent and structured glucose monitoring through CGMs can induce positive changes in behavior, such as improvements in dietary choices and physical activity. Studies have shown that CGMs can display the benefits of exercise and the impact of specific food choices on blood glucose levels. Walking after meals, for instance, has been shown to be more beneficial to average 24-hour glucose levels than continuous daily walking. Moreover, CGMs can offer real-time feedback on interventions, a feature that has been underutilized but can significantly benefit patients, especially those making dietary changes or increasing physical activity (22).

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Summary

CGMs are revolutionary devices transforming the management of metabolic disorders. Working through a sensor placed beneath the skin, they consistently track blood glucose levels, providing valuable real-time data. These insights allow individuals to make informed decisions about diet, exercise, and medication, enhancing their metabolic health management. Additionally, CGMs enable healthcare practitioners to customize patient care, particularly regarding nutrition. The use of CGMs paired with patient education can foster increased self-management and positive behavior changes, leading to healthier lifestyle decisions and improved metabolic health.