No one stands in anyone's way when it comes to making a decision about their health and body. Some choose to do nothing. Some choose to go all the way and see their doctor every other day. Some pay attention to Google Doctor. And then there are those that are "sensible" and take care of their bodies.
And yes, to an extent I do object to being educated through monitoring biomarkers. They are invasive and also expensive. Who will pay for them? The patient? Does medical insurance cover the cost? How will a person react to "bad news"?
But I agree that biomarkers are useful if the person shows symptoms of a disease, such as dementia.
Health education should start at a young age. Does it? I think not. And you can't educate someone if they don't want to be educated.
Bottom line: the key to good health, healthy lifestyle, better weight control is NOT MORE MONITORING/DATA/TECHNOLOGY. Physicians and US health care have been accused of "medicalizing" everything - too many prescriptions, focus on drugs, etc. The secret to health, therefore, does not rest in more gadgets (for the believers: "wearable technology"). Wearable technology is not the key to being healthy! I don't think you need a CGM to tell you to limit sugar and processed carbs. Knowing what eating a potato does to your blood sugar is not the key. It doesn't take tech to tell you that eating a bagel (or a muffin or a donut) is going to raise your blood sugar! Otherwise, eating healthy, non processed foods does not require a monitor.
The main "study" that might bear some merit would be looking at whether this "tool" is helpful for sustained weight loss in any group. My educated guess is that it does no better than anything else. The docs who try to sell people on CGM are typically profiting in some way from the endeavor. I have no problem with individual people getting a CGM if that's what they feel like spending their time on - just does not need to be advice coming from a physician. Does not need to be covered by any insurance. The "worried well" likely don't need more data to review, but we're not going to stop individuals from doing what they want - nor is that a physicians role.
A more interesting topic would be to look at how much heart rate monitors cause anxiety, medical evaluations/visits, and cost to the health care system. Now that one is a can of worms. I've had to tell numerous patients to TURN THE HEART RATE MONITOR OFF. we don't treat heart rate monitors - we evaluate symptoms. The anxiety loop with a heart rate monitor is a huge problem. Somewhere, physicians need to point this out. I'd love to see a study looking at the costs Apple Watch and other heart rate monitors add to our health care spending (unnecessarily). No benefit.
(and where is the data on having elderly wear a heart rate monitor to detect asymptomatic a fib to see if any benefit or decrease in stroke. The lack of this information makes me think it doesn't work even in that regard).
Perhaps your diversity range should include sex rather than gender. Sex is immutable, binary and real whereas gender seems to be delusional and all in the mind.
It would be more Sensible to focus on the pre-diabetes population, helping people with potential metabolic didease by taking responsibility for their health rather than taking a pharma drug to treat symptons
I'd love to have sensible medicine editors reach out to leaders/advocates in the CGM/wellness world to get a counterpoint post. Peter Attia MD, Tim Spector MD, etc. come to mind.
TL:dr This Dr doesn't want healthy patients to understand what contributes to ill health bc he'd prefer to sell them a pill bc pills have 'eViDEnCe'. There's no evidence that CGMs are harmful. There's plenty of evidence that Drs cause illness through medical interventions promoted by pharmaceutical manufacturers.
I wasn't commenting on "moderation", which is typically a sensible position to take on many things in life. You could well manage a number of potential health concerns that way—agreed.
But would you object to people's education about prevention of disease if it had to be through the medium of monitoring biomarkers, which lead to further education about how and why the biology underpinning it works? I'm pushing back on the idea that it is "stupidity" to learn more about your own body, how it works, in what ways it works differently from others, and how food choices affect your health, in a way that is more meaningful and edifying than having a government institution—or a magazine—issue a general recommendation. If people wish to become more knowledgeable, why should anyone stand in their way?
“Worried well” will always be a cash cow waiting to be milked. It spawns an entire cottage industry. CGM in non diabetics is simply latest iteration. And as sure as the sun rising from east tmr, it won’t be the last.
I agree with author. RCT. Hard endpoints ….and since we are talking about healthy asymptomatic people, the only one that matters is body count.
How long does one have to experience cellular pathologies or mitochondrial dysfunction before becoming symptomatic to your standard? Could take decades.
How many of these “cellular pathologies” or “mitochondrial dysfunction” actually will result in clinical events, Vs remaining as merely “test abnormal values”?
We practice to help people live longer, or feel better. Not for better lab results as an end in and of itself.
It’s also scientific method 101. If one is to assert that “intervention X” is “beneficial”, the burden is on proponents of said intervention to demonstrate benefits. And when we are dealing with otherwise asymptomatic and healthy people, that burden is rightfully higher.
Steve I agree with everything you wrote. But if somebody like Chris Palmer is correct, you can add Alzheimer’s, ADHD, bipolar disorder, schizophrenia, more serious forms of anxiety and depression to the list of clinical events related to the above.
More studies are needed. I’ve never advocated for its opposite. But I see a stultified medicine environment that wants to criticize without even knowing the argument in favor.
Yes I think we agree as well. And if you can draw a causal line from tight glycemic control to a reduction of Alzheimer’s or whatever, then sign me up for sure.
What I won’t want to see is a study of a million people showing that tight glycemic control reduces A1c from 5.0% to 4.9% with 5 zeros in the P value, and have that ballyhooed as the reason why we should do this en masse.
Yes, absolutely—I think you've hit on my general objection better than I did, which is people arguing over numbers in a blood panel which are deemed apparently significant or not, as though splitting hairs (or mg/dL) is somehow doing anything. That is not MY obsession. This to me is a red herring that I see people getting stuck on.
And speaking of red herrings, we don't have an easy, wearable way to measure insulin, so instead serum glucose becomes a proxy. Only it's a lousy proxy, because one can be hyperinsulinemic for a long time before seeing the kind of variability in fasting glucose that might alert you to it.
But if a subnormal glucose response to endogenous insulin turns out to be something that you need to manage, absent diabetes mellitus, then serum glucose is one of the main things you want to keep your eyes on, given their causal relationship.
Of course, glucose isn't everything. It does nothing to measure the results of fructose metabolism, an excess of which starts with IR of the liver, causing increased production of uric acid (mine's very high without interventions) and inhibition of endothelial nitric oxide. If you're trying to get maximum glucose and insulin to the brain cells (and you are), I would argue vasoconstriction is one thing you want to avoid.
Now, if it turns out that the same thing that causes gout is also to a degree upstream of vascular dementia (remember the nitric oxide), and food intake has something to do with it, then I think all this is worth investigating. Appreciate the back-and-forth.
Dr Misra, I have been wearing a CGM for one year now, a paying member of one of the few US-based health companies which is also running an ongoing study. The purpose of the CGM is as an education tool for the user, it is not used in this context as a diagnostic device. I found your article to be overly focused on diabetes (not entirely the point), with a dismissive tone directed toward "healthy people who don't need CGMs" that starts and stops at "show me the RCTs or it's meaningless". I was disappointed to note that you did not really engage with the ideas of the doctors, or any of the research, which makes up the foundation of this newer corner of medicine, science and health-seeking. All in all, I see articles such as this popping up, but they tend to be a bit un-sussed on the topic.
Do you have any questions you'd like to ask me? I would be happy to talk about my experiences, and can expound upon the behavioral changes that the program has brought about, with permanent and lasting benefits, some of which may seem orthogonal to what you might perceive is the purpose of the practice. Perhaps I would fit in the category you state of highly-motivated people that are different from the normies you treat on a daily basis—fine. But it might broaden your perspective.
The comments I've read here by readers connecting what seem like "obvious" dots, linking those in the metabolic health space to the same cohort most involved in "helicopter parenting", preposterous over-masking and other Covid hysteria are woefully off the mark. Sensible Medicine is a publication I pay for largely on account of its critical views of those people and the muppets they get their health-related information from.
While I agree that things like CGM can make people anxious and can lead to more harm than good, but it can also provide interesting baseline information that is otherwise hidden. I have done other things of this nature int eh past to good results:
- Baseline a weeks worth of exactly what you eat to better notice all the excess snacking you may do
- Baseline a months worth of exact spending, to really see how all those $8 lattes can add up (this also related to the eating metrics as well)
But these sorts of things are meant to enlighten and give understanding; not to find a bogyman around the corner looking to strike. Using it as diagnostic in asymptomatic people is probably not the right use.
The medico-social historian in me places the fads for CGM, heart rate monitor watches and the like in the same category as patent medicines of the nineteenth century. High-tech trappings are merely the modern iteration of this age-old phenomenon. Claims that these devices will "clean your blood, strengthen your liver, and improve your bedroom performance" are nearly the same script that charlatans used in the old days.
Direct to consumer CGM devices are consumer driven by those interested in biohacking. It's laughable to think you can be upset by their personal choice to "hack" their own biochemistry. Yes in an ideal world, we'd have a RCT to know the data before this trend started, but we don't live in an ideal world. And to compare harms from previous studies is comparing apples to oranges. The people in those trials were on glucose lowering drugs, which caused their hypoglycemia. If people want to make themselves "lunatics" as someone stated in the comments, that's their choice. At least these people are paying attention to lifestyle changes in an era where diabetes is an epidemic costing lives and $$$$ in healthcare dollars.
What are you calling "pre-diabetes"? I get bloodwork done once a year. When hba1c gets as high as 5.7 the lab report flags it as "pre-diabetic", which is ludicrous. Well, actually it's not funny. The companies manufacturing the fancy insulin are behind the campaign that puts up billboards in my town saying "Chance of shark attack 1 in 5 bazillion. Chance of pre-diabetes 1 in 3." Panic sells meds and glucose monitors. My primary doc, a crabby old autocratic African lady, tells me: just don't go pigging out on Christmas candy and you'll be alright.
You are correct. Pre-diabetic is a made up diagnosis that signifies nothing. I would go further and say that Type 2 Diabetes is also a fabricated "disease". In over 40 years of medical practice (Cardiology and Internal Medicine), I never saw any "diabetic" complications beyond those I saw in others in comparable age groups. I understand that my personal observations are not scientific evidence but I have never been convinced that the medical literature showed any significant evidence as well. My advice to patients was to avoid all screening procedures and tests and only consult a doctor when you have a problem or specific question about your health.
At least you finally got it before it was too late. Most people never do. It took me about ten years of medical practice to figure it out---not a popular position among my colleagues in medicine. I wrote some articles for Junkscience.com around 2014-2016 and one was titled "The Healthcare Delusion" which lays out more arguments to substantiate that position. The guy running the site then was an Emergency Room doctor and we had some great medically oriented back and forth discussions during that time. Unfortunately the originator of that website decided to take back control and he failed to archive the stuff that we did; so I can't provide you a link. I did keep copies but am decidedly not tech saavy and don't know how to transmit those. My wife is more knowledgeable and may know how to do it. If not and you are interested, I would be happy to mail you copies of a few of the pertinent articles. You can always reach me directly at ernestncurtis@aol.com. By the way, it sounds like your primary doctor has her head on straight.
I would love to read what you wrote! I'll send you my email address. Thank you! We live in times when critical thinking is anathema to the pharma profit motives. Well, not just pharma. WSJ had an article today on the worry of junk food manufacturers over the market impact of semaglutide. They are concerned that it could hurt their profits by killing appetites for their worthless products.
No one stands in anyone's way when it comes to making a decision about their health and body. Some choose to do nothing. Some choose to go all the way and see their doctor every other day. Some pay attention to Google Doctor. And then there are those that are "sensible" and take care of their bodies.
And yes, to an extent I do object to being educated through monitoring biomarkers. They are invasive and also expensive. Who will pay for them? The patient? Does medical insurance cover the cost? How will a person react to "bad news"?
But I agree that biomarkers are useful if the person shows symptoms of a disease, such as dementia.
Health education should start at a young age. Does it? I think not. And you can't educate someone if they don't want to be educated.
Bottom line: the key to good health, healthy lifestyle, better weight control is NOT MORE MONITORING/DATA/TECHNOLOGY. Physicians and US health care have been accused of "medicalizing" everything - too many prescriptions, focus on drugs, etc. The secret to health, therefore, does not rest in more gadgets (for the believers: "wearable technology"). Wearable technology is not the key to being healthy! I don't think you need a CGM to tell you to limit sugar and processed carbs. Knowing what eating a potato does to your blood sugar is not the key. It doesn't take tech to tell you that eating a bagel (or a muffin or a donut) is going to raise your blood sugar! Otherwise, eating healthy, non processed foods does not require a monitor.
The main "study" that might bear some merit would be looking at whether this "tool" is helpful for sustained weight loss in any group. My educated guess is that it does no better than anything else. The docs who try to sell people on CGM are typically profiting in some way from the endeavor. I have no problem with individual people getting a CGM if that's what they feel like spending their time on - just does not need to be advice coming from a physician. Does not need to be covered by any insurance. The "worried well" likely don't need more data to review, but we're not going to stop individuals from doing what they want - nor is that a physicians role.
A more interesting topic would be to look at how much heart rate monitors cause anxiety, medical evaluations/visits, and cost to the health care system. Now that one is a can of worms. I've had to tell numerous patients to TURN THE HEART RATE MONITOR OFF. we don't treat heart rate monitors - we evaluate symptoms. The anxiety loop with a heart rate monitor is a huge problem. Somewhere, physicians need to point this out. I'd love to see a study looking at the costs Apple Watch and other heart rate monitors add to our health care spending (unnecessarily). No benefit.
(and where is the data on having elderly wear a heart rate monitor to detect asymptomatic a fib to see if any benefit or decrease in stroke. The lack of this information makes me think it doesn't work even in that regard).
Perhaps your diversity range should include sex rather than gender. Sex is immutable, binary and real whereas gender seems to be delusional and all in the mind.
Good news. I am visiting my daughter who has copies of all my articles. She put them on my computer and showed me how to attach them to emails.
It would be more Sensible to focus on the pre-diabetes population, helping people with potential metabolic didease by taking responsibility for their health rather than taking a pharma drug to treat symptons
I'd love to have sensible medicine editors reach out to leaders/advocates in the CGM/wellness world to get a counterpoint post. Peter Attia MD, Tim Spector MD, etc. come to mind.
TL:dr This Dr doesn't want healthy patients to understand what contributes to ill health bc he'd prefer to sell them a pill bc pills have 'eViDEnCe'. There's no evidence that CGMs are harmful. There's plenty of evidence that Drs cause illness through medical interventions promoted by pharmaceutical manufacturers.
The narrative about carbs needs to change. They are a source of energy and an energy source for the brain.
And as with all foods - good and average - moderation is the key.
Maybe then non diabetic people will realise the stupidity of monitoring their life through a machine. There needs to be a reality check.
What happens when the brain cannot take up adequate glucose due to insulin resistant brain cells? Just keep cramming in more and more carbs?
My comment stated moderation as a key.
I wasn't commenting on "moderation", which is typically a sensible position to take on many things in life. You could well manage a number of potential health concerns that way—agreed.
But would you object to people's education about prevention of disease if it had to be through the medium of monitoring biomarkers, which lead to further education about how and why the biology underpinning it works? I'm pushing back on the idea that it is "stupidity" to learn more about your own body, how it works, in what ways it works differently from others, and how food choices affect your health, in a way that is more meaningful and edifying than having a government institution—or a magazine—issue a general recommendation. If people wish to become more knowledgeable, why should anyone stand in their way?
Excellent commentary
“Worried well” will always be a cash cow waiting to be milked. It spawns an entire cottage industry. CGM in non diabetics is simply latest iteration. And as sure as the sun rising from east tmr, it won’t be the last.
I agree with author. RCT. Hard endpoints ….and since we are talking about healthy asymptomatic people, the only one that matters is body count.
How long does one have to experience cellular pathologies or mitochondrial dysfunction before becoming symptomatic to your standard? Could take decades.
How many of these “cellular pathologies” or “mitochondrial dysfunction” actually will result in clinical events, Vs remaining as merely “test abnormal values”?
We practice to help people live longer, or feel better. Not for better lab results as an end in and of itself.
It’s also scientific method 101. If one is to assert that “intervention X” is “beneficial”, the burden is on proponents of said intervention to demonstrate benefits. And when we are dealing with otherwise asymptomatic and healthy people, that burden is rightfully higher.
Steve I agree with everything you wrote. But if somebody like Chris Palmer is correct, you can add Alzheimer’s, ADHD, bipolar disorder, schizophrenia, more serious forms of anxiety and depression to the list of clinical events related to the above.
More studies are needed. I’ve never advocated for its opposite. But I see a stultified medicine environment that wants to criticize without even knowing the argument in favor.
Yes I think we agree as well. And if you can draw a causal line from tight glycemic control to a reduction of Alzheimer’s or whatever, then sign me up for sure.
What I won’t want to see is a study of a million people showing that tight glycemic control reduces A1c from 5.0% to 4.9% with 5 zeros in the P value, and have that ballyhooed as the reason why we should do this en masse.
Yes, absolutely—I think you've hit on my general objection better than I did, which is people arguing over numbers in a blood panel which are deemed apparently significant or not, as though splitting hairs (or mg/dL) is somehow doing anything. That is not MY obsession. This to me is a red herring that I see people getting stuck on.
And speaking of red herrings, we don't have an easy, wearable way to measure insulin, so instead serum glucose becomes a proxy. Only it's a lousy proxy, because one can be hyperinsulinemic for a long time before seeing the kind of variability in fasting glucose that might alert you to it.
But if a subnormal glucose response to endogenous insulin turns out to be something that you need to manage, absent diabetes mellitus, then serum glucose is one of the main things you want to keep your eyes on, given their causal relationship.
Of course, glucose isn't everything. It does nothing to measure the results of fructose metabolism, an excess of which starts with IR of the liver, causing increased production of uric acid (mine's very high without interventions) and inhibition of endothelial nitric oxide. If you're trying to get maximum glucose and insulin to the brain cells (and you are), I would argue vasoconstriction is one thing you want to avoid.
Now, if it turns out that the same thing that causes gout is also to a degree upstream of vascular dementia (remember the nitric oxide), and food intake has something to do with it, then I think all this is worth investigating. Appreciate the back-and-forth.
Dr Misra, I have been wearing a CGM for one year now, a paying member of one of the few US-based health companies which is also running an ongoing study. The purpose of the CGM is as an education tool for the user, it is not used in this context as a diagnostic device. I found your article to be overly focused on diabetes (not entirely the point), with a dismissive tone directed toward "healthy people who don't need CGMs" that starts and stops at "show me the RCTs or it's meaningless". I was disappointed to note that you did not really engage with the ideas of the doctors, or any of the research, which makes up the foundation of this newer corner of medicine, science and health-seeking. All in all, I see articles such as this popping up, but they tend to be a bit un-sussed on the topic.
Do you have any questions you'd like to ask me? I would be happy to talk about my experiences, and can expound upon the behavioral changes that the program has brought about, with permanent and lasting benefits, some of which may seem orthogonal to what you might perceive is the purpose of the practice. Perhaps I would fit in the category you state of highly-motivated people that are different from the normies you treat on a daily basis—fine. But it might broaden your perspective.
The comments I've read here by readers connecting what seem like "obvious" dots, linking those in the metabolic health space to the same cohort most involved in "helicopter parenting", preposterous over-masking and other Covid hysteria are woefully off the mark. Sensible Medicine is a publication I pay for largely on account of its critical views of those people and the muppets they get their health-related information from.
Just shaking my head
While I agree that things like CGM can make people anxious and can lead to more harm than good, but it can also provide interesting baseline information that is otherwise hidden. I have done other things of this nature int eh past to good results:
- Baseline a weeks worth of exactly what you eat to better notice all the excess snacking you may do
- Baseline a months worth of exact spending, to really see how all those $8 lattes can add up (this also related to the eating metrics as well)
But these sorts of things are meant to enlighten and give understanding; not to find a bogyman around the corner looking to strike. Using it as diagnostic in asymptomatic people is probably not the right use.
The medico-social historian in me places the fads for CGM, heart rate monitor watches and the like in the same category as patent medicines of the nineteenth century. High-tech trappings are merely the modern iteration of this age-old phenomenon. Claims that these devices will "clean your blood, strengthen your liver, and improve your bedroom performance" are nearly the same script that charlatans used in the old days.
Direct to consumer CGM devices are consumer driven by those interested in biohacking. It's laughable to think you can be upset by their personal choice to "hack" their own biochemistry. Yes in an ideal world, we'd have a RCT to know the data before this trend started, but we don't live in an ideal world. And to compare harms from previous studies is comparing apples to oranges. The people in those trials were on glucose lowering drugs, which caused their hypoglycemia. If people want to make themselves "lunatics" as someone stated in the comments, that's their choice. At least these people are paying attention to lifestyle changes in an era where diabetes is an epidemic costing lives and $$$$ in healthcare dollars.
What are you calling "pre-diabetes"? I get bloodwork done once a year. When hba1c gets as high as 5.7 the lab report flags it as "pre-diabetic", which is ludicrous. Well, actually it's not funny. The companies manufacturing the fancy insulin are behind the campaign that puts up billboards in my town saying "Chance of shark attack 1 in 5 bazillion. Chance of pre-diabetes 1 in 3." Panic sells meds and glucose monitors. My primary doc, a crabby old autocratic African lady, tells me: just don't go pigging out on Christmas candy and you'll be alright.
You are correct. Pre-diabetic is a made up diagnosis that signifies nothing. I would go further and say that Type 2 Diabetes is also a fabricated "disease". In over 40 years of medical practice (Cardiology and Internal Medicine), I never saw any "diabetic" complications beyond those I saw in others in comparable age groups. I understand that my personal observations are not scientific evidence but I have never been convinced that the medical literature showed any significant evidence as well. My advice to patients was to avoid all screening procedures and tests and only consult a doctor when you have a problem or specific question about your health.
Your last sentence describes where I am right now. I wish it hadn't taken me fifty years to figure it out.
At least you finally got it before it was too late. Most people never do. It took me about ten years of medical practice to figure it out---not a popular position among my colleagues in medicine. I wrote some articles for Junkscience.com around 2014-2016 and one was titled "The Healthcare Delusion" which lays out more arguments to substantiate that position. The guy running the site then was an Emergency Room doctor and we had some great medically oriented back and forth discussions during that time. Unfortunately the originator of that website decided to take back control and he failed to archive the stuff that we did; so I can't provide you a link. I did keep copies but am decidedly not tech saavy and don't know how to transmit those. My wife is more knowledgeable and may know how to do it. If not and you are interested, I would be happy to mail you copies of a few of the pertinent articles. You can always reach me directly at ernestncurtis@aol.com. By the way, it sounds like your primary doctor has her head on straight.
I would love to read what you wrote! I'll send you my email address. Thank you! We live in times when critical thinking is anathema to the pharma profit motives. Well, not just pharma. WSJ had an article today on the worry of junk food manufacturers over the market impact of semaglutide. They are concerned that it could hurt their profits by killing appetites for their worthless products.
For clarity the fourth sentence should read: ....never saw any "diabetic" complications in patients labeled as Type 2 Diabetics beyond those.....