Q&A: Using Continuous Glucose Monitoring in Non-Diabetic Patients

According to Ashley Koff, RD, using a continuous glucose monitor (CGM) doesn’t always equal better care. During an Integrative Practitioner Webinar, Koff, the founder of The Better Nutrition Program, explained that CGMs present an opportunity for practitioners to create more personalized, effective patient care plans, but only when they have the right tools and resources.

In the webinar, The Pros and Considerations of Continuous Glucose Monitoring in Non-Diabetic Patients, which took place last week, Koff discussed her strategies for using the new technology to improve her treatment protocols even in patients without diabetes.

At the end of her presentation, Koff answered several live audience questions. In this article, we’ve rounded up some of the top questions and responses on analyzing CGM data, experiments to see how certain factors impact glucose levels, preventing sensors from falling off, and more.

Q: With the understanding that there is biochemical individuality, what does optimization of blood glucose look like? Not many peaks? Not many valleys? Diurnal variation? For example, some of my integrative medicine teachers preach the importance of having a fasting blood sugar of 60 to 80, an insulin level of two to six, and an A1C of four to five.

Ashley Koff, RD: We have to debunk the myth that flatline blood glucose, or low blood glucose on a consistent basis, or even low with rolling hills, is desirable. We want to understand somebody’s peaks and valleys. That’s when we learn how their body works and what signals it is sharing with us.

I've seen people with a fasting insulin of four and a C-reactive protein (CRP) of 12; that's not a healthy person. So, we don't want to sit there and say, “You are your number.” Instead, we want to say, “This is what your body's numbers are telling us.”

The A1C has never allowed us to talk to somebody about their metabolic health in real-time and in a truly personalized manner. The CGM data allows us to do that.

Q: I've had many [CGM sensors] fall off or mess up. Do the manufacturers replace them?

Koff: We see a lot of issues pop up when a new version of a sensor comes out. So, in that case, the manufacturer should replace it. But, for instance, when patients need to take them off for an MRI, we need to share with the manufacturer that it fell off for them to replace it. And one thing to note is that it might take them one or even two weeks to replace it.

Oftentimes we have people buy two sensors at once. Then, we have a backup one as an option. But the other reason that it falls off is if they aren't wearing a patch. Sometimes, the sensors can get shipped without a patch. If that's the case, I send people to the drug store to get the patch. I had somebody who used duct tape, and I said, "No, that's not comfortable for your arm. Let's use an actual adhesive CGM patch.” So, patches are also important to consider.

It’s also great to give patients tips on how to wear them. Things like wearing it on your non-dominant hand is a good idea. If you're a parent who is constantly picking up a kid or has a kid who's pulling on your arm, these are the things you should be thinking about. Determining what side or location works best for the patient’s sleeping style is also helpful. And then, if you're somebody who sweats a lot or has a good amount of hair on the arm, we have some recommendations for how to address that too.

There are ways to prevent the sensors from falling off, but you're still at the company's whim to replace them. However, we generally find that the companies are good about it.

Q: Would you recommend similar CGM strategies and experiments with type 2 diabetics?

Koff: Absolutely. Obviously, if somebody has diabetes, it will shift how we look at certain things regarding expectations for numbers or how their body will respond. Anecdotally, I would say the same thing also holds for a person with type 1 diabetes. Of course, we just want to protect them with safe experiments.

I was just doing an experiment with a type 1 diabetic to work on hydration optimization. The experiment showed them that adequate hydration can improve their body's response to insulin. So, absolutely, these experiments can be across the board; there isn't a limitation.

Q:  Can a CGM be useful for patients on, say, Metformin, or might you boldly think to have them discontinue their Metformin for a few months so that they can work with a clean slate and perhaps someday help them no longer need the drug?

Koff: So, a couple of things. Drugs are tools, right? And we can use them in a variety of ways. Absolutely, I have patients who are diabetic and prediabetic on Metformin, semaglutide, etc., and we are using the CGM, gathering the data, personalizing their nutrition, and driving better outcomes while they're on the medication.

I've also been using the CGM to help wean off or reduce the dosage and frequency of, say, semaglutide and tripeptide to see how a patient’s body responds to certain diets without the medication. So, you could taper the Metformin. I will sometimes have them try reducing their dose for a month and, after three weeks, redo a continuous glucose monitor sensor.

However, when I do these experiments, it depends on their situation. For instance, I would never have somebody go down on their Metformin and do their continuous glucose monitor while they're on vacation or while their kids are home from school. Try to create scenarios that are as similar as possible, do try the experiment then.

I wouldn't say to somebody, “Hey, I want you off metformin for the next three months," and not do anything else. If someone wanted to go off Metformin, I would give them things that I thought were supportive for that period and then look at the impact two to three months later of how being off of it may be working better for them.

Q:  What are the top non-diabetic patient populations for which you would suggest a CGM?

Koff: The top one, I would say, is humans. I think that pretty much everyone can benefit from doing this. I think that it helps us. So, when done better, as I'm talking about here, it helps me be more efficient with supplement recommendations. It helps me take away the depersonalization or partial personalization of things like caloric windows, carbs, and protein.

I highly recommend it; that being said, you must do it at the right time. For instance, if somebody is coming in with digestive issues, we know you can’t improve blood sugar without your digestion being better. In that case, I would try a 30-day digestive tune-up, depending on the severity of what was happening. Similarly, if somebody is coming in for something acute like a new diagnosis of celiac disease, then we first need to focus on getting them to be 100 percent gluten-free.

This is a period where we're asking patients to be really involved in tracking and sharing data with us. That has to be something that is realistic for them in their stage of life. However, it's an extremely valuable tool. I'm involved in a research study with some gestational diabetics where we're using CGMs. I would love to see CGMs used to evaluate the early stages of pregnancy. So, there are all sorts of opportunities, but it is a financial investment and, more importantly, an investment in time for both the practitioner and the patient.

Editor’s Note: This is an excerpt from the webinar "The Pros and Considerations of Continuous Glucose Monitoring in Non-Diabetic Patients. To access the webinar on demand, click here.