Latest / The Antisocial Doctors Podcast / Episode 21: Is Continuous Glucose Monitoring Actually Helpful?

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Episode 21: Is Continuous Glucose Monitoring Actually Helpful? · The Antisocial Doctors Podcast

• 1:27
  Sonia Singh MD: You're listening to The Antisocial Doctors Podcast, hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.
• 1:38
  Rebecca Berens MD: And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.
• 1:43
  Sonia Singh MD: We're also millennial women, anxious moms, and curious humans navigating social media.
• 1:48
  Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
• 1:56
  Rebecca Berens MD: This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health.
• 2:05
  Rebecca Berens MD: In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.
• 2:12
  Sonia Singh MD: This is not your average debunking podcast.
• 2:15
  Sonia Singh MD: We wanna explore not just what is trending on social media, but why.
• 2:18
  Sonia Singh MD: Why are so many people drawn to this?
• 2:20
  Sonia Singh MD: What is the nugget of truth here?
• 2:21
  Sonia Singh MD: What are the facts?
• 2:23
  Sonia Singh MD: What can we learn from this as patients and doctors?
• 2:25
  Sonia Singh MD: No shame, no blame, no snark.
• 2:27
  Rebecca Berens MD: We're so glad you're here.
• 2:42
  Sonia Singh MD: Hi, Rebecca.
• 2:43
  Rebecca Berens MD: Hi, Sonia.
• 2:45
  Sonia Singh MD: So I feel like all of our episodes in this batch are piggybacking off each other which is kinda nice,'cause they're building.
• 2:51
  Sonia Singh MD: But our last episode that we recorded was about fitness trackers, and now we're doing an entire episode around a more specific subset of that.
• 3:00
  Sonia Singh MD: So do you wanna share the patient story and the topic for today?
• 3:04
  Rebecca Berens MD: Yeah, so I have a few patient stories again.
• 3:06
  Rebecca Berens MD: And again, with very different use cases for this situation.
• 3:11
  Rebecca Berens MD: So the first one is a patient of mine who's uninsured and has been on multiple medications for managing their diabetes that unfortunately was diagnosed very late because of their lack of access to healthcare.
• 3:23
  Rebecca Berens MD: But we made a lot of progress with with meds and were able to get it down to an A1C of eight, and we just could not get it past there despite medications.
• 3:32
  Rebecca Berens MD: And they got a commercial over-the-counter CGM themselves online and started using it, and they were able to pretty significantly improve their A1C and get it finally into the low sevens which was wonderful.
• 3:45
  Rebecca Berens MD: Then I have another patient who has a recent diagnosis of pre-diabetes and metabolic-associated fatty liver disease, who I referred to a dietician, and the dietician remeng- r- recommended that they start working with a CGM while they were making their, Dietary changes in context with a dietician.
• 4:02
  Rebecca Berens MD: And they found it very helpful to understand how food impacts their blood sugar, and they were able to get their A1C from a low sixes down to normal after about four months, which was great.
• 4:13
  Rebecca Berens MD: But then I have another patient who was in eating disorder treatment and had a continuous glucose monitor placed for that because they were having hypoglycemic episodes related to their eating disorder, and kept getting alarms after eating that their blood sugar was dropping and noticed that their blood sugar was better when they didn't eat, so then they stopped eating as recommended by the treatment team.
• 4:36
  Rebecca Berens MD: So all continuous glucose monitors with varying impacts on people's health conditions and we'll talk about how that...
• 4:46
  Rebecca Berens MD: how, why that may be as we go through this episode.
• 4:49
  Sonia Singh MD: Yeah, I'm glad you shared multiple examples in this case,'cause I think, when you only share one, it starts framing it a certain way, and you d- you covered the full spectrum of- Yeah Highly useful scenario to possibly harmful scenario.
• 5:02
  Sonia Singh MD: Yeah, I'm glad that, I'm glad that we're describing the full spectrum of outcomes.
• 5:05
  Sonia Singh MD: So what do you think are the claims made around CGMs or continuous glucose monitors?
• 5:11
  Rebecca Berens MD: Yeah.
• 5:11
  Rebecca Berens MD: So I've seen several, but a lot of it plays into the same things that we've been talking about in general.
• 5:17
  Rebecca Berens MD: More data is better.
• 5:18
  Rebecca Berens MD: If you have the most data, you can optimize your health.
• 5:22
  Rebecca Berens MD: You can learn which diet is right for your body, which foods you react well to and you don't react well to, what you should be eating, what you shouldn't be eating based on how your glucose is responding.
• 5:31
  Rebecca Berens MD: I think there's also a lot of telehealth companies or not even telehealth, but telecoach companies- where they're saying"We can help you lose weight, and use this tracker, and it'll help help you lose weight.
• 5:41
  Rebecca Berens MD: And we'll help you, interpret the data." Then I think there's also this idea of hidden illness.
• 5:47
  Rebecca Berens MD: There could be something wrong with you, and no one's diagnosed it yet, and this is a way that you can get the data to diagnose it before someone else would...
• 5:54
  Rebecca Berens MD: before your doctor will know.
• 5:55
  Rebecca Berens MD: Again, being, proactive, being more proactive than the healthcare system.
• 5:59
  Rebecca Berens MD: The healthcare system is waiting until you're really sick, and this is a way you can proactively address your own health and i- identify a problem before it can be diagnosed a- another way.
• 6:08
  Rebecca Berens MD: And then there's also just the idea of glucose is bad, and sugar is bad, and sugar spikes are bad, and they're gonna make you sick, and this is how you can make sure you avoid those.
• 6:17
  Rebecca Berens MD: So those are a lot of the claims that I've seen.
• 6:19
  Rebecca Berens MD: What about you?
• 6:19
  Rebecca Berens MD: What have you seen on social media for these?
• 6:22
  Sonia Singh MD: Yeah, I think, Blood sugar is one of those kind of boogeymen, like hormones and some other things in the wellness world where people feel generally unwell, and they start to think"Maybe it's my blood sugar.
• 6:34
  Sonia Singh MD: Maybe my blood sugar is too high.
• 6:36
  Sonia Singh MD: Maybe it's too low.
• 6:37
  Sonia Singh MD: Maybe I'm having spikes.
• 6:38
  Sonia Singh MD: Maybe I'm having crashes." And it's also one of these things where I think most people have experienced at some times feeling like,"Oh, I'm really hungry.
• 6:45
  Sonia Singh MD: I need to eat," and that badness of that feeling, and then thinking"Oh,""maybe some mild version of that is happening to me at other times, and I'm just not aware of it," and the doctor's not catching it because they're only che- checking an occasional blood test.
• 6:56
  Sonia Singh MD: Or the A1C's just inadequate, and it's not catching that, these...
• 7:00
  Sonia Singh MD: Even though my average blood sugar might be normal, what if I'm having these huge spikes and dips and I'm not knowing about it, so I think that's part of it.
• 7:08
  Sonia Singh MD: Yeah, the, those are the claims that I've heard around them.
• 7:10
  Sonia Singh MD: It's this way to get...
• 7:13
  Sonia Singh MD: get a better understanding of how different foods are making you feel or how your body is reacting to different foods or activities.
• 7:21
  Rebecca Berens MD: Yeah.
• 7:22
  Rebecca Berens MD: Yeah, with the idea then that you will increase the ones that make you feel good and make your glucose look good, quote, unquote, and cut out the ones that make you feel bad or make your glucose spike.
• 7:35
  Sonia Singh MD: Yes.
• 7:35
  Sonia Singh MD: Yeah.
• 7:35
  Sonia Singh MD: And it plays into this idea that everyone is really different.
• 7:38
  Sonia Singh MD: And maybe a cup of brown rice is okay for somebody else, but it's not okay for you because- it spikes your blood sugar, and you might not realize.
• 7:45
  Sonia Singh MD: Yeah, I think that all of those are rolled into,, what the claims are around some of these devices.
• 7:49
  Rebecca Berens MD: Yeah.
• 7:51
  Sonia Singh MD: So why do you think these are becoming so popular at this time?
• 7:55
  Sonia Singh MD: Because the technology of this is not that new.
• 7:58
  Sonia Singh MD: So why do you think they have risen to fame over the last couple of years?
• 8:02
  Rebecca Berens MD: Yeah.
• 8:02
  Rebecca Berens MD: So similarly, like we've talked about before optimization culture has become mainstream with, I think since COVID, since, more social media health content in general.
• 8:13
  Rebecca Berens MD: And there's more of a demand for more data, and so there are companies that have these devices that can supply that data to you.
• 8:21
  Rebecca Berens MD: And so then they market said devices using social media, using influencers.
• 8:26
  Rebecca Berens MD: There's telehealth companies that can capitalize on that trend and and, build into programs.
• 8:31
  Rebecca Berens MD: And again, this is something that if a telehealth company is delivering to you not just,"We're gonna talk with you," but,"We're gonna give you data"- like I see a lot of those things where it's like, this is part of our program.
• 8:42
  Rebecca Berens MD: It's very comprehensive.
• 8:43
  Rebecca Berens MD: Look how much data you get." I think it just it adds to the marketing that plays into that optimization desire.
• 8:50
  Rebecca Berens MD: And then like we talked about too, I think the idea of personalized care versus generic healthcare.
• 8:55
  Rebecca Berens MD: You kinda touched on this.
• 8:55
  Rebecca Berens MD: Like- Yeah what works for me is different than other people, which, fair.
• 8:59
  Rebecca Berens MD: It's true.
• 8:59
  Rebecca Berens MD: Yeah.
• 9:00
  Rebecca Berens MD: But also we'll get into the harms of that as well.
• 9:03
  Rebecca Berens MD: But yeah, I think it's an idea of getting something that's more personalized and not just generic and and basic and not the full picture like you get- from normal healthcare, right?
• 9:12
  Rebecca Berens MD: And then I think again, the, a lot of this did balloon in the face of COVID, and I think that was partially increased perception of mor- our mortality, fear of health problems.
• 9:21
  Rebecca Berens MD: It, it was- commonly discussed that metabolic conditions were a risk factor for more severe COVID cases.
• 9:28
  Rebecca Berens MD: And so that obviously is gonna make people concerned.
• 9:31
  Rebecca Berens MD: Am I someone that might be at increased risk?
• 9:33
  Rebecca Berens MD: Is this something that's a risk factor for me?
• 9:35
  Rebecca Berens MD: A lot of people have seen family members go through, horrible complications related to uncontrolled diabetes, for example.
• 9:41
  Rebecca Berens MD: The number of patients I have that come in and they're concerned about diabetes specifically because they saw a family member who had an amputation.
• 9:47
  Rebecca Berens MD: I think that's a really common fear that people have when they've observed that happening to a loved one, and they're like,"I don't want that to be me." How can I prevent that?
• 9:55
  Rebecca Berens MD: How can I...
• 9:56
  Rebecca Berens MD: and again, it's like you wanna be proactive.
• 9:58
  Rebecca Berens MD: You wanna be doing everything you can t- for your health.
• 10:01
  Sonia Singh MD: Yeah.
• 10:02
  Sonia Singh MD: I also think there's this whole- movement happening right now around metabolic health that weirdly has become politicized in some way.
• 10:08
  Sonia Singh MD: Yes.
• 10:09
  Sonia Singh MD: So I think there's just a lot more interest in and attention in metabolic health, which is...
• 10:13
  Sonia Singh MD: if you had told me that would be a hot topic or people would be into that 20 years ago, I would've just laughed in your face because it just seems it, it seems like a very unsexy, uninteresting thing for, people to be so b- buzzed about.
• 10:26
  Sonia Singh MD: But they are, and it's become, I'm, I'm glad, but people are aware that this is a thing that is happening on a societal level.
• 10:34
  Sonia Singh MD: But I think when you go to the sort of extremes or what I would've considered the fringes of that movement, you'll find people that basically have this view that sugar is the greatest evil that has like ever existed.
• 10:47
  Sonia Singh MD: And so I think, a lot of people come back to the idea that like, okay, if you can just track and monitor your blood sugar, really diligently, all of that other stuff you know- Yeah will not happen.
• 10:57
  Rebecca Berens MD: It's the root of all problems.
• 10:58
  Rebecca Berens MD: Like everything-
• 10:59
  Sonia Singh MD: It's the root of all
• 10:59
  Rebecca Berens MD: problems.
• 11:00
  Sonia Singh MD: Yeah.
• 11:00
  Rebecca Berens MD: Yeah.
• 11:00
  Rebecca Berens MD: Everything that's wrong with you is because of the sugar, and it's well-
• 11:02
  Sonia Singh MD: Yeah, there was a tweet around this.
• 11:04
  Sonia Singh MD: I can't remember what the tweet was, but yeah.
• 11:05
  Sonia Singh MD: It was something about like sugar was like the most harmful substance or something like that- Yeah that's ever been created.
• 11:11
  Sonia Singh MD: So I, I think along with that demonization of sugar, there's this idea that okay, if you can just control and fine-tune it really perfectly, that would be the ideal.
• 11:19
  Sonia Singh MD: That's the, one of the, holy grails of somebody who's trying to be healthy.
• 11:23
  Rebecca Berens MD: Yeah.
• 11:24
  Rebecca Berens MD: Yeah, absolutely.
• 11:26
  Sonia Singh MD: So what do you think is the nugget of truth around the benefits with CGMs or around some of those claims?
• 11:33
  Rebecca Berens MD: Yeah.
• 11:33
  Rebecca Berens MD: So the first thing I'll say is it is true that having uncontrolled high blood sugar over many years has serious complications.
• 11:41
  Rebecca Berens MD: That's why we care about diabetes, right?
• 11:43
  Rebecca Berens MD: We treat diabetes because it, there are these long-term complications that can happen with exposure to very high blood sugars, damage to, blood vessels, nerves, Can increase in infections, immune system dysfunction, all of these things related to uncontrolled high blood sugars over time.
• 12:00
  Rebecca Berens MD: So it is important, especially if, if you have diabetes, to control your blood sugar.
• 12:06
  Rebecca Berens MD: That is true, right?
• 12:08
  Rebecca Berens MD: But normal glucose fluctuations, like the spikes that people are worrying about on these CGMs, that's not the same thing.
• 12:15
  Rebecca Berens MD: So we'll get more into the details of that.
• 12:17
  Rebecca Berens MD: Yeah.
• 12:17
  Rebecca Berens MD: But I think, I don't wanna gloss over the fact that yes, it is important to control your blood sugar when you have diabetes.
• 12:22
  Rebecca Berens MD: That is absolutely true.
• 12:23
  Rebecca Berens MD: The other nugget of truth is that there actually is good data that these devices can be beneficial for some patients, particularly patients who have type 1 or type 2 diabetes, and even sometimes with prediabetes- to help them be better able to manage their blood sugar and support their behavioral modifications, support adjustment of medications, and give more, more insight compared to in the past when we had a lot less data that we were going off of to make recommendations and decisions about changes.
• 12:51
  Rebecca Berens MD: And it's real time for patients, too.
• 12:53
  Rebecca Berens MD: Yeah.
• 12:53
  Rebecca Berens MD: Right?
• 12:53
  Rebecca Berens MD: You're, they are able to to learn and adjust their behaviors based on feedback on a more real-time scale versus every three to six months finding out like,"Oh, turns out that I've actually not been doing very well, and I didn't know."
• 13:06
  Sonia Singh MD: Yeah
• 13:06
  Rebecca Berens MD: yeah, so you know, I think there's truth to that.
• 13:08
  Rebecca Berens MD: But again, just because it's beneficial for some people, maybe not for others, and we'll get into that.
• 13:14
  Sonia Singh MD: And just, so just to clarify for maybe some of our non-medical listeners, when we're talking about CGMs, we're talking about continuous glu- glucose monitoring, which is different than checking a finger stick blood sugar- Yes which many people have been doing for many years.
• 13:28
  Sonia Singh MD: The technology for CGMs is a little bit newer.
• 13:30
  Sonia Singh MD: At this point it's not particularly new, it had been only available by prescription for patients with insulin-dependent diabetes.
• 13:36
  Sonia Singh MD: That's the context that I learned it in.
• 13:38
  Sonia Singh MD: And then it trickled down to other patients with diabetes, and then it trickled down to patients with prediabetes.
• 13:43
  Sonia Singh MD: And truthfully, I feel like I was a really big fan of CGMs until they became available as consumer products.
• 13:49
  Rebecca Berens MD: Yeah.
• 13:50
  Sonia Singh MD: So you know I, d- you know, with, for my patients with those conditions, I was always encouraging if they wanted them.
• 13:56
  Sonia Singh MD: And now, I, I I guess it's partially just the population that I take care of now, but I'm much more likely to get questions about it or get sent data from somebody who does not have any of those conditions that is asking me- about, this, the, what their results mean.
• 14:09
  Sonia Singh MD: So okay.
• 14:10
  Sonia Singh MD: So let's talk a little bit about what the actual facts are and what the science tells us about CGMs and how they work, what benefits they have.
• 14:18
  Sonia Singh MD: Give us a little more information on that.
• 14:20
  Rebecca Berens MD: Yeah.
• 14:20
  Rebecca Berens MD: So I'll start with just explaining like what is- a CGM and how is it different than a finger stick blood glucose?
• 14:26
  Rebecca Berens MD: Oh, okay.
• 14:26
  Rebecca Berens MD: 'Cause the last year alluded to, they are different, right?
• 14:28
  Rebecca Berens MD: Yes.
• 14:28
  Rebecca Berens MD: Yeah.
• 14:28
  Rebecca Berens MD: And so as you said, a continu- a CGM is this continuous glucose monitor, and so it's measuring your glucose pretty much continuously.
• 14:37
  Rebecca Berens MD: The prescription options are measuring every, between one to five minutes, and reporting on that every one to five minutes.
• 14:43
  Rebecca Berens MD: The over-the-counter options are also measuring about every five minutes, but they only send reports every 15 minutes to the- the apps associated with them.
• 14:50
  Rebecca Berens MD: So that's the difference between those two.
• 14:52
  Rebecca Berens MD: But the way that they are measuring glucose is different than the way that a finger stick or a venous blood sample measures glucose.
• 14:58
  Rebecca Berens MD: They are actually this is a little small circular device.
• 15:01
  Rebecca Berens MD: Everyone at this point has probably seen w- someone walking around with these on their upper arm,'cause they're everywhere.
• 15:06
  Rebecca Berens MD: And it's usually placed on the upper arm, and has a teeny little electrode thing, needle, tiny little thing that goes on, and it's actually measuring interstitial fluid glucose.
• 15:17
  Rebecca Berens MD: It is not measuring blood glucose.
• 15:20
  Rebecca Berens MD: Whereas when you get a finger stick blood sugar or a venous sample of your blood, that is measuring your, directly the blood sugar.
• 15:26
  Rebecca Berens MD: And so the interstitial fluid glucose is the fluid around in between your skin and tissues is what it's measuring.
• 15:33
  Rebecca Berens MD: It's not measuring the blood directly.
• 15:35
  Rebecca Berens MD: So that's the first sort of important thing to to clarify the difference between the two, because those are not the same thing.
• 15:41
  Rebecca Berens MD: Now it is going to approximate the blood sugar, but it's going to lag because the interstitial fluid and the blood glucose levels will equilibrate and approximate each other, right?
• 15:53
  Rebecca Berens MD: But they're not the same thing, and there is gonna be a lag.
• 15:56
  Rebecca Berens MD: So when your blood sugar is changing, there's gonna be a lag in that showing up in the, Interstitial fluid interstitial fluid.
• 16:02
  Rebecca Berens MD: Okay.
• 16:03
  Rebecca Berens MD: And the benefit of the CGM is it gives you lots of data over time, and so you can see trends, and that's really what the CGMs are most helpful for, is understanding trends and how your blood sugar is going up and going down, again, with a slight lag a slight delay.
• 16:18
  Rebecca Berens MD: Whereas a finger stick or a venous sample is giving you more of an absolute value what is your actual, the actual value of your blood sugar in a very accurate way.
• 16:27
  Rebecca Berens MD: And during rapid changes to your blood sugar if your blood sugar is rapidly dropping or rapidly increasing the number that you see on the CGM is not necessarily going to match the number that you see on a finger stick blood sugar.
• 16:39
  Rebecca Berens MD: They can be quite different,'cause again, takes time for it to re-equilibrate, recalibrate.
• 16:44
  Rebecca Berens MD: That's the difference between those two things.
• 16:47
  Rebecca Berens MD: I think it's also important to note that there are several factors that can influence the readings on the CGM that are actually unrelated to what your blood sugar is.
• 16:56
  Rebecca Berens MD: So for example if the device is compressed, and this happens a lot when people are sleeping, if they roll over and press on the device that can restrict blood flow to the area, and it can cause a false low reading.
• 17:08
  Rebecca Berens MD: If you're, exercising or sweaty or get dehydrated'cause you're sick, that's gonna affect your fluid levels- and that's gonna affect the reading.
• 17:16
  Rebecca Berens MD: There's certain medications that can affect it.
• 17:18
  Rebecca Berens MD: On some older models, maybe not so much the new ones, but Tylenol was one that that did have an impact on on the measured levels with the CGM.
• 17:26
  Rebecca Berens MD: Vitamin C at high doses also can, and hydroxyurea, which is taken by some sickle cell patients.
• 17:32
  Rebecca Berens MD: And then it also matters how you place it, right?
• 17:33
  Rebecca Berens MD: If you place it incorrectly and the little electrode thing is not where it's supposed to be in the skin- if it's in the muscle or, or it's in skin that's too thin or something like that, and it's not able to get a good reading, that's also gonna impact it.
• 17:46
  Rebecca Berens MD: That kind of is a brief overview of how they work.
• 17:50
  Rebecca Berens MD: Anything you can think of that I might have missed, Sonia, or that you think- questions people might have if they're non-medical?
• 17:56
  Sonia Singh MD: No, I didn't know the thing about vitamin C potentially causing false high readings, which is interesting, because when you're taking any supplemental vitamin C, it tends to be high doses.
• 18:05
  Sonia Singh MD: It's always 1,000% of your daily value.
• 18:08
  Sonia Singh MD: I can imagine somebody drinking a little Emergen-C or one of those greens powders or something and being like,"Oh my God, it really spikes my sugar." So yeah, those are all good little caveats to know about.
• 18:18
  Sonia Singh MD: Yeah.
• 18:18
  Sonia Singh MD: So what is the evidence on who can actually benefit from CGMs?
• 18:23
  Rebecca Berens MD: Okay.
• 18:24
  Rebecca Berens MD: So yeah, to start with as we talked about, these were designed for people with diabetes, and initially, in particular, people with insulin-dependent and initially, specifically Type 1 diabetes.
• 18:35
  Rebecca Berens MD: For example, people who've been on insulin pumps for- Type 1 diabetes, that's been around for a while.
• 18:40
  Rebecca Berens MD: Yeah.
• 18:41
  Rebecca Berens MD: Continuous glucose monitoring for them is not a new phenomena.
• 18:44
  Rebecca Berens MD: Yeah but it started to be applied to people without pumps, so just with Type 1 diabetes who are insulin dependent without pumps.
• 18:50
  Rebecca Berens MD: And I wanna just share a few studies talking about the use of these medications in patients with diabetes, because there, there is good evidence for benefit with these patients.
• 18:59
  Rebecca Berens MD: So the first one I'll share is called Effects of Continuous Glucose Monitoring on Metrics of Glycemic Control in Diabetes: A Systematic Review with Meta-Analysis of Randomised Controlled Trials.
• 19:08
  Rebecca Berens MD: So this meta-analysis and systemic review the randomized controlled trials that they assessed were looking at changes in A1C time spent in the target blood sugar range, so TIR, time spent below the target range, so TBR, that's if the blood sugar is too low, and time above target range, meaning blood sugar is too high.
• 19:28
  Rebecca Berens MD: And it was i- showing the impact of using a CGM on those metrics for these patients.
• 19:33
  Rebecca Berens MD: And these were all patients who had either type 1 or type 2 diabetes who were on insulin.
• 19:40
  Rebecca Berens MD: So very important to note, these all were patients on insulin.
• 19:45
  Rebecca Berens MD: Okay?
• 19:45
  Rebecca Berens MD: And this was either continuous insulin or multiple shots a day, so not even just one basal dose of insulin for a type 2 diabetic.
• 19:51
  Rebecca Berens MD: This is someone- Yeah who's taking an intensive insulin regimen.
• 19:55
  Rebecca Berens MD: And they did see with this a modest reduction in the A1C, which is by about le- minus.17%, so not huge, but a little bit.
• 20:02
  Rebecca Berens MD: Increased time in range, and lower time outside of the range, meaning too high, too low.
• 20:09
  Rebecca Berens MD: And the increase of time in range was significant and robust independently of diabetes type, so it didn't matter if they were type 1 or type 2, and method of insulin delivery, so whether it was a pump or injections.
• 20:19
  Rebecca Berens MD: So good evidence there that there's some improvement in keeping the blood sugar in the target range when you're on insulin if you're using a CGM.
• 20:28
  Sonia Singh MD: Yeah, so fewer extremes, basically- yeah is what they were able
• 20:30
  Rebecca Berens MD: to achieve.
• 20:30
  Rebecca Berens MD: And the extremes are what we care about, right?
• 20:32
  Rebecca Berens MD: Because- Yeah the hypoglycemic events, particularly if you're on in, on insulin, and you have a severe hypoglycemic event that can kill you.
• 20:39
  Rebecca Berens MD: Medical
• 20:39
  Sonia Singh MD: emergency,
• 20:39
  Rebecca Berens MD: yeah.
• 20:40
  Rebecca Berens MD: Hypoglycemia is really dangerous.
• 20:41
  Rebecca Berens MD: Yeah.
• 20:41
  Rebecca Berens MD: And that's something that's important to be able to quickly identify and correct.
• 20:45
  Rebecca Berens MD: And then again, if you're persistently above your range, that's keeping your blood sugar in a high range over a long period of time, that's where we see those complications of diabetes increase.
• 20:56
  Rebecca Berens MD: And so that keeping them in that target range is not only reducing your risk in the short term, it's also reducing your risk in the long term for complications- of diabetes.
• 21:07
  Rebecca Berens MD: There was also a study similarly, that was done in more of a General living population, which was done at the VA.
• 21:14
  Rebecca Berens MD: And they initiated CGMs for patients with type 1 and type 2 diabetes within the VA system.
• 21:20
  Rebecca Berens MD: And the interesting thing to note about this is that so type 1 diabetes is an exclusion criteria for military service, so these were all patients with adult onset type 1 type- diabetes.
• 21:29
  Rebecca Berens MD: Okay.
• 21:30
  Rebecca Berens MD: So just important note there on the population.
• 21:32
  Rebecca Berens MD: And they were looking to compare glucose control as well as hypoglycemia or hyperglycemia related admissions to the emergency room or hospital, as well as all cause hospitalization.
• 21:43
  Rebecca Berens MD: So this is more than just are we keeping the glucose controlled, but is it also impacting the patient's, short term- Clinical outcomes, yeah with health, right?
• 21:51
  Rebecca Berens MD: Are they getting hospitalized m- less?
• 21:53
  Rebecca Berens MD: And these also, again, were all on insulin, so I have to be very clear with that.
• 21:58
  Rebecca Berens MD: These are type, people with type 1 and type 2 diabetes on insulin, not people- Yep who are not on insulin.
• 22:03
  Rebecca Berens MD: Okay.
• 22:03
  Sonia Singh MD: Yep.
• 22:05
  Rebecca Berens MD: So they did see with this that significantly greater declines in A1C in patients who were using CGMs with both type 1 and type 2 diabetes at 12 months, and a greater percentage of patients who were able to get their A1C less than eight and less than nine.
• 22:22
  Rebecca Berens MD: So these are patients who are very uncontrolled with their A1Cs in the past and now have been able to get them lowered with the use of the CGM.
• 22:30
  Rebecca Berens MD: And in type 1 diabetics, CGM was associated with a significantly reduced risk of hypoglycemia and all-cause hospitalization.
• 22:37
  Rebecca Berens MD: In patients with type 2 diabetes, there was a reduction in risk of hyperglycemia in CGM r- users, so they're reducing the high blood sugar events- as well as all-cause hospi- hospitalization for these patients.
• 22:52
  Sonia Singh MD: Okay.
• 22:52
  Sonia Singh MD: Pretty good data- Yeah supporting their use in those populations.
• 22:54
  Rebecca Berens MD: Yeah.
• 22:54
  Rebecca Berens MD: So if you are a diabetic of either type and you use insulin, solid evidence this is good for you, right?
• 23:00
  Sonia Singh MD: Yep.
• 23:00
  Rebecca Berens MD: Okay.
• 23:01
  Rebecca Berens MD: So next we have the much larger population, which is people who have type 2 diabetes and are not on insulin.
• 23:06
  Rebecca Berens MD: Yeah.
• 23:06
  Rebecca Berens MD: 'Cause that's a very large number of people with diabetes.
• 23:08
  Rebecca Berens MD: And I will say importantly, a lot of times insurance companies will not approve- Yeah the use of CGMs in people who are not using insulin.
• 23:16
  Rebecca Berens MD: And so that's a, that's just an important caveat because I think that impacts access for a lot of people to these devices.
• 23:25
  Rebecca Berens MD: So this study that I'm gonna cite was continuous glucose monitoring in non-insulin treated type 2 diabetes, a critical review of reported trials with an updated systematic review and meta-analysis of random c- randomized control trials.
• 23:38
  Rebecca Berens MD: And, They looked at randomized controlled trials that enrolled mixed populations with Type 2.
• 23:43
  Rebecca Berens MD: So some were on insulin, some were not.
• 23:45
  Rebecca Berens MD: That's what they mean by mixed populations but were including non-insulin diabetics in these.
• 23:50
  Rebecca Berens MD: And then they specifically did a systematic review of the randomized controlled trials that were only non-insulin treated compared to just usual care whether they were using a CGM or not.
• 24:01
  Rebecca Berens MD: In these s- in this study or in this meta-analysis and review there was a consistent benefit demonstrated of CGM on both glycemic and non-glycemic outcomes.
• 24:13
  Rebecca Berens MD: So meaning improved A1C, improved time and range and reduced healthcare resource utilization for this, these population.
• 24:23
  Sonia Singh MD: Okay.
• 24:23
  Sonia Singh MD: So looks like there's decent data too for using in patients with diabetes who are not insulin dependent.
• 24:29
  Rebecca Berens MD: Yeah.
• 24:29
  Rebecca Berens MD: Great.
• 24:30
  Rebecca Berens MD: So solid.
• 24:32
  Rebecca Berens MD: No concerns there.
• 24:33
  Rebecca Berens MD: Next up, pre-diabetes/ Okay metabolic syndrome.
• 24:37
  Rebecca Berens MD: So these are people who do not have diabetes and definitely would not be able to get one of these approved through insurance.
• 24:44
  Rebecca Berens MD: But have evidence of impaired glucose tolerance, meaning they have higher than normal fasting glucose, they have a higher than normal but still below the diabetes threshold A1C or average glucose over the last three months or they're showing evidence of insulin resistance or have other metabolic health complications associated with that, like a metabolic associated fatty liver disease, for example.
• 25:05
  Rebecca Berens MD: And this was again, a systematic review and meta-analysis continuous glucose monitoring in non-diabetic populations, a systematic review of observational and interventional studies with meta-analysis.
• 25:16
  Rebecca Berens MD: And most of the studies that they were looking at were targeting health promotion through lifestyle interventions for improving blood sugar, weight management, dietary behavior modification, and enh-enhanced adherence to recommend-- like medical treatment recommendations when it comes to lifestyle.
• 25:34
  Rebecca Berens MD: And they did demonstrate that the CGM significantly improved their blood glucose, but there was no significant difference on body mass index.
• 25:43
  Rebecca Berens MD: That was- So
• 25:44
  Sonia Singh MD: did not help with weight loss, but- Did
• 25:45
  Rebecca Berens MD: not help with weight
• 25:46
  Sonia Singh MD: loss it did help with lowering the
• 25:48
  Rebecca Berens MD: average Yes.
• 25:48
  Rebecca Berens MD: Did help with with blood sugars.
• 25:50
  Rebecca Berens MD: But the important thing that I thought was really interesting, was CGM was associated with higher behavioral adherence and specific dietary modifications.
• 25:58
  Rebecca Berens MD: Notably, CGM improved glycemic control in individuals with prediabetes, whereas no appreciable glycemic benefit was observed in healthy, normal glycemic populations.
• 26:07
  Rebecca Berens MD: So because some of the studies that they were looking at were just general health promotion- there was maybe some people involved that were not actually,
• 26:15
  Sonia Singh MD: Pre-diabetic
• 26:16
  Rebecca Berens MD: pre-diabetic.
• 26:17
  Rebecca Berens MD: And so there was im- improved control for people with prediabetes, but not really an appreciable change if you don't have prediabetes.
• 26:23
  Rebecca Berens MD: Okay.
• 26:24
  Sonia Singh MD: Okay.
• 26:26
  Sonia Singh MD: And is this the best we have in terms of benefits of CGMs for a healthy population, a normal glycemic population?
• 26:36
  Rebecca Berens MD: There's not a lot of other study on this population- Okay as it relates to any benefits, that I could find, anyway.
• 26:43
  Rebecca Berens MD: And I think when we get into the harms, there's been some study on that in healthy populations who do not have prediabetes.
• 26:50
  Rebecca Berens MD: And the key thing also is to understand that we don't have normalized ranges- for glucose fluctuations in healthy individuals, right?
• 27:01
  Rebecca Berens MD: It's even hard to say what is a better blood sugar if you're already- Yes normal.
• 27:05
  Rebecca Berens MD: How do we make- it better?
• 27:06
  Rebecca Berens MD: So it's even hard to measure, yeah.
• 27:08
  Rebecca Berens MD: What are we controlling it against?
• 27:09
  Rebecca Berens MD: How do we say it's better?
• 27:10
  Rebecca Berens MD: We don't know what it's, what we're trying to get it to if it's already normal.
• 27:14
  Sonia Singh MD: Yes.
• 27:15
  Sonia Singh MD: Okay, one thing I wanna point out before you move on is I think what a lot of people's perception of how they feel when their blood sugar is high or low is a little bit not in line with what is the medical reality.
• 27:27
  Sonia Singh MD: And so I think a lot of people turn to CGMs when they're thinking"Why am I so fatigued?""Why do I feel foggy?
• 27:33
  Sonia Singh MD: Like, why am I dragging?
• 27:35
  Sonia Singh MD: Why do I have this slump in the afternoon?" And of note, there is no study that's looking at CGM effect on fatigue or energy level.
• 27:43
  Sonia Singh MD: There's no study showing-
• 27:44
  Rebecca Berens MD: Yeah
• 27:44
  Sonia Singh MD: The things that I think people believe it is likely to help with are things that we have literally no data on.
• 27:51
  Sonia Singh MD: Because honestly, there isn't even a really great physiologic pathway there that makes a lot of sense.
• 27:57
  Sonia Singh MD: Anyway, okay.
• 27:58
  Sonia Singh MD: So there's not much data for CGMs in healthy populations for- I guess you, y- if you were to study in that population, the question would be like what is the outcome you're looking for if there already-
• 28:09
  Rebecca Berens MD: I'm like, what would you, what
• 28:10
  Sonia Singh MD: would you measure?
• 28:10
  Sonia Singh MD: If they already have normal blood sugar.
• 28:12
  Sonia Singh MD: What are you targeting?
• 28:13
  Sonia Singh MD: Yeah.
• 28:13
  Sonia Singh MD: I'm
• 28:13
  Rebecca Berens MD: like, how do we measure that it's better when it's already normal?
• 28:16
  Sonia Singh MD: That it's working.
• 28:16
  Rebecca Berens MD: Yeah.
• 28:17
  Rebecca Berens MD: Yeah.
• 28:17
  Rebecca Berens MD: And
• 28:17
  Sonia Singh MD: that would...
• 28:17
  Sonia Singh MD: That...
• 28:18
  Sonia Singh MD: that's probably why those don't exist,'cause, like the question is what are you aiming for?
• 28:21
  Sonia Singh MD: Yeah.
• 28:22
  Sonia Singh MD: What's the goal here?
• 28:23
  Rebecca Berens MD: Yeah.
• 28:23
  Rebecca Berens MD: I wouldn't- I wouldn't know what to say.
• 28:24
  Rebecca Berens MD: But it is notable that there was no change in BMI because I do think that is often a reason that it is touted.
• 28:31
  Rebecca Berens MD: And even in- Yeah this p- in this population who...
• 28:33
  Rebecca Berens MD: These are people who do have maybe pre-diabetes or metabolic issues it was not appreciably changing their BMI to use the CGM.
• 28:40
  Rebecca Berens MD: Now, does that mean on an individual level if a person uses a CGM and changes their behaviors significantly because of the feedback they're getting from the CGM that they won't lose weight?
• 28:50
  Rebecca Berens MD: No, they might.
• 28:52
  Sonia Singh MD: It's
• 28:52
  Rebecca Berens MD: possible.
• 28:52
  Rebecca Berens MD: But it's not something that you can say"This is going to make you lose weight." We don't have data to support that.
• 28:56
  Sonia Singh MD: Okay.
• 28:56
  Sonia Singh MD: I have- So- I have a theoretical question for you.
• 28:59
  Sonia Singh MD: Within the normal range of blood sugar, what if somebody says my average blood sugar is 95, but wouldn't it be better if it was 90?" So tell me what your thoughts are on that.
• 29:12
  Rebecca Berens MD: I don't know how we could possibly know.
• 29:15
  Rebecca Berens MD: I don't know how we could know that.
• 29:17
  Sonia Singh MD: Okay.
• 29:18
  Sonia Singh MD: So your answer is we don't really know if that's any-
• 29:20
  Rebecca Berens MD: Yeah.
• 29:20
  Rebecca Berens MD: I don't think that we know if that's better.
• 29:22
  Rebecca Berens MD: I think we do know if you are, say, at the high end of normal for your baseline-
• 29:30
  Sonia Singh MD: Yeah
• 29:30
  Rebecca Berens MD: are you maybe going to have a more pronounced response to certain foods when you eat them- and therefore have a higher spike?
• 29:38
  Rebecca Berens MD: Maybe.
• 29:39
  Rebecca Berens MD: But what matters to me more so is is it coming back down appropriately?
• 29:42
  Sonia Singh MD: Yes.
• 29:42
  Rebecca Berens MD: Or are you struggling to lower it after it was high?
• 29:45
  Rebecca Berens MD: And that, I think, is a different, that's a different measurement than av- what is your baseline?
• 29:51
  Sonia Singh MD: Yeah.
• 29:52
  Sonia Singh MD: I just think about that in terms of...
• 29:53
  Sonia Singh MD: I get this question a lot.
• 29:54
  Sonia Singh MD: I go over lab results with patients in really great and gory detail because I have the privilege of being able to do that in my practice model.
• 30:02
  Sonia Singh MD: But when you do that, you find that people often have these questions about my potassium was 3.6, and now it's 3.9," and, but- or,"Now it's, four point- 4.4 and doesn't that, isn't that kind of concerning?
• 30:16
  Sonia Singh MD: They see something that looks close to the range that is a high or low, and they think doesn't that mean something?
• 30:21
  Sonia Singh MD: And with something like potassium, I feel really confident saying,"Look, it's gonna fluctuate day-to-day." Yeah.
• 30:26
  Sonia Singh MD: That little blip between- Hour
• 30:28
  Rebecca Berens MD: to hour.
• 30:29
  Sonia Singh MD: Yes.
• 30:29
  Sonia Singh MD: All these little variations within the normal range are so meaningless to me.
• 30:33
  Sonia Singh MD: Do not worry about that.
• 30:34
  Sonia Singh MD: That is not a thing.
• 30:35
  Sonia Singh MD: I think it's slightly harder to make that argument about the blood sugar, and that's where I think a lot of patients get hung up.
• 30:42
  Sonia Singh MD: I even have patients get hung up on the A1C where they're like, but it's 5.5, and 5.6 is the cutoff for prediabetes don't you think I should jump on this now and get the CGM and get this thing down?" And I'm asking you'cause I genuinely don't know how strong this data is.
• 30:59
  Sonia Singh MD: What I usually tell them is"Look even prediabetes is, for us it's a red flag, it is a sign of something.
• 31:05
  Sonia Singh MD: But many of those people will never progress to diabetes." You still have plenty of opportunity to work on this.
• 31:10
  Sonia Singh MD: And, each of those.1 percentages is probably farther apart than you think it is." I have a whole spiel on it.
• 31:15
  Sonia Singh MD: But I do wonder can I point to data that's"Look, it's okay for you to be 85 versus 90 versus 95 versus 99 o- of an average blood sugar"?
• 31:26
  Sonia Singh MD: And I don't know the answer.
• 31:28
  Rebecca Berens MD: Yeah.
• 31:28
  Rebecca Berens MD: I think one thing that I would say is they came up with the cutoffs for a reason.
• 31:34
  Rebecca Berens MD: Even for people with diabetes, our goal is not to get their A1C to 5.6.
• 31:38
  Rebecca Berens MD: Yeah.
• 31:39
  Rebecca Berens MD: Our goal is to get their A1C less than 7.0.
• 31:41
  Rebecca Berens MD: And that has to do with with a break point of we see an increased rate of complications- Yeah above that.
• 31:48
  Rebecca Berens MD: And targeting too low below that has risks, too- of overmedication, right?
• 31:54
  Rebecca Berens MD: And so when you have someone who's not even high and we try to lower it further, I think you are in- incurring greater risk of overmanagement without- Yeah clear evidence of benefit.
• 32:08
  Rebecca Berens MD: Yeah.
• 32:08
  Rebecca Berens MD: Okay I
• 32:08
  Sonia Singh MD: think- I think that's a great answer.
• 32:09
  Sonia Singh MD: Yeah.
• 32:10
  Sonia Singh MD: Yeah.
• 32:10
  Sonia Singh MD: Yeah.
• 32:10
  Sonia Singh MD: No I think the argument that's okay, look, maybe your average blood sugar is 95.
• 32:14
  Sonia Singh MD: Maybe you would like to see it be 90,'cause that feels safer and better to you.
• 32:19
  Sonia Singh MD: But what we know is having this average blood sugar consistently below 100 is completely within normal physiology.
• 32:25
  Sonia Singh MD: So whatever efforts and changes you would make to try to lower that- may not have any tangible benefit.
• 32:31
  Sonia Singh MD: I guess that's a reasonable answer- Yeah to say m- maybe, but we can't really quantify that benefit or tell you really concretely what that would be, and there would likely be some potential harms in Yes whatever you would be, whatever you would be doing, restricting, changing in order to do that.
• 32:48
  Rebecca Berens MD: Yeah.
• 32:48
  Rebecca Berens MD: And I think that's the key is like it's always, okay, what's the potential benefit?
• 32:51
  Rebecca Berens MD: What's the potential harm?
• 32:53
  Rebecca Berens MD: If we don't have any potential benefit that we can really point to, then you only have harm.
• 32:57
  Rebecca Berens MD: So then-
• 32:58
  Sonia Singh MD: But I think- a lot of people listening to this, and again, I'm playing devil's advocate.
• 33:01
  Sonia Singh MD: I'm pushing here- because this is what I hear.
• 33:02
  Rebecca Berens MD: Yeah.
• 33:03
  Rebecca Berens MD: This
• 33:03
  Sonia Singh MD: is what I hear from people.
• 33:04
  Sonia Singh MD: Yeah, sure.
• 33:04
  Sonia Singh MD: I think their answer to that would be like sugar...
• 33:06
  Sonia Singh MD: Isn't sugar bad?" Sugar- is bad, and so wouldn't having less sugar, reducing the sugar in my diet, wouldn't that be good?
• 33:14
  Sonia Singh MD: Even if, yes, I'm just moving from five points in the normal range to five points lower than the normal range, wouldn't that still be a positive thing for my health?
• 33:22
  Rebecca Berens MD: I think that depends very much on what is the current sugar content of your diet because there is a point at which it's too low.
• 33:31
  Rebecca Berens MD: Yeah.
• 33:32
  Rebecca Berens MD: Right?
• 33:32
  Rebecca Berens MD: We need to have carbs.
• 33:33
  Rebecca Berens MD: You have to have carbs.
• 33:34
  Rebecca Berens MD: I think, we certainly know that if you are eating a lot of highly processed foods with refined sugars that do not have a lot of fiber you're going to get more prominent spikes and dips in your blood sugar, which, we can get into all of that in a little bit here.
• 33:49
  Rebecca Berens MD: But, there...
• 33:50
  Rebecca Berens MD: Yes, if You're consistently getting a lot of sugar to the exclusion of other important nutrients I could see how, yes, it would s- we could say"Yes, there may be a benefit for you," but I would still say it and add those things, not take away- Yes.
• 34:03
  Rebecca Berens MD: The sugar.
• 34:04
  Rebecca Berens MD: Like I wouldn't, I would never express it that way because I think it's unhelpful.
• 34:09
  Rebecca Berens MD: And also, the sugar is not bad, especially if your body is able to use it properly.
• 34:15
  Sonia Singh MD: Yeah.
• 34:16
  Rebecca Berens MD: That's not the problem.
• 34:17
  Rebecca Berens MD: The problem is if your body is not able to use it properly and it's staying higher than it should for a longer period after you eat, that is where the problem comes in.
• 34:28
  Rebecca Berens MD: I don't think that we can prove that there's any problem to having a spike in your blood sugar that comes right back down again and normalizes in an appropriate span of time.
• 34:37
  Rebecca Berens MD: I, I've, I don't know, I've never seen anything that's proven any harm to that.
• 34:40
  Sonia Singh MD: Okay.
• 34:40
  Sonia Singh MD: I'm assuming we're gonna get into the, the- the, that in more detail.
• 34:45
  Sonia Singh MD: Yeah.
• 34:45
  Sonia Singh MD: But okay.
• 34:45
  Sonia Singh MD: I took you on a tangent.
• 34:47
  Sonia Singh MD: Yeah.
• 34:47
  Sonia Singh MD: So let's get back to what is the data on CGM use in eating disorders?
• 34:51
  Sonia Singh MD: I didn't even know...
• 34:52
  Sonia Singh MD: I am not familiar with this data at all, so I'm really curious what you-
• 34:55
  Rebecca Berens MD: Yeah.
• 34:55
  Rebecca Berens MD: So there's not a ton of data, but I will say this is an emerging area of like very active discussion and, And trials, I will say.
• 35:05
  Rebecca Berens MD: So there has been some-- for anorexia, for example, anorexia has a very high mortality rate, and some of that is related to suicide, but some of that is related to medical complications one of which is hypoglycemia.
• 35:19
  Rebecca Berens MD: Okay?
• 35:20
  Rebecca Berens MD: So low blood sugars especially overnight can result in death for patients with anorexia.
• 35:25
  Rebecca Berens MD: So there was this idea hey, if we can monitor blood sugar for patients who have anorexia or have another eating disorder, maybe it can help us to avoid some of that complication.
• 35:37
  Rebecca Berens MD: I think there's also the idea of maybe we can get more accurate data about, how often the patient is eating because maybe their report is not always accurate, and we can get more information from trends on a CGM.
• 35:54
  Rebecca Berens MD: So there's not a hun-- a whole ton of data on it actually but it is something that I think is is being actively discussed and looked at, and probably there will be more data in the near future'cause it's currently being studied.
• 36:04
  Rebecca Berens MD: But I think also there is the idea of helping to prove to a patient that there's a problem.
• 36:13
  Rebecca Berens MD: Yeah.
• 36:13
  Rebecca Berens MD: If a patient doesn't believe you that they're really that sick which is a common feature of eating disorders is like,"Everything's fine,""I feel fine.
• 36:22
  Rebecca Berens MD: There's nothing wrong." And often labs are normal on these patients- Yeah too, and so especially if the patient has a quote-unquote"normal BMI," because only about six percent of people with eating disorders are at a below normal BMI it's really hard sometimes to convince them that what's happening is actually harmful.
• 36:42
  Rebecca Berens MD: And so- sometimes having, again, some data to be like,"Hey, this is what we're seeing that, that tells us that you're having a problem," there's some idea of using it for that reason as well.
• 36:51
  Rebecca Berens MD: But anyway the studies that I did find there was one which is continuous glucose monitoring assessment in patients suffering from anorexia reveals chronic prolonged mild hypoglycemia throughout the day.
• 37:02
  Rebecca Berens MD: And this was a pretty small study.
• 37:05
  Rebecca Berens MD: It was done in Europe and it's twenty-eight women who have anorexia and were at a very low BMI, below seventeen point five, between the ages of eighteen and thirty.
• 37:17
  Rebecca Berens MD: Eighteen of them were pure restrictive anorexia, and four were binge purge type.
• 37:21
  Rebecca Berens MD: And they had no other medical comorbidities that would have been thought to affect their glucose, like diabetes, renal failure, or anything like that.
• 37:29
  Rebecca Berens MD: And th- they on average had anorexia for 59.2 months, so almost five years, so long-standing anorexia.
• 37:37
  Rebecca Berens MD: So their average glucose was in the normal range, but ninety-one percent of them had at least one episode of hypoglycemia less than seventy.
• 37:47
  Rebecca Berens MD: And within the twenty-four hours, the percentage of time pers- spent below seventy was 20.82% with a maximum of fifty-two percent.
• 37:57
  Rebecca Berens MD: So for some of these patients, they were spending up to fifty-two percent of the day with low- Yeah blood sugar.
• 38:03
  Rebecca Berens MD: But on average, about twenty percent of the day with low blood sugar.
• 38:06
  Rebecca Berens MD: So again, evidence of significant concern related to hypoglycemia that can have resultant complications and lead to death for that patient.
• 38:16
  Rebecca Berens MD: And so that was basically just a descriptive study of this is what we see happening.
• 38:22
  Rebecca Berens MD: And but doesn't tell us anything about does monitoring that help in any way?
• 38:25
  Rebecca Berens MD: Do we know anything-- ha- have we made any difference to the patient by knowing that?
• 38:29
  Rebecca Berens MD: 'Cause it doesn't give us any idea of what to do about it.
• 38:33
  Sonia Singh MD: So then- I'm curious about the symptomatology.
• 38:35
  Sonia Singh MD: What I think of as symptoms of hypoglycemia are feeling shaky, sweaty, jittery, just needing some glucose and then having resolution with food.
• 38:44
  Sonia Singh MD: But if you're chronically in this state, what does that look like?
• 38:48
  Sonia Singh MD: Do you-- I don't know if you're-
• 38:49
  Rebecca Berens MD: yeah
• 38:50
  Sonia Singh MD: It's not what the
• 38:50
  Rebecca Berens MD: study was looking at.
• 38:51
  Rebecca Berens MD: That's a great question.
• 38:51
  Rebecca Berens MD: And so one thing that's commonly seen in patients with anorexia is they do not feel symptoms of hypoglycemia.
• 38:58
  Rebecca Berens MD: Because your body has adapted to being chronically low.
• 39:01
  Rebecca Berens MD: Yeah.
• 39:01
  Rebecca Berens MD: And that's why it's so dangerous, because they don't know.
• 39:04
  Sonia Singh MD: Right.
• 39:05
  Rebecca Berens MD: And and that's why the risk of death is so high because you don't know that it's happening.
• 39:09
  Rebecca Berens MD: And so you can have th- this drop that eventually can lead to death.
• 39:15
  Rebecca Berens MD: Because it's...
• 39:16
  Rebecca Berens MD: If you're not feeling anything you may not feel anything until the point of you have a seizure or you go into a coma, which can happen- Yeah with severely low blood sugars.
• 39:24
  Rebecca Berens MD: And so I think that's one kind of thought process behind like how can-- what could we use this data for?
• 39:30
  Rebecca Berens MD: Can this help us identify who's experiencing that and intervene such that we can improve outcomes?
• 39:37
  Rebecca Berens MD: And I think that's where we don't have that data yet.
• 39:39
  Rebecca Berens MD: But- Yeah but this is an initial step towards like maybe this is something we can do to better help these patients.
• 39:44
  Sonia Singh MD: Yeah.
• 39:44
  Sonia Singh MD: Interesting.
• 39:45
  Rebecca Berens MD: Okay.
• 39:46
  Rebecca Berens MD: The next study that I wanna talk about is a little bit more, More varied.
• 39:51
  Rebecca Berens MD: So this one's called Tracking Glucose Trends, Unveiling Clinical Patterns: Insights from Continuous Glucose Monitoring in Patients at the Extremes of BMI and Eating Disorders Pathology.
• 40:00
  Rebecca Berens MD: And so this one's also from Europe.
• 40:01
  Rebecca Berens MD: And this one, again, very small, 30 patients.
• 40:04
  Rebecca Berens MD: 15 of them had anorexia, 15 of them had binge eating disorder.
• 40:07
  Rebecca Berens MD: So again, like the opposite extremes of eating disorder pathology- or behavioral pathology.
• 40:13
  Rebecca Berens MD: So they were wearing continuous glucose monitors while while synchronously collecting data on their food intake to correlate with that.
• 40:21
  Rebecca Berens MD: And the CGM output was extracted and correlated with their nutritional intake, their dai- daily meals, and their self report.
• 40:27
  Rebecca Berens MD: The interesting thing about this was they used different CGMs for the different populations.
• 40:35
  Rebecca Berens MD: Okay.
• 40:36
  Rebecca Berens MD: Which I felt was a little bit, makes it harder to interpret, but it was a necessity based on their situation, so the the individuals with binge eating disorder had the Dexcom G6, which is a continuous real-time CGM versus the patients with anorexia had an intermittently scanned CGM by FreeStyle Libre which I think was one of the older models that you had to actually scan it- to get the data to pull.
• 41:01
  Rebecca Berens MD: It didn't just automatically report.
• 41:03
  Rebecca Berens MD: And this was done because for the patients with anorexia they didn't want them to see the data.
• 41:08
  Rebecca Berens MD: I see.
• 41:08
  Rebecca Berens MD: Because it would influence maybe their behaviors.
• 41:11
  Rebecca Berens MD: I
• 41:11
  Sonia Singh MD: see.
• 41:11
  Rebecca Berens MD: Okay and They wanted to remove that variable they wanted it to go to a caregiver.
• 41:14
  Rebecca Berens MD: But then it's hard-- You can't compare the two necessarily- Not the same anymore because they're different.
• 41:18
  Rebecca Berens MD: It's different situations, right?
• 41:19
  Rebecca Berens MD: But anyway and let me see.
• 41:24
  Rebecca Berens MD: So what they saw for this was that 74% of the participants did experience hypoglycemia with unique trends based on their diagnosis.
• 41:32
  Rebecca Berens MD: So for patients with anorexia, they had prolonged hypoglycemia between meals and including overnight, w- where versus with binge eating disorder, they did have hypoglycemic episodes, but they tended to be short-lived and typically postprandial.
• 41:45
  Rebecca Berens MD: After eating a meal, they were getting a kind of an exaggerated insulin response and then a dip in their blood sugar to a hypoglycemic range during the day after eating.
• 41:55
  Rebecca Berens MD: So just again, this is describing the differences in how we might see blood sugar trends in these diagnoses.
• 42:03
  Sonia Singh MD: Okay.
• 42:04
  Sonia Singh MD: Yeah.
• 42:04
  Sonia Singh MD: Interesting.
• 42:05
  Rebecca Berens MD: But again, nothing about this to say this is what we should do.
• 42:09
  Rebecca Berens MD: I think the thought process is, Now that we know this, and this is again what's currently being studied, and we're still gonna get more data on this, is can we use this information to be able to intervene and prevent deaths in patients with anorexia?
• 42:24
  Rebecca Berens MD: Can we use this information as helpful biofeedback advice for patients to understand, how their eating pattern is affecting their glucose, and maybe see over time how it's improving with treatment?
• 42:36
  Rebecca Berens MD: But then there's also the potential that it might reinforce their maladaptive behavior.
• 42:41
  Rebecca Berens MD: For the patient I mentioned at the beginning- they would get dips, and they were like,"Every time I eat, I get a dip," which is totally expected to happen during treatment for anorexia.
• 42:49
  Rebecca Berens MD: But it becomes a concern that's anxiety pr- provoking for them, and so then they're actually not eating what they need to eat- to be able to have the appropriate- Response response.
• 43:01
  Rebecca Berens MD: There's also, continuous monitoring while you're already struggling with eating disorder treatment.
• 43:07
  Rebecca Berens MD: And there's...
• 43:09
  Rebecca Berens MD: eating disorders as a feature already involve a lot of obsession about body metrics- Yeah in most cases, and so we're adding another body metric now for you to worry about.
• 43:20
  Rebecca Berens MD: Is that beneficial, or is it harmful?
• 43:21
  Rebecca Berens MD: I think that probably depends on the patient.
• 43:24
  Rebecca Berens MD: Yeah and again, we don't really know yet what to do with this evidence.
• 43:28
  Rebecca Berens MD: It gives us- some information, and at least, say if we have a patient who has anorexia, and we see their blood sugar tanking, and they can get an alarm from a CGM, maybe they can go eat, and maybe we do prevent a death or a hospitalization or something.
• 43:40
  Rebecca Berens MD: But we don't have the data to prove that yet, at least that I could find.
• 43:43
  Rebecca Berens MD: I could be wrong, but I think that's what's currently being explored and better studied so we can know what impact does this have that's beneficial, and what impact does this have that's maybe not beneficial.
• 43:54
  Sonia Singh MD: Yeah.
• 43:56
  Sonia Singh MD: Honestly, it's just heartening to even hear people studying this because I think so often there's this perception of yeah, it's a technology.
• 44:03
  Sonia Singh MD: We just use it, yeah.
• 44:04
  Sonia Singh MD: It's not...
• 44:05
  Sonia Singh MD: y- you have to think about in each population that you're planning to use this in, what are the benefits, what are the harms, and then what actually happens when you try to do it in people?
• 44:13
  Sonia Singh MD: And so we often, it feels like in, the current wellness landscape, just completely skip that step and jump- Yeah st- straight to slap it on your arm, put it on, let's start using it without ever asking the question of have we even shown this benefits anybody or what the potential harms or unintended consequences might be.
• 44:33
  Sonia Singh MD: So let's talk about some of those.
• 44:34
  Sonia Singh MD: So what are some potential harms from CGMs?
• 44:38
  Rebecca Berens MD: Yeah.
• 44:38
  Rebecca Berens MD: So I think one of the first one to be watchful for is, As I mentioned, there are several things that can affect the accuracy of these devices, one of which is compression.
• 44:48
  Rebecca Berens MD: And if you compress it, particularly while you're sleeping, you may get a low.
• 44:51
  Rebecca Berens MD: And so there was actually a an article I found in JAMA.
• 44:54
  Rebecca Berens MD: It's called Continuous Glucose Monitor Use: Avoiding Overuse.
• 44:58
  Rebecca Berens MD: And I wasn't able to read the whole full text, which was quite annoying, but it had a case report of a patient who had an unnecessary hospitalization due to misinterpretation of hypoglycemic events on their CGM.
• 45:09
  Rebecca Berens MD: And they turned out to be from compression.
• 45:11
  Rebecca Berens MD: Based on the summary of the article that I was able to read.
• 45:13
  Rebecca Berens MD: But they were getting alerts overnight when they were sleeping for glucoses in the 40s and 50s, which, yeah, it does sound concerning.
• 45:20
  Rebecca Berens MD: And they were afraid to sleep so then they ended up getting a whole medical workup.
• 45:25
  Sonia Singh MD: The hypoglycemia workup is not a small thing.
• 45:29
  Rebecca Berens MD: No.
• 45:29
  Sonia Singh MD: Like, when patients
• 45:30
  Rebecca Berens MD: come
• 45:30
  Sonia Singh MD: to me- It is very
• 45:30
  Rebecca Berens MD: challenging.
• 45:31
  Rebecca Berens MD: and they're
• 45:31
  Sonia Singh MD: like,"I think I have hypoglycemia," I'm like,"Don't joke about that.
• 45:34
  Sonia Singh MD: We gotta be very specific about what exactly you're experiencing and what the glucose is- Yeah and prove it," because committing you to a true hypoglycemia evaluation is not a small thing.
• 45:45
  Rebecca Berens MD: Yeah.
• 45:45
  Rebecca Berens MD: And that to, to your point, which you alluded to earlier, but I wanna just spell out here we have to know is it hypoglycemia, and the way to prove that is with Whipple's triad.
• 45:54
  Rebecca Berens MD: Yeah.
• 45:55
  Rebecca Berens MD: So Whipple's triad is the patient experiences symptoms of hypoglycemia.
• 45:59
  Rebecca Berens MD: They feel shaky, clammy, sweaty, hungry, agitated.
• 46:03
  Rebecca Berens MD: They have a demonstrated low venous blood sugar.
• 46:07
  Rebecca Berens MD: So your CGM doesn't count, so we have to document it with a venous sample.
• 46:11
  Rebecca Berens MD: And then there is a resolution of symptoms with eating.
• 46:14
  Rebecca Berens MD: So that is the requirement.
• 46:17
  Rebecca Berens MD: And again very difficult to do that because it's very hard to be in the lab when you're having the symptoms.
• 46:21
  Rebecca Berens MD: And so we often do end up having to rely on these less optimal measurements.
• 46:26
  Rebecca Berens MD: But it is, like you said, a very challenging workup, and not something that you want to submit yourself to unnecessarily.
• 46:32
  Rebecca Berens MD: Yeah.
• 46:32
  Rebecca Berens MD: And very costly.
• 46:33
  Rebecca Berens MD: Yeah.
• 46:34
  Rebecca Berens MD: And anxiety provoking.
• 46:35
  Rebecca Berens MD: This person was afraid to sleep, that's terrifying.
• 46:37
  Rebecca Berens MD: Yes.
• 46:37
  Rebecca Berens MD: Yes.
• 46:37
  Rebecca Berens MD: And very harmful.
• 46:38
  Rebecca Berens MD: Important to be aware of that potential risk.
• 46:42
  Rebecca Berens MD: And again, it's difficult if they're having these things overnight.
• 46:45
  Rebecca Berens MD: That's, I think, maybe why this happened is it's hard to know if were you having symptoms- When you're sleeping Right But so yeah it's just, it's a challenging case.
• 46:53
  Rebecca Berens MD: And so we wanna make sure we're not over-diagnosing potential hypoglycemia and doing the resultant workup when it actually was not necessary.
• 47:01
  Rebecca Berens MD: I think the other thing to be aware of is pathologizing normal fluctuation.
• 47:05
  Rebecca Berens MD: So this is what I was talking about.
• 47:06
  Rebecca Berens MD: If you eat something that...
• 47:08
  Rebecca Berens MD: drink some soda or eat some refined sugar, and you have a spike in your sugar, and then it comes right back down.
• 47:12
  Rebecca Berens MD: That's normal.
• 47:12
  Rebecca Berens MD: That's okay
• 47:14
  Sonia Singh MD: I mean- so there, there are many people who would disagree with you.
• 47:17
  Sonia Singh MD: And we won't, we shall not name this entity But a certain glucose deity is out there that really strongly believes that those spikes are a problem.
• 47:33
  Sonia Singh MD: So I feel that I can hear...
• 47:36
  Sonia Singh MD: somebody who follows that entire mantra may not even have gotten this far in this episode but-
• 47:40
  Rebecca Berens MD: Yeah
• 47:41
  Sonia Singh MD: I believe there are people out there that are like,"That is not normal.
• 47:45
  Sonia Singh MD: That is not a normal, appropriate physiologic response, and that's that's because we're eating poison, and that is not what you should be seeing." So not just for this topic, but the pathologizing of normal human physiology and normal human responses is a big problem.
• 48:05
  Sonia Singh MD: And it's funny because I feel like a lot of people can see it when it comes to, Or they think they can see it when it comes to mental health or something.
• 48:13
  Sonia Singh MD: They'll say,"That person's not...
• 48:15
  Sonia Singh MD: That, that doctor just wanted to put them on meds'cause they said they had depression, but they're just in a slump.
• 48:20
  Sonia Singh MD: They're having a bad day.
• 48:21
  Sonia Singh MD: They're just grieving their mom." Whatever it is.
• 48:23
  Sonia Singh MD: The,"That's not a disease.
• 48:24
  Sonia Singh MD: They're making it a disease.
• 48:25
  Sonia Singh MD: It's not a disease," right?
• 48:27
  Sonia Singh MD: But it seems I think people have a really hard time seeing it when it comes to stuff that has objective data with it.
• 48:33
  Sonia Singh MD: 'Cause they're like,"But look at these numbers," Yeah.
• 48:36
  Sonia Singh MD: But yeah.
• 48:37
  Sonia Singh MD: I think this is a great example of pathologizing and fear-mongering around completely normal human physiologic response.
• 48:45
  Rebecca Berens MD: Yeah.
• 48:46
  Rebecca Berens MD: Yeah,'cause up until, a few years ago, however many years it's been, I don't know, that we had people without diabetes putting these on, we don't know what our blood sugars were doing.
• 48:56
  Sonia Singh MD: You're right.
• 48:56
  Rebecca Berens MD: Like like- We were
• 48:57
  Sonia Singh MD: blissfully unaware
• 48:59
  Rebecca Berens MD: so to, to say that you know that, oh, it's because of these spikes that this is happening, like, how could you possibly know that?
• 49:07
  Rebecca Berens MD: You can't possibly know that,'cause we didn't have this information, ever.
• 49:12
  Sonia Singh MD: Yeah.
• 49:12
  Sonia Singh MD: And I, I've heard the claim, and I don't know if this is true, and we came across it.
• 49:16
  Sonia Singh MD: I've heard the claim also that, CGMs are not quite as accurate when you're looking at the numbers within the physiologic range as they are for higher- than normal blood sugars.
• 49:25
  Sonia Singh MD: But I don't know if that's true.
• 49:27
  Rebecca Berens MD: So at the very, very extremes, like very low and very high, it's actually more inaccurate.
• 49:32
  Sonia Singh MD: Okay,
• 49:33
  Rebecca Berens MD: but the other thing is that the absolute number is not necessarily accurate.
• 49:38
  Rebecca Berens MD: It's the trend.
• 49:40
  Rebecca Berens MD: And which is the same as we talked about with the h- with the fitness tracker.
• 49:42
  Rebecca Berens MD: So that's the thing is it's if it tells you your baseline is 80, and it tells you next month that your baseline is 85, and you're just like,"Oh my God, my baseline went up," I'm like,"I don't know if it did."
• 49:53
  Sonia Singh MD: Okay.
• 49:53
  Rebecca Berens MD: It may- it probably didn't.
• 49:55
  Rebecca Berens MD: It's, but it's the trend over time that matters, and that's why I say when I see a spike, I'm like, okay, if you have a spike and it returns to normal and you go back to your baseline, I don't see how we can say that's harmful.
• 50:05
  Rebecca Berens MD: If you have a spike and it never quite returns to baseline, and then you have another spike and it goes even higher, and now your baseline is high, and it's never come back down to normal, yes, that makes sense that's likely an issue that your body is not properly able to lower the blood sugar.
• 50:20
  Rebecca Berens MD: But that's not what most people are seeing.
• 50:21
  Rebecca Berens MD: Most people are seeing,"There's a spike when I eat, and then it goes back down to my baseline, and I stay at my baseline," right?
• 50:26
  Rebecca Berens MD: So I think I think that's the other thing is what are we talking about when we say spike?
• 50:30
  Sonia Singh MD: Yeah.
• 50:31
  Rebecca Berens MD: I think it's not, I don't think we're even all talking about the same thing when we use these words, and like you said the people that are talking about this on the internet w- with their various credentials or not credentials, it's like I don't know- what you even mean by that.
• 50:45
  Rebecca Berens MD: But anyway there was a study which I appreciated because we struggled with this with the fitness trackers, like no one was studying is this har- hurting people psychologically.
• 50:55
  Rebecca Berens MD: Yes.
• 50:55
  Rebecca Berens MD: But there was a study I found that understanding the benefits and psychological burdens of using continuous glucose monitoring for- Oh lifestyle change.
• 51:01
  Rebecca Berens MD: So I was like,"This is great," because- that's exactly what we're talking about.
• 51:05
  Rebecca Berens MD: So this was a digital questionnaire adminis- administered to adults with and without diabetes, not on insulin.
• 51:11
  Rebecca Berens MD: So no one had insulin, but some of them had diabetes, who had used a CGM in the last year.
• 51:16
  Rebecca Berens MD: So tricky because this is retrospective, right?
• 51:19
  Rebecca Berens MD: This is not a controlled thing.
• 51:21
  Rebecca Berens MD: These are all people who did use it.
• 51:22
  Rebecca Berens MD: And so these
• 51:23
  Sonia Singh MD: people independently, like they chose to use this, like they, they went out and got a CGM and used it, or they were, given
• 51:28
  Rebecca Berens MD: one?
• 51:28
  Rebecca Berens MD: They had used one, and I actually, I don't remember how they found these people, but yes, they had already used one
• 51:34
  Sonia Singh MD: independently.
• 51:34
  Sonia Singh MD: I'm just wondering if they're self-selecting.
• 51:36
  Sonia Singh MD: Yes.
• 51:36
  Sonia Singh MD: They're, if this is a population that chose to go out and buy a CGM and put it on when
• 51:40
  Rebecca Berens MD: they did not have to.
• 51:40
  Rebecca Berens MD: My, my theory is yes- Okay because they didn't tell them to use it- for the study.
• 51:45
  Rebecca Berens MD: Yes.
• 51:46
  Rebecca Berens MD: They had already used it.
• 51:47
  Rebecca Berens MD: Yes, okay.
• 51:47
  Rebecca Berens MD: So either someone else had recommended- So people- it to them and they'd done it, or they went out and did it themselves.
• 51:51
  Rebecca Berens MD: You know- Okay caveats.
• 51:52
  Rebecca Berens MD: But, But they then rated characteristics of the participants, psychological traits, and ratings of their CGM-related distress.
• 52:00
  Rebecca Berens MD: Which again, retrospective, so I don't know how accurate it all was, but it's just an interesting...
• 52:06
  Rebecca Berens MD: these people were then reflecting on their experience with- Yeah the CGM.
• 52:10
  Rebecca Berens MD: Okay?
• 52:10
  Rebecca Berens MD: There were 56 adults.
• 52:12
  Rebecca Berens MD: Their CGM-related distress varied widely.
• 52:15
  Rebecca Berens MD: More than two-thirds of participants reported fear of Type 2 diabetes when they observed high glucose levels.
• 52:22
  Rebecca Berens MD: Younger age and obesity were associated with greater distress, which I think is very important to mention, because this is exactly who I think is often being recommended-
• 52:32
  Sonia Singh MD: Yeah
• 52:32
  Rebecca Berens MD: these devices, is people who are concerned about their weight and people who are young and trying to be proactive.
• 52:39
  Rebecca Berens MD: So they are also the people having the highest distress with using CGMs.
• 52:44
  Rebecca Berens MD: Agreeableness was associated with greater fear and unhappiness in response to observing elevated glucose levels, and higher eating disorder symptoms correlated with distress over CGM's appearance.
• 52:57
  Rebecca Berens MD: And a qualitative theme was that despite distress, most participants reported positive dietary or physical activity changes in response to CGM.
• 53:04
  Rebecca Berens MD: Again, positive in their view.
• 53:06
  Rebecca Berens MD: But to me, I was just like,"These are the highest risk patients to have an eating disorder." Young, want to lose weight, highly agreeable, maybe already have eating disorder symptoms, and using a CGM and are feeling a lot of distress, and may be fueling their dietary and physical activity changes in what may be perceived societally as a positive thing, but may actually for that person turn into something very negative when taken to an extreme as it would be in an eating disorder.
• 53:37
  Sonia Singh MD: Yeah, don't wanna gloss over that.
• 53:38
  Sonia Singh MD: So 89% thought that...
• 53:41
  Sonia Singh MD: they felt as though they, they made positive dietary and/or physical- activity changes in response to the CGM.
• 53:47
  Sonia Singh MD: Yeah.
• 53:48
  Sonia Singh MD: But
• 53:48
  Rebecca Berens MD: interesting- So they were definitely using the data.
• 53:50
  Rebecca Berens MD: In their view, they were like,"I was taking that data, and I was making a change as a result."
• 53:55
  Sonia Singh MD: But this study tells us nothing about any actual outcomes in terms of their objective health measures.
• 54:03
  Rebecca Berens MD: Yeah.
• 54:03
  Rebecca Berens MD: No, this was just how did they feel about using- the CGM.
• 54:06
  Sonia Singh MD: Right.
• 54:06
  Rebecca Berens MD: So it does definitely tell us that yes, people are distressed.
• 54:10
  Sonia Singh MD: Yeah.
• 54:10
  Sonia Singh MD: Which is interesting,'cause they're, a lot of them are ackno- the majority are acknowledging that it caused them f- some fear and distress.
• 54:15
  Sonia Singh MD: But they're also like,"No, but it was good."
• 54:17
  Rebecca Berens MD: Yeah.
• 54:18
  Sonia Singh MD: But again- this
• 54:19
  Rebecca Berens MD: is
• 54:19
  Sonia Singh MD: this is prob- it sounds like this is a self-selected population.
• 54:22
  Sonia Singh MD: Yes.
• 54:22
  Sonia Singh MD: Yeah.
• 54:22
  Rebecca Berens MD: But that- But that's who would use it, right?
• 54:25
  Rebecca Berens MD: That is- Yes the population we're talking to, is- The population of people who are like,"Yeah, I'm gonna go get one of those'cause I wanna get healthier."
• 54:32
  Sonia Singh MD: That
• 54:32
  Rebecca Berens MD: is you.
• 54:33
  Rebecca Berens MD: And it might be hard for you.
• 54:35
  Sonia Singh MD: It's...
• 54:35
  Sonia Singh MD: I- it's funny'cause there's this phenomenon of patients that I already think are, hypervigilant and overly restrictive, and they're always the ones that want to jump on these technologies that give them more da- I'm like,"I don't want you to have any more reason to become more vigilant and more restrictive." And, they like all of those technologies because often it does give them some reason- to become more vigilant and more restrictive.
• 54:55
  Sonia Singh MD: And, I guess whether that translates to better health is really the root question here.
• 54:58
  Sonia Singh MD: But-
• 54:59
  Rebecca Berens MD: Yeah.
• 54:59
  Rebecca Berens MD: And I would argue that we have to look at health as a whole.
• 55:03
  Sonia Singh MD: Yeah.
• 55:03
  Sonia Singh MD: So
• 55:03
  Rebecca Berens MD: if it makes your blood sugar better, but it makes your life miserable- because you're, fixated on your glucose every second of every day and"Oh, I can't eat this.
• 55:12
  Rebecca Berens MD: Last time I ate that my glucose did this," which the other thing I think is important to note is you could eat the exact same meal every day, and every day the response would be different.
• 55:22
  Rebecca Berens MD: You're not gonna get an identical spike based on the food that you ate, right?
• 55:26
  Rebecca Berens MD: 'Cause there's so many other situational factors that affect- Right your glucose in that moment.
• 55:30
  Rebecca Berens MD: But it...
• 55:31
  Rebecca Berens MD: So I could see someone having"Okay, I'm gonna have this for breakfast'cause it didn't do anything to my blood sugar," and then the next day they're like,"I had the same breakfast.
• 55:37
  Rebecca Berens MD: Why did it go up higher?""I gotta take out this thing." And it's like by the end you're like,"What can I eat?" Nothing.
• 55:42
  Rebecca Berens MD: Yeah.
• 55:43
  Rebecca Berens MD: And so I think it's it's very easy for this to become very rigid and extreme.
• 55:48
  Rebecca Berens MD: And even if you are someone who maybe even has prediabetes- and you're wanting to prevent progression to diabetes, and you're, using this data that rigidly and even if it lowers your blood sugar, I don't know if there was net benefit to you.
• 56:03
  Sonia Singh MD: Yeah.
• 56:03
  Rebecca Berens MD: For your overall life.
• 56:05
  Rebecca Berens MD: For you to have to be so focused on that and miss out on normal life.
• 56:10
  Sonia Singh MD: Yeah.
• 56:12
  Sonia Singh MD: I wonder if before we move on, you can talk a little bit about the conversation we were having before we started recording, which is the response in patients who are chronically restricting, especially restricting carbohydrates, who then start introducing some of those foods, like what happens to their blood glucose?
• 56:31
  Sonia Singh MD: Because I have now...
• 56:33
  Sonia Singh MD: And n- now that we've been talking, I'm thinking of more and more, a few different patients that I've had who have fairly restrictive diets, and, I think the outside world would perceive them as eating really clean, and re- clean in quotes.
• 56:46
  Sonia Singh MD: Really healthy, like only eating real food.
• 56:48
  Sonia Singh MD: And- Almost universally they complain of fatigue and brain fog.
• 56:53
  Sonia Singh MD: And almost universally they will tell me...
• 56:57
  Sonia Singh MD: I remember for one of them, m- we- her cholesterol was high and we talked about trying to in- introduce oats into her diet, and she started eating the oatmeal and she was like,"I just feel so awful after I eat the oatmeal.
• 57:07
  Sonia Singh MD: I have this terrible slump and I just cannot recover, and I just feel like I need to lie down." And I was telling you an- another situation of a similar patient who had ketogenic diet for a long time, introduced some carbohydrates back into her diet, and complained of,"I'm having these big glucose spikes and then these big crashes, and I feel terrible.
• 57:26
  Sonia Singh MD: I think I'm better off not having carbohydrates in my diet." So talk a little bit about the physiology about that and what that...
• 57:32
  Sonia Singh MD: what comes up for you when you hear that.
• 57:34
  Rebecca Berens MD: Yeah.
• 57:34
  Rebecca Berens MD: So when you've had chronically restricted intake like for example we looked at these patients with anorexia for several years.
• 57:41
  Rebecca Berens MD: Yeah.
• 57:42
  Rebecca Berens MD: They are having chronically low blood sugars.
• 57:44
  Rebecca Berens MD: Once you start s- do start eating more, or particularly if you haven't been eating carbs and now you're eating carbs, when you eat carbs you will get an insulin spike That is your normal response to take the sugar out of your bloodstream and put it in your body where it needs to go.
• 57:58
  Rebecca Berens MD: And if you're someone who's been chronically restricted, you are going to be very much more sensitive to that insulin response than someone who is not.
• 58:06
  Rebecca Berens MD: So- I think we talk a lot about insulin resistance, right?
• 58:08
  Rebecca Berens MD: People who are insulin resistant, they're not responding appropriately to insulin and so they have to produce- Yeah a higher amount to lower their blood sugar.
• 58:14
  Rebecca Berens MD: This is the opposite.
• 58:15
  Rebecca Berens MD: You're very insulin sensitive.
• 58:17
  Rebecca Berens MD: So you get a surge of insulin pull the sugar out of your bloodstream.
• 58:21
  Rebecca Berens MD: Now it's over-corrected and now your blood sugar has dipped.
• 58:24
  Rebecca Berens MD: And in extreme cases, like with extremely malnourished people who are refeeding, this is what causes refeeding syndrome.
• 58:30
  Rebecca Berens MD: You get the insulin surge is not only pulling glucose out of the cell, but also potassium and phosphorus- are being affected.
• 58:38
  Rebecca Berens MD: And that can cause cardiac arrhythmias, and that's why we care about this in refeeding syndrome.
• 58:41
  Rebecca Berens MD: But for the average person who's just very restricted, what I think they're feeling is- Yeah an exaggerated insulin response to having not had carbs for a long time, and now when they have it, they're actually getting probably a postprandial or post-meal hypoglycemia, or low blood sugar- Yeah related to having eaten again after not eating consistently or enough for a while.
• 59:03
  Sonia Singh MD: So if you were in the patient's shoes and you had this feeling, I think it's a very normal-
• 59:08
  Rebecca Berens MD: Yes
• 59:08
  Sonia Singh MD: reaction to think I should just not do this'cause this feels terrible." But in fact, based on the physiology and what you're describing, the solution is really to continue eating carbohydrates regularly in order- to not have this kind of exaggerated insulin response every time you have a carbohydrate.
• 59:26
  Sonia Singh MD: Exactly.
• 59:27
  Sonia Singh MD: Exactly.
• 59:28
  Sonia Singh MD: Which is...
• 59:28
  Sonia Singh MD: I think that's really challenging when you're being bathed in this messaging of"These spikes are bad.
• 59:34
  Sonia Singh MD: Carbohydrates are bad." You don't need them yeah.
• 59:37
  Sonia Singh MD: Ketosis is the goal.
• 59:39
  Sonia Singh MD: I think that's a really hard sell.
• 59:41
  Sonia Singh MD: I'm not sure how I'm going to be able to con- Yeah convince people of that,
• 59:45
  Rebecca Berens MD: it is a hard sell because, like you said, it is...
• 59:47
  Rebecca Berens MD: There's constant messaging to the contrary, right?
• 59:50
  Sonia Singh MD: Yes.
• 59:50
  Rebecca Berens MD: Yeah.
• 59:50
  Rebecca Berens MD: And you're telling someone to eat carbs regularly.
• 59:52
  Rebecca Berens MD: But I have to tell you even some of my patients who don't have eating disorders who have been restricting carbs...
• 59:58
  Rebecca Berens MD: I had one patient recently that I'm thinking of that was, so tired.
• 1:00:01
  Rebecca Berens MD: Their hair was falling out.
• 1:00:02
  Rebecca Berens MD: They were just not feeling good.
• 1:00:03
  Rebecca Berens MD: And they weren't restricting total calories.
• 1:00:06
  Rebecca Berens MD: They were eating- consistent meals.
• 1:00:07
  Rebecca Berens MD: They just were really not eating much carbs.
• 1:00:09
  Rebecca Berens MD: And I did, my labs that I do, and their thyroid, their T3 was low like we talked about on the thyroid episode.
• 1:00:14
  Rebecca Berens MD: Yeah.
• 1:00:14
  Rebecca Berens MD: You're not converting.
• 1:00:14
  Rebecca Berens MD: I was like,"I think you need to eat more-
• 1:00:17
  Sonia Singh MD: Yeah
• 1:00:17
  Rebecca Berens MD: carbs." And they did.
• 1:00:18
  Rebecca Berens MD: And guess what?
• 1:00:19
  Rebecca Berens MD: They felt better.
• 1:00:20
  Rebecca Berens MD: And- I
• 1:00:21
  Sonia Singh MD: mean, did that take convincing?
• 1:00:22
  Sonia Singh MD: H- I'm
• 1:00:23
  Rebecca Berens MD: probably- It took possibly a year and a half.
• 1:00:26
  Sonia Singh MD: Okay.
• 1:00:26
  Sonia Singh MD: That makes me feel better.
• 1:00:27
  Sonia Singh MD: 'Cause I just imagine that you have had a lot of practice having that conversation, and you have had that conversation with a lot of people.
• 1:00:33
  Sonia Singh MD: But to me it's...
• 1:00:34
  Sonia Singh MD: Yeah, I feel...
• 1:00:35
  Sonia Singh MD: I know that I am going to be one voice telling them this one crazy thing, and that everything around them is going to be saying the opposite.
• 1:00:43
  Sonia Singh MD: And I can't imagine how that's going to sound to them, yeah.
• 1:00:46
  Sonia Singh MD: Or, how they're going to be able to buy into that.
• 1:00:48
  Sonia Singh MD: But yeah.
• 1:00:49
  Sonia Singh MD: When you think about the physiology, it makes sense.
• 1:00:51
  Sonia Singh MD: And now that I've, now that I can think of it in several people, I'm like,"Oh, yeah, I think that really would explain a lot of what these- Yeah people are experiencing." And I have sent a couple of people for hypoglycemia work-ups that I just- you don't wanna ignore it when you see that low sugar, yeah.
• 1:01:05
  Sonia Singh MD: But at the same time, it, it's, Especially when they're postprandial, people are just like,"Why would this be happening?""I just ate though." You're, it...
• 1:01:13
  Sonia Singh MD: But,"And now you're telling me I need to eat more?""How can that be?" So yeah, it's one of those tricky situations where I think it's counterintuitive, and it's- Yeah hard from the patient perspective to really get on board with that.
• 1:01:26
  Rebecca Berens MD: Yeah.
• 1:01:26
  Rebecca Berens MD: For sure.
• 1:01:26
  Rebecca Berens MD: It's, it is challenging.
• 1:01:27
  Rebecca Berens MD: And I hope that this episode is something that we'll shout into the void and-
• 1:01:33
  Sonia Singh MD: Yeah
• 1:01:34
  Rebecca Berens MD: and someone will hear it, and it will...
• 1:01:36
  Rebecca Berens MD: The tide will start to turn, and we will stop voluntarily starving ourselves.
• 1:01:40
  Sonia Singh MD: Yeah.
• 1:01:41
  Sonia Singh MD: Somebody will take off their CGM and just- Yes put it away Yeah put it in the drawer.
• 1:01:46
  Sonia Singh MD: Okay.
• 1:01:46
  Sonia Singh MD: So what can we learn from this as doctors and humans?
• 1:01:50
  Rebecca Berens MD: Yeah.
• 1:01:50
  Rebecca Berens MD: So I think there are certainly benefits to CGMs for the right patient with the right support also, I think is key.
• 1:01:59
  Rebecca Berens MD: Because I...
• 1:01:59
  Rebecca Berens MD: In trying to interpret this data on your own is very challenging and can be very confusing, and so you need to have support.
• 1:02:06
  Rebecca Berens MD: But there's also harm Right?
• 1:02:09
  Rebecca Berens MD: So it's like everything else.
• 1:02:10
  Rebecca Berens MD: It's not for everyone.
• 1:02:11
  Rebecca Berens MD: It could be really beneficial for some people, it could be really harmful for other people.
• 1:02:15
  Rebecca Berens MD: And so I think it's understanding the specific reason that you're using it and what you're doing with that information and how you're interpreting that information, what support you have in understanding that information.
• 1:02:28
  Rebecca Berens MD: Because I could certainly see...
• 1:02:29
  Rebecca Berens MD: you can buy these things over the counter without a prescription.
• 1:02:31
  Rebecca Berens MD: I could see a person buy one of these devices online and upload their charts into ChatGPT and be like,"Chat, what should I do?" And I have no idea- Yeah what would come out of that.
• 1:02:41
  Rebecca Berens MD: But versus having a conversation, looking at all of the variables with someone who knows them and has some lab data to understand better what's going on with them and is unders- is observing what the psychological impact might be, and being able to discuss all of that and come to a helpful solution.
• 1:03:01
  Sonia Singh MD: Or who also is, hopefully you get to the point where you have a relationship where that person can challenge you or push back a little bit- Yeah.
• 1:03:07
  Sonia Singh MD: Yeah because ChatGPT- Like, that's not going to happen is never gonna do that.
• 1:03:10
  Sonia Singh MD: No.
• 1:03:10
  Sonia Singh MD: I am learning really- You're always
• 1:03:11
  Rebecca Berens MD: the smartest person in the world when
• 1:03:12
  Sonia Singh MD: you're talking to ChatGPT and every day I am like...
• 1:03:14
  Sonia Singh MD: ChatGPT is so sycophantic.
• 1:03:16
  Sonia Singh MD: It just cannot stop gassing me up.
• 1:03:18
  Sonia Singh MD: I tell it regularly not to, and then it will still go back to it.
• 1:03:21
  Sonia Singh MD: So I guarantee you, if you uploaded that data, even if They were completely normal and you were normal a- there's nothing there for Chat to say, it would tell you,"This is a great move.
• 1:03:32
  Sonia Singh MD: It is so great that you wanna know more about your health, that you're doing this deeper dive to really get into-" what would be right for your body." That's what Chat's gonna say, yeah.
• 1:03:41
  Sonia Singh MD: 'Cause it's just always gonna build you up.
• 1:03:43
  Sonia Singh MD: But anyway I would say, for me, some of the take home points from this is especially as a doctor, and for patients, we really have no data to show that there is benefits from this thing for patients who do not have diabetes or pre-diabetes or some pathology going on in terms of metabolic syndrome or something that...
• 1:04:01
  Sonia Singh MD: And if you really think about it, you should ask yourself before you embark on one of these things or put one of them on, what is the outcome I'm looking for?
• 1:04:09
  Sonia Singh MD: Am I looking for more energy?
• 1:04:11
  Sonia Singh MD: Am I looking for less brain fog?
• 1:04:12
  Sonia Singh MD: Because there's literally no evidence that it's going to do those things, am I looking to lose weight?
• 1:04:17
  Sonia Singh MD: Also no evidence, even in those populations that have not normal blood sugars.
• 1:04:22
  Sonia Singh MD: So I think you have to ask yourself that, first of all.
• 1:04:25
  Sonia Singh MD: And then I think it's really important as a human to just check in with yourself and know yourself and say- How am I likely to respond to having this additional data?
• 1:04:34
  Sonia Singh MD: Because I have patients that will come to me and say,"Do not tell me to track anything because I will get obsessional over it, and then it will take over my brain- and then I will just do it obsessively, and I don't wanna g- fall into that rabbit hole." And I'm so grateful when they tell me that is how they are because there's a lot of times when I sense that is what is happening, and they don't quite have the insight yet to see that's what's happening and to realize, how much time and energy they're expending or how obsessive they're becoming over these little fluctuations.
• 1:05:01
  Sonia Singh MD: And so I just think, you have to really notice and check in with yourself about that as a potential harm and whether you're somebody who's likely to respond that way.
• 1:05:10
  Sonia Singh MD: I generally love data and I love intellectualizing things.
• 1:05:14
  Sonia Singh MD: I love gamifying things.
• 1:05:16
  Sonia Singh MD: This seems to me like something that would be right up my alley, and, the reason I'm not such a fan is just'cause I don't think the evidence is there.
• 1:05:23
  Sonia Singh MD: But I think if you've been fed lots of content in marketing that suggests that there is evidence for it, you might jump at it.
• 1:05:32
  Sonia Singh MD: And I think that if I was just a non-medical person consuming stuff on social media I'd have no doubt that I would be interested in getting one.
• 1:05:38
  Sonia Singh MD: Hopefully having this fuller conversation and giving you a peek into all the reasoning that goes into whether or not we would recommend it for a patient helps people have some of that perspective.
• 1:05:48
  Rebecca Berens MD: Yeah.
• 1:05:50
  Rebecca Berens MD: And when I do talk to patients about this, another thing I commonly recommend is if they're someone who does have some evidence of benefit, like maybe they have metabolic syndrome or they have diabetes, is using it temporarily- to learn.
• 1:06:02
  Rebecca Berens MD: And then once you kinda have it down, then just stop.
• 1:06:06
  Sonia Singh MD: Yeah.
• 1:06:06
  Rebecca Berens MD: You don't need to keep using it forever'cause, one, it's expensive, and and then you're reducing the potential harm, right?
• 1:06:12
  Rebecca Berens MD: 'Cause the potential harms related to psychological impact l- likely increase with prolonged use, right?
• 1:06:19
  Rebecca Berens MD: 'Cause the longer you use it- Yeah the more likely something's gonna happen that for me that's weird, and then you're more likely to then be exposed to the risk of an unnecessary workup or a lot of anxiety over some weird thing that turned out to be a faulty sensor.
• 1:06:31
  Rebecca Berens MD: Anything like that- Yeah could happen.
• 1:06:33
  Rebecca Berens MD: And so if you use it on a temporary basis you can start to learn and understand.
• 1:06:38
  Rebecca Berens MD: And then you, once you kinda have it down, then you just, you don't have to use it anymore.
• 1:06:41
  Sonia Singh MD: I think that's a great point.
• 1:06:43
  Sonia Singh MD: I don't think I've had...
• 1:06:44
  Sonia Singh MD: Other than insulin-dependent diabetics, I don't think I've ever had a patient that actually did use it for a very long term.
• 1:06:50
  Sonia Singh MD: Even my patients that have had success with it for type 2 diabetes or prediabetes, typically they're using it for a period of months.
• 1:06:57
  Sonia Singh MD: And like you said, they kinda get a sense of"Oh- I see the way my glucose response to dinner is so much better when I go take a walk afterwards.
• 1:07:04
  Sonia Singh MD: Yeah.
• 1:07:04
  Sonia Singh MD: And oh, I notice when I have sushi I really notice it.
• 1:07:06
  Sonia Singh MD: They make those connections, and then they know what to do from there, and they don't need to have it on all the time.
• 1:07:11
  Sonia Singh MD: And like you said, it's expensive to keep buying the sensors and the re- Yeah doing all the tracking.
• 1:07:16
  Sonia Singh MD: Yeah, I think that really is probably the best case use for these for many people I think there's a benefit from temporary use in the educational piece, and the bio- the biof- it's really biofeedback is what they get.
• 1:07:25
  Sonia Singh MD: Yeah.
• 1:07:26
  Sonia Singh MD: Rather than taking a walk and seeing no tangible, objective, result of that, they're taking the walk and seeing how it changes- Yeah the slope of their glucose curve.
• 1:07:35
  Sonia Singh MD: Okay, cool.
• 1:07:36
  Sonia Singh MD: Anything else in terms of how you would talk about it with patients?
• 1:07:39
  Rebecca Berens MD: Think really honing in on what are you gonna do with this information?
• 1:07:43
  Sonia Singh MD: Yeah,
• 1:07:43
  Rebecca Berens MD: right.
• 1:07:44
  Rebecca Berens MD: Because I think it can be really useful for learning and for seeing the impact.
• 1:07:49
  Rebecca Berens MD: But I think if what you're going to do with it is say"Oh, I'm gonna learn which foods are good for me, which, and which ones aren't based on spikes," I'm...
• 1:07:59
  Rebecca Berens MD: If the answer is gonna be,"I'm just gonna cut out all those foods," that is an extreme- Reaction.
• 1:08:04
  Rebecca Berens MD: I think we need to talk about some nuance there.
• 1:08:06
  Rebecca Berens MD: Yeah.
• 1:08:06
  Rebecca Berens MD: Because, again I don't think it's useful to say cut out lots of things.
• 1:08:10
  Rebecca Berens MD: I think it's useful to add other things that are missing.
• 1:08:13
  Rebecca Berens MD: So even if you have a refined sugar and you see a big spike, it's"Hey, you know what?
• 1:08:17
  Rebecca Berens MD: Maybe try having that with some protein and some fiber next time," and- Yeah see what's different.
• 1:08:21
  Rebecca Berens MD: And then you can see it's actually not so bad.
• 1:08:23
  Rebecca Berens MD: It's just the context that you're in.
• 1:08:27
  Sonia Singh MD: Yeah.
• 1:08:27
  Sonia Singh MD: But the scary part about these is that because they're just available to anybody who wants to buy, so many people are going and getting that data, and may not really have anybody to talk to- about what that means or, for instance, suggesting changes that may be actually positive and helpful.
• 1:08:43
  Sonia Singh MD: Yeah, I think there's a lot of caveats when it comes to, how you interpret that and what you do with the results that you get.
• 1:08:48
  Rebecca Berens MD: Yeah.
• 1:08:49
  Rebecca Berens MD: I love to use these in conjunction with a dietician in those patients.
• 1:08:52
  Rebecca Berens MD: Yeah.
• 1:08:52
  Rebecca Berens MD: Like the patient I mentioned at the beginning who started working with a dietician and using...
• 1:08:55
  Rebecca Berens MD: amazing results.
• 1:08:56
  Sonia Singh MD: Yeah.
• 1:08:57
  Sonia Singh MD: Yeah.
• 1:08:57
  Rebecca Berens MD: So much.
• 1:08:58
  Rebecca Berens MD: And- Yeah they are seeing the dietician every other week.
• 1:09:01
  Rebecca Berens MD: Yeah.
• 1:09:01
  Rebecca Berens MD: Because like you said, it's also a lot of data.
• 1:09:04
  Rebecca Berens MD: It's not practical probably for you to go over that with your doctor,
• 1:09:08
  Sonia Singh MD: right?
• 1:09:08
  Rebecca Berens MD: Yeah.
• 1:09:09
  Rebecca Berens MD: It's probably just not gonna happen.
• 1:09:11
  Rebecca Berens MD: I do generally look at the general trends when I see my patients, but I have a lot of patients that I do see pretty frequently.
• 1:09:16
  Rebecca Berens MD: But Most people are not seeing their doctor that regularly, and you have a lot of other things to cover.
• 1:09:21
  Rebecca Berens MD: It's probably not something you're gonna have a lot of time to get into with your doctor.
• 1:09:24
  Rebecca Berens MD: Dieticians are wonderful.
• 1:09:26
  Rebecca Berens MD: Yeah.
• 1:09:26
  Rebecca Berens MD: This is literally their thing.
• 1:09:27
  Rebecca Berens MD: So they can review this with you.
• 1:09:29
  Rebecca Berens MD: So you can always, I would definitely recommend at least working with a registered dietician if you're using this, not a random coach from the internet.
• 1:09:36
  Sonia Singh MD: Not a- Not
• 1:09:37
  Rebecca Berens MD: ChatGPT nutritionist.
• 1:09:38
  Sonia Singh MD: Not a nutritionist who is not a not an RD.
• 1:09:40
  Rebecca Berens MD: Yeah, someone who has a license as a registered dietician.
• 1:09:43
  Sonia Singh MD: Yeah.
• 1:09:44
  Sonia Singh MD: Okay, where can people go for more info?
• 1:09:46
  Rebecca Berens MD: So I'll be linking all of the resources from the papers that we talked about in in the Substack.
• 1:09:54
  Rebecca Berens MD: And I will link also a couple of endocrine specialists that I know that have talked about these as well on their social media and might have some more insights that people can read.
• 1:10:04
  Sonia Singh MD: Okay, awesome.
• 1:10:05
  Sonia Singh MD: Thanks, Rebecca.
• 1:10:06
  Sonia Singh MD: Yeah, thanks.
• 1:10:10
  Sonia Singh MD: Hey, guys.
• 1:10:11
  Sonia Singh MD: Last but not least, we have a very important disclaimer.
• 1:10:14
  Sonia Singh MD: This podcast is intended for educational and entertainment purposes only.
• 1:10:19
  Sonia Singh MD: The content shared on this podcast, including but not limited to opinions, research, discussions, case examples, and commentary is not medical advice and should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.
• 1:10:33
  Sonia Singh MD: Listening to this podcast does not establish a physician-patient relationship between you and the hosts.
• 1:10:38
  Sonia Singh MD: We are doctors, but not your doctors.
• 1:10:41
  Sonia Singh MD: Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances.
• 1:10:48
  Sonia Singh MD: Always seek the advice of your own qualified healthcare professional regarding any questions you have about your health, medical conditions, or treatment options.
• 1:10:56
  Sonia Singh MD: Never disregard or delay medical advice because of something you've heard on this podcast.
• 1:11:01
  Sonia Singh MD: While the hosts are licensed physicians, the views and opinions expressed are our own and do not represent those of our employers, institutions, organizations, or professional societies with which we are affiliated.
• 1:11:12
  Sonia Singh MD: Although we do our best to stay up to date, please note that this podcast includes discussion of emerging research, evolving medical concepts, and differing professional opinions.
• 1:11:21
  Sonia Singh MD: Medicine is not static, and information may change over time.
• 1:11:25
  Sonia Singh MD: We, the hosts, make no guarantees about the accuracy, completeness, or applicability of this content, and we disclaim any liability for actions taken or not taken based on the information provided in this podcast.
• 1:11:37
  Sonia Singh MD: By listening to the Antisocial Doctors podcast, you have agreed to these terms.
• 1:11:41
  Sonia Singh MD: Thanks again for joining
• 1:11:43
  us.