Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / What's the deal with continuous glucose monitors?

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What's the deal with continuous glucose monitors? · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:01
  Speaker 1: I'm a starver. Full disclosure, I am doing this podcast
• 0:09
  Speaker 1: on an empty stomach. I have had nothing to eat
• 0:12
  Speaker 1: yet today.
• 0:14
  Speaker 2: I think that's terrible. I literally have had three meals already.
• 0:18
  Speaker 3: It's that thirty in the morning.
• 0:19
  Speaker 2: I've had three meals, And what do you think your
• 0:22
  Speaker 2: glucose is?
• 0:24
  Speaker 1: Well? So people always have this idea that there's this like,
• 0:27
  Speaker 1: oh my glucose is low, I'm hypoglycemic, you know, and
• 0:30
  Speaker 1: that's why I'm angry or I'm confused or whatnot. But
• 0:33
  Speaker 1: the beautiful thing about the human body, assuming all physiology
• 0:37
  Speaker 1: is normal and you don't have diabetes and you're not
• 0:39
  Speaker 1: taking exogenous insulin, is that you've got plenty of glucose
• 0:43
  Speaker 1: going around. You have glycogen in your liver that is
• 0:48
  Speaker 1: stored and rapidly converted to glucose. And even when you
• 0:50
  Speaker 1: run out of glycogen, you have fat stores and things
• 0:53
  Speaker 1: like that that can be liberated to give you some glucose.
• 0:57
  Speaker 1: And so I feel great. And yes, I'm staring at
• 1:01
  Speaker 1: this box of thin mints that is right next to me,
• 1:06
  Speaker 1: just in case.
• 1:07
  Speaker 3: Just in case, I will say.
• 1:08
  Speaker 2: You did have to start the cold open twice, and
• 1:11
  Speaker 2: I think maybe you should take a gel or a
• 1:14
  Speaker 2: thin mint to kind of cut you out.
• 1:17
  Speaker 1: I think we should do the experiment the next time
• 1:19
  Speaker 1: I say something stupid, eat a thin mint. I'll eat
• 1:22
  Speaker 1: a thin min and then we'll see.
• 1:26
  Speaker 2: I'm Emily Aster, I'm an economist and a data expert.
• 1:29
  Speaker 1: And I'm Perry Wilson, I'm a medical doctor.
• 1:31
  Speaker 2: It's Thursday, April sixteenth, twenty twenty six. And this is
• 1:35
  Speaker 2: wellness actually.
• 1:37
  Speaker 1: Because you're getting a staggering amount of health and wellness
• 1:40
  Speaker 1: information nowadays from every source imaginable, and some of it
• 1:44
  Speaker 1: is awesome and.
• 1:45
  Speaker 2: Some of it is well actually both Fortunately we are
• 1:51
  Speaker 2: both people who know how to read studies, how to
• 1:53
  Speaker 2: parse the data, and can tell you what's worth thinking
• 1:56
  Speaker 2: about and what you can safely ignore.
• 1:58
  Speaker 1: But before we dig in, another that this podcast is
• 2:01
  Speaker 1: for educational purposes and should not be construed as medical advice.
• 2:04
  Speaker 1: We don't know your unique situation, so talk to your
• 2:07
  Speaker 1: doctor for personal health decisions.
• 2:09
  Speaker 2: This week, we're asking what's the deal with continuous glucose monitors?
• 2:14
  Speaker 2: Perry and I will give the official smasher pass, and
• 2:17
  Speaker 2: then we'll get to your question of the week. But
• 2:19
  Speaker 2: first let's do the health news roundup after the break, and.
• 2:34
  Speaker 1: We are back with the health news of the week. Emily,
• 2:37
  Speaker 1: I want to start with a really interesting article that
• 2:41
  Speaker 1: came to us from the New York Times showing that
• 2:45
  Speaker 1: birth rates are on the decline overall, but with some
• 2:50
  Speaker 1: nuance that I think you might be able to walk
• 2:53
  Speaker 1: us through. So can you tell me about what's going
• 2:55
  Speaker 1: on with birth rates?
• 2:57
  Speaker 2: Yeah, so globally birth rates are declining. This has gotten
• 3:01
  Speaker 2: a lot of discussion in the last few years. We
• 3:04
  Speaker 2: are seeing many countries with far below replacement, which includes
• 3:08
  Speaker 2: the US replacement fertilities about two point two births per woman.
• 3:13
  Speaker 2: And so the kind of headline finding on this is
• 3:16
  Speaker 2: that the fertility rate in twenty twenty five fell to
• 3:19
  Speaker 2: a new low, and that is being driven largely by
• 3:26
  Speaker 2: very big declines in fertility among younger people. So the
• 3:31
  Speaker 2: teen birth rate has like totally cratered in the past
• 3:35
  Speaker 2: twenty years, which I just want to be clear, is good,
• 3:39
  Speaker 2: Like it's good. Fifteen to nineteen year olds broadly is
• 3:43
  Speaker 2: not the group you want to be having the most babies.
• 3:45
  Speaker 2: And so what we've seen is, for you know, younger cohorts,
• 3:48
  Speaker 2: there's a cratering of the fertility rate, and then for
• 3:51
  Speaker 2: older cohorts it's going up.
• 3:53
  Speaker 3: So births among forty.
• 3:55
  Speaker 2: Five to fifty four year olds have increased about eighty
• 3:59
  Speaker 2: five percent eighty three percent since two thousand seven, so
• 4:03
  Speaker 2: we're kind of seeing a shift, and that's making it
• 4:06
  Speaker 2: a little hard to know exactly where, like completed fertility
• 4:10
  Speaker 2: will end up. So at the end of people's lives,
• 4:12
  Speaker 2: will they actually have fewer kids. I think the truth
• 4:16
  Speaker 2: is they will end up having fewer kids because if
• 4:18
  Speaker 2: you wait until you're forty five to start having children,
• 4:20
  Speaker 2: you're not going to have as many children. It's going
• 4:23
  Speaker 2: to be harder. So there's a lot of complexities here.
• 4:27
  Speaker 1: Can I just tell you, I don't know if I've
• 4:28
  Speaker 1: ever told you that I have three recurring nightmares, like
• 4:32
  Speaker 1: three genres.
• 4:33
  Speaker 3: Hey, we're going to say three children and then but
• 4:35
  Speaker 3: maybe it's the same. I don't know.
• 4:37
  Speaker 1: One is about the first kid. Okay, my three recurring nightmares.
• 4:40
  Speaker 1: One I have the thing where like your teeth are
• 4:42
  Speaker 1: falling out, like that very uncomfortable thing. Two We're in
• 4:46
  Speaker 1: college and it's final exam and I realize I have
• 4:50
  Speaker 1: not gone to class all year, and I have no
• 4:52
  Speaker 1: idea what's going on? Which is kind of accurate from
• 4:54
  Speaker 1: my college experience. And then my third is that I'm
• 4:58
  Speaker 1: having another baby. I'm forty six years old and my
• 5:02
  Speaker 1: wife tells me like, oh, We're having another baby. And
• 5:06
  Speaker 1: I can just say, for very good surgical reasons, this
• 5:10
  Speaker 1: is not possible for me, thankfully, but I still have
• 5:14
  Speaker 1: that dream. So forty five to fifty four year olds
• 5:17
  Speaker 1: having some babies. Good for you, I salute you. It
• 5:22
  Speaker 1: terrifies me at this point.
• 5:24
  Speaker 2: Yeah, same here, but but I think, I mean, it's
• 5:29
  Speaker 2: a very interesting demographic shift, and we are going to
• 5:32
  Speaker 2: have to wait and see where this ends up. But
• 5:37
  Speaker 2: my instinct is will end up with your kids overall,
• 5:40
  Speaker 2: even if it is maybe not as many fewer as
• 5:43
  Speaker 2: you would have anticipated without taking into account the movement
• 5:46
  Speaker 2: in time, Okay, shifting gears significantly. Last week, there was
• 5:54
  Speaker 2: a report that the CDC, and in particular Jay Boticharia,
• 5:57
  Speaker 2: the head of the both the CDC and the NIH,
• 6:00
  Speaker 2: has delayed a publication in the Mortality and Morbidity Weekly Report,
• 6:05
  Speaker 2: which is a CDC publication.
• 6:07
  Speaker 3: He's delayed a report.
• 6:09
  Speaker 2: That was calculating COVID vaccine effectiveness against hospitalization, and this
• 6:16
  Speaker 2: got some attention as potentially politically motivated. He said it
• 6:20
  Speaker 2: was because he doesn't like the methods.
• 6:22
  Speaker 3: What do you think?
• 6:24
  Speaker 1: Okay, Well, so the Morbidium Metality Weekly report by the
• 6:27
  Speaker 1: CDC something we've referenced before on this podcast. It's a
• 6:31
  Speaker 1: wonderful source for sort of up to the minute, or
• 6:34
  Speaker 1: at least the past month disease epidemiology in the US
• 6:38
  Speaker 1: and sometimes abroad. And they will periodically report on vaccine effectiveness,
• 6:42
  Speaker 1: which is like, how good was last year's vaccine? We
• 6:46
  Speaker 1: talked on a prior episode that last year's flu vaccine,
• 6:48
  Speaker 1: for example, not a great one. We didn't have a
• 6:51
  Speaker 1: great flu vaccine. It was like thirty percent effective at
• 6:53
  Speaker 1: present preventing hospitalizations. This report showed that last year's COVID
• 6:57
  Speaker 1: vaccine was about fifty percent effective at venting hospitalizations, which means,
• 7:03
  Speaker 1: you know, all else being equal, that you were half
• 7:05
  Speaker 1: as likely enough up in the hospital if you had
• 7:07
  Speaker 1: been vaccinated as if you hadn't been vaccinated. That report
• 7:11
  Speaker 1: passed the Scientific Review Group at the CDC, but, according
• 7:15
  Speaker 1: to the Washington Post, was held up by doctor Bodicharia
• 7:19
  Speaker 1: for quote methodologic concerns. I mean the thing about that.
• 7:23
  Speaker 1: So this methodology is called a test negative case control design.
• 7:27
  Speaker 1: It basically looks at people who have infections that show
• 7:31
  Speaker 1: up with infections that look like COVID, like the respiratory infections,
• 7:35
  Speaker 1: So it could be flu, it could be a bad cold,
• 7:37
  Speaker 1: could be COVID. Who knows. They get tested and they
• 7:41
  Speaker 1: assess their vaccination status, and you basically find that, oh,
• 7:47
  Speaker 1: if you are vaccinated for COVID, that thing you showed
• 7:51
  Speaker 1: up with, that respiratory infection you showed up with is
• 7:53
  Speaker 1: much less likely to be COVID than if you weren't
• 7:55
  Speaker 1: vaccinated with COVID. That's how it works. This design has
• 7:59
  Speaker 1: been used for for years and.
• 8:01
  Speaker 3: Years and years, very common zine, very.
• 8:03
  Speaker 1: Common design, and even was recently in the Morbiditing Immortality
• 8:08
  Speaker 1: Weekly report when they reported on flu vaccine effectiveness. And
• 8:12
  Speaker 1: theoretically it's the exact same analysis. So I don't see
• 8:15
  Speaker 1: why it's like bad for the COVID vaccine, but it's
• 8:17
  Speaker 1: not bad for other vaccines.
• 8:19
  Speaker 2: I find this decision so interesting because you're totally right.
• 8:25
  Speaker 2: This method is used all the time, and so this
• 8:28
  Speaker 2: singling out the COVID vaccine and saying we're going to
• 8:31
  Speaker 2: pull this report for COVID when we just published the
• 8:34
  Speaker 2: same exact thing for flu. Seems totally politically motivated, particularly
• 8:39
  Speaker 2: coming out of an administration that has generally been very
• 8:42
  Speaker 2: skeptical of the COVID vaccine, even though they did develop.
• 8:45
  Speaker 1: It develop it.
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  Speaker 2: On the other hand, I think this method is very
• 8:51
  Speaker 2: poor and I share like I come out of the
• 8:53
  Speaker 2: same intellectual tradition as Jay, and I share a lot
• 8:56
  Speaker 2: of his concerns about this method, and so I'm sort
• 8:59
  Speaker 2: of very interested in what was behind his decision. And
• 9:02
  Speaker 2: I will just like shameless plug. I am interviewing Jay
• 9:07
  Speaker 2: on April twenty fourth at a National Academy's panel. We
• 9:10
  Speaker 2: can put the registration link in the show notes, and
• 9:13
  Speaker 2: I'm going to ask him about this exact Please ask him.
• 9:17
  Speaker 1: Yeah, it is. It is not a perfect design. It's
• 9:19
  Speaker 1: not a randomized trial. Obviously, we don't do randomized trials
• 9:22
  Speaker 1: once we confirm that a drug or vaccine works because
• 9:24
  Speaker 1: it's unethical to randomize people to place ebo. There are
• 9:28
  Speaker 1: other methods to assess vaccine effectiveness, but as you point out,
• 9:31
  Speaker 1: this one has the one that we use. It's the
• 9:33
  Speaker 1: one that we use. So I look forward to your
• 9:36
  Speaker 1: hard hitting questions for doctor j.
• 9:39
  Speaker 2: Okay I'm just going to call him that because that's
• 9:42
  Speaker 2: going to start an interview with somebody.
• 9:46
  Speaker 1: Turning now to the great state of California. Laws in
• 9:51
  Speaker 1: California tend to have the effect of like propagating across
• 9:56
  Speaker 1: the US because it's such a huge market, and California
• 9:59
  Speaker 1: is soon to be mandating that their corn tortillas get
• 10:05
  Speaker 1: supplemented with folic acids. So, Emily, as you know, folate
• 10:09
  Speaker 1: is one of the supplements that gets added to like
• 10:13
  Speaker 1: wheat flour and stuff like that all across the country.
• 10:16
  Speaker 1: There's some important public health implications, but it was actually
• 10:19
  Speaker 1: news to me that the corn meal and corn flour
• 10:22
  Speaker 1: that is used for tortillas it doesn't have folate added. So, Emily,
• 10:26
  Speaker 1: I assume you're a fan of folate.
• 10:28
  Speaker 3: I am a fan of folate.
• 10:29
  Speaker 4: Yeah.
• 10:30
  Speaker 3: I mean, when we look at prenatal vitamins, a.
• 10:31
  Speaker 2: Lot of the stuff they put in there is not useful,
• 10:33
  Speaker 2: but fullic acid or folate is in fact a very
• 10:37
  Speaker 2: well established evidence based way to prevent neural to defects,
• 10:41
  Speaker 2: and not everybody gets prenatal vitamins at the range that
• 10:45
  Speaker 2: they should, so it's very important that people get folate
• 10:48
  Speaker 2: or folic acid in food, and in particular in Hispanic communities,
• 10:54
  Speaker 2: corn tortillas. Corn meal is a more common source of
• 10:58
  Speaker 2: carbohydrates than flour, and so I think this is a
• 11:02
  Speaker 2: directionally good idea to put this in corn. So I'm
• 11:07
  Speaker 2: a fan of this. RFK was not a fan, but
• 11:09
  Speaker 2: he hasn't exactly said why. He said it was insanity,
• 11:13
  Speaker 2: but I wasn't totally.
• 11:15
  Speaker 3: Clear vanity and it is targeting.
• 11:20
  Speaker 2: The poor, which is actually true, but like in a
• 11:23
  Speaker 2: positive way. So I'm not really I'm not totally sure
• 11:26
  Speaker 2: what the objection is to this particular, Like who could
• 11:29
  Speaker 2: object to this, I'm not except that the tortilla makers
• 11:32
  Speaker 2: who have to add something which costs money.
• 11:34
  Speaker 3: But other than that, yeah, I don't Yeah.
• 11:37
  Speaker 1: Yeah, Okay, that's strange case. Opresa from RFK.
• 11:41
  Speaker 3: Wow, that is that is.
• 11:42
  Speaker 2: I hope that none of the college classes that you're
• 11:44
  Speaker 2: dreaming about were in Spanish, Verry, because it's.
• 11:49
  Speaker 1: Not my best language. Maybe it is time for a
• 11:52
  Speaker 1: thin mint. That's it for the health news of the week.
• 11:55
  Speaker 1: After the break, what's the deal with continuous glucose monitors?
• 12:04
  Speaker 1: And we're back to talk about what's the deal with
• 12:07
  Speaker 1: continuous glucose monitors? To start us off, Emily, I'm going
• 12:11
  Speaker 1: to play you a clip of our friend Casey means
• 12:14
  Speaker 1: she's been mentioned multiple times on this podcast, perennial Surgeon
• 12:17
  Speaker 1: General candidate. Still I think nominee Casey means talking to
• 12:23
  Speaker 1: Andrew Huberman about continuous glucose monitors.
• 12:28
  Speaker 5: The purpose of the glucose monitor is curiosity, essentially an
• 12:31
  Speaker 5: MRI for how all of our different dietarian lifestyle strategies
• 12:36
  Speaker 5: are creating this readout of glucose in our body, which
• 12:39
  Speaker 5: I think can be really interesting.
• 12:41
  Speaker 1: So, Emily, cgms, simply put, are an MRI of glucose.
• 12:48
  Speaker 3: No, that's not I don't know what does that mean.
• 12:52
  Speaker 1: It's just it's an MRI of glucose. Mrizer fancy and
• 12:55
  Speaker 1: complicated and is a.
• 12:57
  Speaker 3: Giant machine Perry which image is.
• 13:01
  Speaker 1: It's okay, I thought you'd like it.
• 13:03
  Speaker 3: I didn't like it.
• 13:04
  Speaker 1: I you know, continuous glucose monitors are things that measure
• 13:10
  Speaker 1: glucose and we're going to talk a little bit about
• 13:12
  Speaker 1: how they do that and why you might want that.
• 13:15
  Speaker 1: But I thought it would be good to play that
• 13:17
  Speaker 1: clip right off the bat, because it sets the tone
• 13:20
  Speaker 1: for what we see and a ton of influencer marketing
• 13:23
  Speaker 1: and social media. You've got the music in the background,
• 13:27
  Speaker 1: You've got you know, these sort of medical and scientific
• 13:31
  Speaker 1: terms like MRI getting thrown about, and yet contextually I'm
• 13:35
  Speaker 1: not entirely sure what she's saying, right, Like, is there
• 13:39
  Speaker 1: a statement of fact there that we can hang our
• 13:42
  Speaker 1: hat on and ask for some evidentiary support.
• 13:45
  Speaker 2: What I think is interesting about that statement I think
• 13:47
  Speaker 2: we're going to come back to is she starts by
• 13:49
  Speaker 2: saying like continuous glugo monitors, but she uses.
• 13:51
  Speaker 3: The word curiosity.
• 13:52
  Speaker 2: Yeah. Yeah, I actually think that is a big piece
• 13:55
  Speaker 2: of why many people outside of diabetics, of course talk
• 13:59
  Speaker 2: about that case. But that's that's a reason that many
• 14:02
  Speaker 2: people use this. And one of the things I think
• 14:05
  Speaker 2: I'm going to push a little bit more later is
• 14:09
  Speaker 2: like this, like with any of these sort of self
• 14:13
  Speaker 2: tracking things, should be in the service of a decision,
• 14:17
  Speaker 2: probably not just in the service of curiosity. And so
• 14:20
  Speaker 2: it should be in the service of a decision or
• 14:22
  Speaker 2: an action, because this isn't maybe something you need to
• 14:26
  Speaker 2: be curious about unless you were going to use it
• 14:29
  Speaker 2: for something.
• 14:30
  Speaker 3: But we can get into that more.
• 14:31
  Speaker 2: I will say I was at a race a couple
• 14:34
  Speaker 2: of weeks ago and there were a bunch of people.
• 14:36
  Speaker 3: A lot of athletes are wearing these on their arms.
• 14:39
  Speaker 1: I'm seeing them more and more.
• 14:40
  Speaker 3: I see them a lot.
• 14:41
  Speaker 1: Yeah, I was on vacation last week and so I
• 14:43
  Speaker 1: saw them like by the pool. And you know, as
• 14:46
  Speaker 1: a physician, I've seen these for a long time, but
• 14:49
  Speaker 1: typically just in patience with diabetes. I mean originally just
• 14:52
  Speaker 1: in patience with type one diabetes. And then you know,
• 14:55
  Speaker 1: you can see how this market has grown and for
• 14:57
  Speaker 1: people who might not be as familiar. Continuous glucose monitors
• 15:02
  Speaker 1: are these patches that you can stick on your body.
• 15:06
  Speaker 1: Typically they'll go on the back of the arm or
• 15:08
  Speaker 1: sometimes the belly. They have a small wire in them
• 15:13
  Speaker 1: that sticks into the skin and can sense the glucose
• 15:17
  Speaker 1: content of this what's called the interstitial fluid, So it's
• 15:20
  Speaker 1: not sitting in your blood per se, but it's kind
• 15:21
  Speaker 1: of like the fluid that kind of percolates throughout your body.
• 15:26
  Speaker 1: And these used to be prescription devices that your doctor
• 15:29
  Speaker 1: would write your prescription for if you had diabetes to
• 15:32
  Speaker 1: help monitor your blood sugar. These were really a godsend
• 15:35
  Speaker 1: for people that were doing fingersticks frequently because finger sticks
• 15:37
  Speaker 1: hurt and it's annoying. You're carrying around all these needles
• 15:40
  Speaker 1: and stuff like that. So you know, you just stick
• 15:42
  Speaker 1: this thing on it measures it through an app. But
• 15:47
  Speaker 1: as of I think twenty twenty four, the FDA had
• 15:51
  Speaker 1: approved a over the counter version, which you know anyone
• 15:55
  Speaker 1: can use, and that caused this explosion in the wellness
• 16:00
  Speaker 1: base of people without diabetes using these devices for all
• 16:06
  Speaker 1: sorts of purposes that we'll get into.
• 16:08
  Speaker 2: Yeah, So I actually think it's worth backing up just
• 16:10
  Speaker 2: one more step into talking about why you might care
• 16:13
  Speaker 2: about your glucose and how glucose is sort of operating
• 16:17
  Speaker 2: in the body. So I'm going to ask you, because
• 16:20
  Speaker 2: you're the doctor, when I eat, it turns into glucose,
• 16:26
  Speaker 2: and why would I care how much of that there is?
• 16:30
  Speaker 1: Yeah, Glucose is the sort of energy currency of the body. Basically, right,
• 16:36
  Speaker 1: you put things into your body and buying large proteins
• 16:40
  Speaker 1: and carbohydrates are going to turn into glucose. Fats can
• 16:43
  Speaker 1: also turn into glucose sort of eventually, although it takes
• 16:45
  Speaker 1: a few more steps and your cells literally burn glucose
• 16:50
  Speaker 1: to make energy. It takes a glucose molecule and it
• 16:53
  Speaker 1: turns it into carbon dioxide and water. If you ever
• 16:56
  Speaker 1: remember from like sixth grade science class, you could take
• 17:00
  Speaker 1: some sugar and you know, you add chemicals and it
• 17:02
  Speaker 1: like off gas is carbon dioxide and things like that. That's
• 17:05
  Speaker 1: the same stuff that's happening in your self.
• 17:07
  Speaker 2: Science class is much better than mine.
• 17:11
  Speaker 1: And so yeah, I mean you need glucose to survive.
• 17:14
  Speaker 1: I think what's relevant to continuous glucose monitors is that
• 17:17
  Speaker 1: glucose is is kept in a very narrow range in
• 17:21
  Speaker 1: your blood because glucose itself can be toxic. So it's necessary,
• 17:27
  Speaker 1: but it's also sort of evil. And things that are
• 17:29
  Speaker 1: necessary and yet evil tend to be regulated in like
• 17:32
  Speaker 1: very narrow bands in the human body. And it's insulin
• 17:36
  Speaker 1: that does that. And so your blood sugar, for example,
• 17:39
  Speaker 1: which you know, normal blood sugar, let's say, is ninety
• 17:42
  Speaker 1: miligrams per test leader or something that's corresponds to about
• 17:46
  Speaker 1: a teaspoons worth of sugar being dissolved in your blood
• 17:50
  Speaker 1: at any given time. So that's not much, right, Like
• 17:54
  Speaker 1: put a teaspoon of sugar in my coffee this morning,
• 17:56
  Speaker 1: that's all the sugar in your blood, which should tell
• 17:59
  Speaker 1: you how much is going on in your body to
• 18:02
  Speaker 1: pull it out of your blood and put it into
• 18:03
  Speaker 1: cells and put it into storage and make glycogen, which
• 18:06
  Speaker 1: sits in the liver is like a warehouse for glucose
• 18:08
  Speaker 1: if you need it in the future. And so it's
• 18:10
  Speaker 1: highly highly regulated, and when it becomes disregulated, that's what
• 18:15
  Speaker 1: we call diabetes, and obviously that's one of the major
• 18:19
  Speaker 1: chronic health conditions of our time.
• 18:21
  Speaker 2: Great, Okay, So the idea behind these cgms is that
• 18:26
  Speaker 2: they will tell you in more real time what your
• 18:30
  Speaker 2: blood sugar is. And let's sort of get the diabetes
• 18:35
  Speaker 2: piece of this out of the way, because I think
• 18:37
  Speaker 2: this is a place where it's very clear this innovation
• 18:41
  Speaker 2: has made huge strides for.
• 18:43
  Speaker 3: People living with diabetes.
• 18:44
  Speaker 2: So one of the core issues, whether you have type
• 18:47
  Speaker 2: one or type two diabetes is monitoring where your blood
• 18:49
  Speaker 2: sugar is so you can both think about which you
• 18:54
  Speaker 2: know foods cause your blood sugar to rise above levels
• 18:57
  Speaker 2: that are safe, and so you can make sure your
• 19:00
  Speaker 2: blood sugar doesn't fall too low. And for people with
• 19:02
  Speaker 2: type one diabetes, they need to dose with insulin or
• 19:06
  Speaker 2: possibly get more sugar if their blood sugar drops too low.
• 19:10
  Speaker 2: Before continuous monitoring you're taking fingersticks very frequently. That is
• 19:15
  Speaker 2: both unpleasant, time consuming, and also subject to quite a
• 19:20
  Speaker 2: lot of noise because of course you're not continuously pricking
• 19:23
  Speaker 2: your finger. This is effectively a way to be continuously
• 19:26
  Speaker 2: pricking your finger without the pain and discomfort of doing so.
• 19:31
  Speaker 2: And so we have a lot of evidence that you know,
• 19:34
  Speaker 2: for type one diabetes, this is clearly very beneficial and
• 19:38
  Speaker 2: especially for kids, lowers the risks of hypoglycemia, which is
• 19:42
  Speaker 2: in blood sugar drops too low. It improves anxiety in parents.
• 19:46
  Speaker 2: It's a kind of follow on, but we just have
• 19:49
  Speaker 2: a lot of evidence type two and type one diabetes
• 19:52
  Speaker 2: from RCTs that people are spending more time in the
• 19:55
  Speaker 2: appropriate range, that their A one c's are going down.
• 19:58
  Speaker 2: Like all of the metrics you would have for successfully
• 20:01
  Speaker 2: managed diabetes are improved with this kind of monitoring for
• 20:06
  Speaker 2: reasons that seem totally obvious to me.
• 20:07
  Speaker 1: Yeah, I mean, it's it is a slam dunk for
• 20:11
  Speaker 1: type one diabetics. It is a pretty darn close for
• 20:13
  Speaker 1: type two diabetics. One of the cool things for people
• 20:16
  Speaker 1: type one diabetes is that some of the prescription continues
• 20:19
  Speaker 1: glucose monitors actually integrate with insulin pumps, and so not
• 20:24
  Speaker 1: only is it measuring the glucose in your you know,
• 20:28
  Speaker 1: interstitial fluid, which is close to your blood. It lags
• 20:31
  Speaker 1: behind the blood by about ten minutes, but it's getting
• 20:33
  Speaker 1: relatively updated glucose measurements. But it can also control how
• 20:37
  Speaker 1: much insulin is being released by the pump, which is
• 20:39
  Speaker 1: it's like you put those two things together and you
• 20:42
  Speaker 1: basically have a pancreas. I mean it's not perfect, but
• 20:45
  Speaker 1: like that's more or less what the pancreas is doing,
• 20:47
  Speaker 1: and it's been a total game changer, you know.
• 20:50
  Speaker 2: I think the other piece of this is in people
• 20:54
  Speaker 2: with type two diabetes, even if they are not insulin dependent,
• 20:57
  Speaker 2: or even people with pre diabetes, there is some evidence
• 21:01
  Speaker 2: that this can help people basically manage their food intake
• 21:06
  Speaker 2: in a way that keeps their blood sugar more Even
• 21:09
  Speaker 2: because you're getting a continuous set of feedback and different
• 21:11
  Speaker 2: foods raise people's blood sugar different amounts, there's a kind
• 21:15
  Speaker 2: of general sense that like refined carbohydrates, like those thin
• 21:18
  Speaker 2: mints that you're definitely going to eat happy through this episode,
• 21:21
  Speaker 2: that those raise your blood glucose quite fast and sort
• 21:24
  Speaker 2: of slow processing carbohydrates or protein raise it more slowly,
• 21:28
  Speaker 2: but that's not true for every individual in exactly the
• 21:31
  Speaker 2: same way. And so these are a way for people
• 21:34
  Speaker 2: to kind of both get real time feedback but also
• 21:37
  Speaker 2: figure out kind of what works for them. And there's
• 21:39
  Speaker 2: some evidence that can help people keep their blood sugar
• 21:42
  Speaker 2: in the range that you're looking for, which is something
• 21:45
  Speaker 2: like sort of seventy two one hundred and forty is
• 21:48
  Speaker 2: the range people are typically looking for over the course
• 21:51
  Speaker 2: of a.
• 21:51
  Speaker 1: Day, right, And for people with pre diabetes, cgms have
• 21:55
  Speaker 1: been shown in some studies at least to delay the
• 21:57
  Speaker 1: progression or even prevent the progression into full blown diabetes,
• 22:02
  Speaker 1: which is obviously an important outcome. And so for these
• 22:06
  Speaker 1: people with disorders of insulin metabolism. Right, So, from pre
• 22:12
  Speaker 1: diabetes through diabetes, there's something disordered about this highly regulated system,
• 22:17
  Speaker 1: where a window into how that system is working can
• 22:21
  Speaker 1: help you engage in behavioral changes to keep things working
• 22:24
  Speaker 1: well for longer. But where the rubber meets the road then,
• 22:28
  Speaker 1: is like, what about all the people for whom the
• 22:32
  Speaker 1: system is already working as intended? Is their marginal benefit
• 22:36
  Speaker 1: there and the vast majority of people who are using
• 22:39
  Speaker 1: these over the counter continuous glucose monitors are really those types.
• 22:45
  Speaker 1: So you know, I think that what people really want
• 22:47
  Speaker 1: to know is like, Okay, I'm not diabetic. I don't
• 22:50
  Speaker 1: have pre diabetes, I don't have you know, the metabolic syndrome,
• 22:54
  Speaker 1: which is a risk factor for diabetes. But I see
• 22:57
  Speaker 1: these things out there, and there's influencers online telling me
• 22:59
  Speaker 1: that like, I need to use this to lose weight.
• 23:02
  Speaker 1: I need to lose this to get my muscle's better.
• 23:04
  Speaker 2: I need to I think a lot of the messaging
• 23:07
  Speaker 2: is even much more specific than that. It's not like
• 23:09
  Speaker 2: this is going to help you lose weight or get
• 23:10
  Speaker 2: your muscles better, although that's out there. It's just like,
• 23:14
  Speaker 2: you should use this to keep your glucose in a
• 23:17
  Speaker 2: in a rate, like you should use this to not
• 23:20
  Speaker 2: have glucose spikes and to sort.
• 23:22
  Speaker 3: Of do various things to make your glucose.
• 23:25
  Speaker 2: Like there's this idea that like the optimal glucose is
• 23:27
  Speaker 2: a flat line at ninety like all the time somehow,
• 23:31
  Speaker 2: like and we're all we should be like navigating our diets,
• 23:34
  Speaker 2: so our life is flat at ninety all the time.
• 23:35
  Speaker 1: Oh my gosh, yeah, so important. No, And actually, as
• 23:40
  Speaker 1: I was researching the study, and I was looking at
• 23:42
  Speaker 1: some of these things, you know, you see all these
• 23:44
  Speaker 1: people being like, I had no idea how much my
• 23:46
  Speaker 1: glucose spiked after I did X, Y or Z, And
• 23:49
  Speaker 1: I think there's even like the automoonopoeia of the word spike.
• 23:52
  Speaker 1: It's just like that sounds bad, right, pointy sharp. We
• 23:57
  Speaker 1: don't like spiking things, and so I but I wanted
• 24:01
  Speaker 1: to dig into literature a little bit just to like
• 24:03
  Speaker 1: check my priors and be like, wait, is that bad?
• 24:06
  Speaker 1: Like is it bad that you know, after you eat
• 24:09
  Speaker 1: something that has a lot of carbohydrates in it, the
• 24:11
  Speaker 1: glucose level in your blood goes up. And of course
• 24:14
  Speaker 1: it turns out that like, well, of course the glucose
• 24:17
  Speaker 1: level in your blood goes up when you eat carbohydrates,
• 24:19
  Speaker 1: because that's that's what they do. That's what they do,
• 24:22
  Speaker 1: and that's what you want them to do.
• 24:24
  Speaker 3: So four people who are thinking about this is just
• 24:26
  Speaker 3: like level set?
• 24:27
  Speaker 2: What is it that one acquires in doing this? So
• 24:31
  Speaker 2: you can go on the internet and you can purchase
• 24:33
  Speaker 2: from a couple of different companies.
• 24:36
  Speaker 3: Abb It makes one, xcom makes one. You can purchase
• 24:40
  Speaker 3: one of these monitors.
• 24:41
  Speaker 2: You can purchase it for like a long term subscription,
• 24:43
  Speaker 2: or you can actually buy them for like fifty bucks.
• 24:45
  Speaker 2: You can get this for two weeks and it's like
• 24:47
  Speaker 2: a two week single use monitor, and they ship it
• 24:51
  Speaker 2: to you and I, I've done this so I can
• 24:54
  Speaker 2: tell us, tell you what happens. They ship you a
• 24:58
  Speaker 2: like a little thing. You stick it in your ow.
• 25:00
  Speaker 3: It doesn't really hurt, like a tiny needle. It goes
• 25:03
  Speaker 3: into your arm.
• 25:04
  Speaker 2: It sticks on your arm, and it links up to
• 25:06
  Speaker 2: an app and the app will tell you in something
• 25:10
  Speaker 2: close to you know, realish time kind of how your
• 25:13
  Speaker 2: blood glucose is moving around, and that's it. Then you
• 25:17
  Speaker 2: like look at that app at different times and use
• 25:20
  Speaker 2: it for some kind of decision making and there's a
• 25:22
  Speaker 2: little line and that's that's it.
• 25:25
  Speaker 1: Okay. One of the problems we have in research of
• 25:28
  Speaker 1: where we have frequently sampled data. Take a hospitalized patient's
• 25:33
  Speaker 1: blood pressures. Okay, so we have a patient in the hospital.
• 25:36
  Speaker 1: They have blood pressure measured every fifteen minutes or something
• 25:38
  Speaker 1: if they're in the intensive carry unit. Right, So we
• 25:40
  Speaker 1: have all this data, we always have the question of
• 25:42
  Speaker 1: like what how do I collapse that into a meaningful number,
• 25:46
  Speaker 1: Like when it comes to a bunch of glucoses. Is
• 25:48
  Speaker 1: it the high that matters? Is it the low? Is
• 25:50
  Speaker 1: it the the variation? Right, like the coefficient of variation?
• 25:55
  Speaker 1: Are the apps breaking that down or is just like
• 25:57
  Speaker 1: here's your line and like it turns red when it's
• 25:59
  Speaker 1: above one.
• 26:01
  Speaker 3: Yeah, it's more of the second thing. I would say.
• 26:04
  Speaker 3: You know, they're not in in this use case.
• 26:08
  Speaker 2: They are generally not trying to provide people, I think,
• 26:12
  Speaker 2: with much beyond like here's how your glucose changes with
• 26:16
  Speaker 2: you know, around the day.
• 26:19
  Speaker 3: And I think it's.
• 26:20
  Speaker 2: Partly because the pitch people are getting is like you
• 26:23
  Speaker 2: can see which foods raise your glucose, so you can put.
• 26:27
  Speaker 3: In like your I did this activity, you know, I
• 26:29
  Speaker 3: ate this whatever.
• 26:30
  Speaker 2: So I think the idea is in principle you could
• 26:32
  Speaker 2: combine this with activity or food consumption tracking and then see,
• 26:36
  Speaker 2: you know, when I eat rice or when I eat cookies,
• 26:39
  Speaker 2: my glucose goes up more, and then when I eat
• 26:43
  Speaker 2: you know, eggs, it doesn't go up as much, And
• 26:45
  Speaker 2: that that would be in some way informative to again
• 26:48
  Speaker 2: achieve this goal that I don't think anyone health wise
• 26:52
  Speaker 2: really should be achieving of like a flag glucose. So
• 26:54
  Speaker 2: I think that's the that's the kind of idea of
• 26:56
  Speaker 2: the of the app, but there's not, and there is
• 27:00
  Speaker 2: some summary measure like they'll be like, your glucose is fine,
• 27:02
  Speaker 2: you know yourte Yeah, I.
• 27:04
  Speaker 1: Want I want a green box or something like that.
• 27:06
  Speaker 1: I can get it. There are of course companies now
• 27:10
  Speaker 1: actually including a company founded by Casey Means, who we
• 27:14
  Speaker 1: played at the beginning of this episode, which will not
• 27:17
  Speaker 1: only sell you, you know, it's a repackaged continuous glucose monitor
• 27:21
  Speaker 1: from one of these companies that you already mentioned, but
• 27:24
  Speaker 1: coupled with their own app that is supposed to contest
• 27:28
  Speaker 1: use AI and combine and give you give you all
• 27:31
  Speaker 1: sorts of health advice, you know. And this is part
• 27:34
  Speaker 1: of the problem with kind of access to too much data,
• 27:38
  Speaker 1: like like, we have so many ways to monitor ourselves,
• 27:41
  Speaker 1: right it started just with step counts, but now we
• 27:43
  Speaker 1: have our heart rape variability and our sleep quality, and
• 27:46
  Speaker 1: we could potentially do continuous glucose monitoring. That's really outpaced
• 27:50
  Speaker 1: our knowledge of what to do with that information, which
• 27:54
  Speaker 1: is why these people who are selling you like, oh,
• 27:56
  Speaker 1: we're going to use this to give you the answer
• 27:58
  Speaker 1: about your health are fundamentally lying because that data just
• 28:01
  Speaker 1: doesn't exist yet. Like, you can make recommendations about eating
• 28:05
  Speaker 1: healthier and that's fine. And I suppose if seeing big
• 28:09
  Speaker 1: deviations in your glucose convinces you to, you know, eat
• 28:14
  Speaker 1: some more protein instead of eating that chocolate chip cookie,
• 28:17
  Speaker 1: then that's like good biofeedback. But we don't really have outcomes.
• 28:20
  Speaker 3: Yeah, so I think this is the real question for
• 28:22
  Speaker 3: the data. I think it's kind of two questions.
• 28:24
  Speaker 2: So one is when we look at, you know, trials
• 28:27
  Speaker 2: of people in the general population use them these, which
• 28:30
  Speaker 2: is actually not a huge space, but we don't really
• 28:33
  Speaker 2: see much evidence that the use of these improves outcomes
• 28:39
  Speaker 2: very much.
• 28:39
  Speaker 3: Would you say that's your read of the of the
• 28:41
  Speaker 3: data in.
• 28:42
  Speaker 1: People without diabetes? Yes, that is that is my read.
• 28:47
  Speaker 1: In terms of hard health metrics, there's not much.
• 28:50
  Speaker 2: But I think there's a second question, which is is
• 28:53
  Speaker 2: this predictive? So one, there's a like a policy question,
• 28:57
  Speaker 2: which is if you gave everybody a CGM, would they
• 28:59
  Speaker 2: be like less like to have diabetes? And I think
• 29:01
  Speaker 2: the answer is like, probably no, at least from what
• 29:03
  Speaker 2: we know so far.
• 29:04
  Speaker 3: There's a second.
• 29:05
  Speaker 2: Question, which is, as a person who's you know, concerned
• 29:09
  Speaker 2: about your health. Could you learn something from this that
• 29:13
  Speaker 2: would be predictive, that would say, you know, well, you
• 29:15
  Speaker 2: actually are at a higher risk for diabetes, you know,
• 29:17
  Speaker 2: relative to your demographics, because something is going on with
• 29:21
  Speaker 2: your blood sugar. And I think that's like in some
• 29:26
  Speaker 2: ways the data there is like a little bit more.
• 29:30
  Speaker 3: Complicated.
• 29:31
  Speaker 2: So you know, they've done a there's a study from
• 29:34
  Speaker 2: the Journal of Diabetes Research which looks at non diabetic
• 29:38
  Speaker 2: people using these cgms, and some of them develop diabetes.
• 29:42
  Speaker 2: There's of course strong predictors here of age and BMI,
• 29:45
  Speaker 2: which we know predict development of diabetes, but there's also
• 29:49
  Speaker 2: some evidence that people who spend more time in a
• 29:52
  Speaker 2: high blood sugar range above one hundred and thirty, there's
• 29:57
  Speaker 2: some predictive capacity.
• 29:58
  Speaker 3: It's not very good, but.
• 29:59
  Speaker 2: It it does sort of suggest that maybe these could
• 30:02
  Speaker 2: pick up something about insulin resistance that would be a
• 30:06
  Speaker 2: little bit predictive. I think is like the best that's
• 30:07
  Speaker 2: like the best case argument.
• 30:09
  Speaker 1: Yeah. So, but this is a classic correlation versus causality
• 30:14
  Speaker 1: issue that we often face in this podcast. So there
• 30:18
  Speaker 1: are multiple studies which show that among people who do
• 30:21
  Speaker 1: not have diabetes, response to an oral glucose tolerance test,
• 30:25
  Speaker 1: which is literally like, you come in fasting, we measure
• 30:27
  Speaker 1: your blood sugar, we give you really sweet drink to drink,
• 30:31
  Speaker 1: and we measure how high your glucose goes up. Like
• 30:34
  Speaker 1: the people who go up higher in that test are
• 30:37
  Speaker 1: more likely to go on to have diabetes. It could
• 30:40
  Speaker 1: be that spending time at high glucose values, you know,
• 30:46
  Speaker 1: flogs you're pancreas enough such that you start becoming insulin resistant.
• 30:51
  Speaker 1: It also could be that what we're doing with all
• 30:55
  Speaker 1: this these testing is just identifying the type of person
• 30:59
  Speaker 1: who all already has some insulin problems and the test
• 31:04
  Speaker 1: is revealing that, or the continuous glucose monitoring is revealing
• 31:07
  Speaker 1: that you have some subclinical insulin resistance, and that's it.
• 31:12
  Speaker 1: And the reason that this matters is because if those
• 31:17
  Speaker 1: spikes of glucose right that you're seeing on your glucose monitor,
• 31:22
  Speaker 1: if those are causing downstream, bad downstream effects like diabetes,
• 31:27
  Speaker 1: then limiting those spikes will limit the downstream effects of diabetes.
• 31:32
  Speaker 1: And we should be telling people like, oh, yeah, you
• 31:34
  Speaker 1: don't want those spikes. The spikes are bad. However, if
• 31:36
  Speaker 1: the spikes are just a sign that you are at risk.
• 31:40
  Speaker 1: You don't know that limiting it changes that risk profile
• 31:44
  Speaker 1: at all.
• 31:45
  Speaker 2: And yeah, and then you could say, okay, well, is
• 31:46
  Speaker 2: there some other action that people should be taking if
• 31:49
  Speaker 2: you knew you were at higher risk for this, would
• 31:51
  Speaker 2: you want to be more cautious about various kinds of
• 31:54
  Speaker 2: health choices that you make, or more monitoring or so on. Now,
• 31:57
  Speaker 2: of course, most of the people who are doing these
• 31:59
  Speaker 2: things as a recreational activity are already doing all the
• 32:02
  Speaker 2: other things which are going to prevent diabetes. So I
• 32:05
  Speaker 2: think it's a little bit it's a little bit tricky there.
• 32:07
  Speaker 1: But the way to tease this out, of course, is
• 32:10
  Speaker 1: to do randomized trials. And one tip for people who
• 32:14
  Speaker 1: are looking at influencers in this space and here's some
• 32:17
  Speaker 1: any remarkable claim is always just to you know, quickly
• 32:20
  Speaker 1: google the thing they're talking about, randomized trial and the
• 32:24
  Speaker 1: claim that they are making, and you'll often get a
• 32:26
  Speaker 1: better sense of the truth than whatever people are saying.
• 32:29
  Speaker 1: I wanted to bring up a meta analysis, which is
• 32:33
  Speaker 1: a summary of trials that randomized people without diabetes to
• 32:38
  Speaker 1: continuous glucose monitoring versus no continuous glucose monitoring, and this
• 32:43
  Speaker 1: actually showed that the people who used the cgms did
• 32:47
  Speaker 1: have a lower mean blood glucose than the people who
• 32:52
  Speaker 1: weren't assigned to use cgms. This is a bit of
• 32:55
  Speaker 1: a self fulfilling prophecy. It's sort of like if you
• 32:57
  Speaker 1: give someone a step counter, they end up taking more
• 33:00
  Speaker 1: steps like you just yes, you do like a hawthorn effect.
• 33:04
  Speaker 2: Basically like watching you, you're watching you. You want to
• 33:08
  Speaker 2: you know, at least in the short term, you're incentivized
• 33:11
  Speaker 2: to like achieve whatever is the thing you're looking.
• 33:13
  Speaker 1: For exactly, and so that's good at least it's like, Okay,
• 33:17
  Speaker 1: there's some conceptual basis here, but but there's no difference
• 33:21
  Speaker 1: in their body mass index at the end of the trial.
• 33:24
  Speaker 1: And so you know, this is an example of the
• 33:27
  Speaker 1: how okay, you got your blood sugar your mean blood
• 33:29
  Speaker 1: sugar down a little bit because you're watching it like
• 33:31
  Speaker 1: a hawk and you are kind of like, oh my god, no,
• 33:33
  Speaker 1: I'm not going to eat that cookie because it's going
• 33:35
  Speaker 1: to give me a spike. But in terms of something
• 33:38
  Speaker 1: that maybe matters more in terms of outcomes, like your BMI,
• 33:41
  Speaker 1: no effect.
• 33:43
  Speaker 2: Yeah, I guess my I have a very simple like
• 33:47
  Speaker 2: takeaway if somebody came to me they said, I'm thinking
• 33:49
  Speaker 2: about getting one.
• 33:50
  Speaker 3: Of these, like what like should I?
• 33:53
  Speaker 2: I think the question is what is the information For
• 33:56
  Speaker 2: the same question I would ask if they told me, like,
• 33:58
  Speaker 2: I'm going to get a very complicated blood panel with
• 34:00
  Speaker 2: like one hundred things in it. Okay, well, what will
• 34:02
  Speaker 2: you be doing? What what action will you be taking
• 34:05
  Speaker 2: differently based on this information? And then you know, what
• 34:08
  Speaker 2: are you like, what's the information you're looking for? Is
• 34:10
  Speaker 2: this going to deliver that? And I think we can
• 34:12
  Speaker 2: talk about whether there are situations in which I think
• 34:14
  Speaker 2: there are some in which this information could be valuable potentially,
• 34:19
  Speaker 2: But that is the question as opposed to just I'm interested.
• 34:22
  Speaker 2: So I can like see where this number is, which
• 34:25
  Speaker 2: is like, okay, yes, when you eat things, it's going
• 34:27
  Speaker 2: to go up. When you're hungry and you're like in
• 34:29
  Speaker 2: the middle of the night, it's going to go down.
• 34:31
  Speaker 2: I promise you will learn that.
• 34:32
  Speaker 1: But like then what, yeah, so what did you learn? Like,
• 34:36
  Speaker 1: give me your personal story. You wore this thing for
• 34:38
  Speaker 1: two weeks, how did it change your behavior? Why did
• 34:40
  Speaker 1: you want in the first place?
• 34:42
  Speaker 2: Okay, so I actually had a reason for this. So
• 34:46
  Speaker 2: one reason is I'm a person who enjoys self tracking,
• 34:48
  Speaker 2: and I was curious. But the main reason was that
• 34:52
  Speaker 2: I had had as part of like a standard blood test,
• 34:54
  Speaker 2: I had had a glucose test, and my glucose, even
• 34:57
  Speaker 2: not fasted, was quite quite low. And so then there
• 35:00
  Speaker 2: was a question of like should I, like, is it
• 35:02
  Speaker 2: so low that I should be worried about it? And
• 35:06
  Speaker 2: so I wore this thing and and I learned like
• 35:11
  Speaker 2: two things. One is that my glucose is sometimes like
• 35:17
  Speaker 2: below the bottom of the range is fifty five, and
• 35:20
  Speaker 2: like I'm frequently dropping like under the like it like
• 35:23
  Speaker 2: grays out at the bottom of the range, and so
• 35:27
  Speaker 2: I like sometimes have very low glugos. But I also
• 35:29
  Speaker 2: then learned I have no symptoms of that. And so
• 35:32
  Speaker 2: my doctor was like, I don't know something. It's the
• 35:34
  Speaker 2: problem That was an example of something was like why
• 35:37
  Speaker 2: did I know that? It's really irrelevant that I did
• 35:40
  Speaker 2: learn one actionable thing, which was about how I respond
• 35:45
  Speaker 2: to eating carbohydrates while I run, which is that I
• 35:48
  Speaker 2: respond quite a lot in a positive way, and so
• 35:51
  Speaker 2: I like you can sort of see when I'm I
• 35:54
  Speaker 2: could see when I was running, like when I took
• 35:56
  Speaker 2: a gel these running gels have like a very like
• 35:59
  Speaker 2: a very very concentrated amount of like sugar.
• 36:02
  Speaker 3: It's like you know, like forty grams of carbohydrates.
• 36:04
  Speaker 2: Like in the like yeah, and so I started taking
• 36:08
  Speaker 2: those earlier in my run. I moved my gel fueling
• 36:11
  Speaker 2: timing from four eight twelve sixteen to two six ten
• 36:14
  Speaker 2: on the mileage.
• 36:15
  Speaker 3: And that's that's what I learned.
• 36:17
  Speaker 1: You've lost me at oh that's the number of miles. Jesus, Emily,
• 36:21
  Speaker 1: Oh my god. You're such an athlete. So when you
• 36:25
  Speaker 1: say like you timed it better, you're watching it and
• 36:28
  Speaker 1: you're like you're running and your glucose is kind of
• 36:30
  Speaker 1: coming down or something as you run, and.
• 36:31
  Speaker 2: Then like, yeah, I didn't watch it while I was
• 36:34
  Speaker 2: running because you would bump your head.
• 36:36
  Speaker 3: Afterwards, I could see.
• 36:37
  Speaker 2: Like basically that I was like like there was a
• 36:41
  Speaker 2: reason that at three miles I was often feeling tired,
• 36:44
  Speaker 2: which is like I could see my glucose was like
• 36:46
  Speaker 2: at fifty or something has rich. And then even if
• 36:50
  Speaker 2: I did nothing, this is part of like the body
• 36:52
  Speaker 2: says me, even if I eat nothing, it will come
• 36:54
  Speaker 2: back up. But if I took a gel at two
• 36:57
  Speaker 2: miles rather than waiting to four miles, and then I
• 37:00
  Speaker 2: could basically stave off that low point because the glucose
• 37:04
  Speaker 2: would maintain at a higher range.
• 37:06
  Speaker 1: You're no doubt aware of this. But the fun physiology here,
• 37:10
  Speaker 1: this hitting the wall physiology, is when you deplete all
• 37:13
  Speaker 1: your liver glycogen stores. So you know, as I said
• 37:17
  Speaker 1: at the beginning, there's actually very little glucose floating around
• 37:19
  Speaker 1: your blood at any given time, like a teaspoons worth,
• 37:22
  Speaker 1: so obviously not enough to sustain a long run, but
• 37:25
  Speaker 1: your liver converts glucose into glycogen, just sticks a bunch
• 37:28
  Speaker 1: of glucoses together basically, which sort of it's like the
• 37:32
  Speaker 1: running gel of the body, like it can be quickly
• 37:35
  Speaker 1: delivered back into the bloodstream and broken down into glucose,
• 37:38
  Speaker 1: but there's a limited amount of it. And typically, yeah,
• 37:41
  Speaker 1: after a depending on what kind of athlete you are
• 37:44
  Speaker 1: and how much you've eaten and all that kind of
• 37:46
  Speaker 1: stuff and carbo loading and things like that, you'll deplete
• 37:49
  Speaker 1: your liver glycogen and you know, let's say two or
• 37:51
  Speaker 1: three miles, and then you switch to what's called glucooneogenesis,
• 37:55
  Speaker 1: which is creating glucose from other stuff, right breaking down
• 37:59
  Speaker 1: protein breaking down fats, so on and so forth, and
• 38:02
  Speaker 1: you do feel that difference. Like you know, athletes like
• 38:05
  Speaker 1: yourself probably know that feeling of like I'm running, everything
• 38:08
  Speaker 1: feels fine, all of a sudden, I'm like dragging a
• 38:10
  Speaker 1: little bit. And you know, if you're very in tune
• 38:13
  Speaker 1: with your body, maybe you know that you feel that
• 38:15
  Speaker 1: coming and you take your glucose gel. But maybe if
• 38:18
  Speaker 1: you're not, a CGM would be useful here.
• 38:20
  Speaker 2: And this is actually, I will say, in the endurance
• 38:23
  Speaker 2: sports space, people use these for this exact reason, which
• 38:28
  Speaker 2: is to sort of figure out what is the timing
• 38:31
  Speaker 2: and approach to fueling that allows them to maintain a
• 38:35
  Speaker 2: high level of glucose throughout a long distance endurance sports activity. Okay,
• 38:40
  Speaker 2: because that is like the easiest way to like you
• 38:44
  Speaker 2: basically don't want to get into that well because then
• 38:47
  Speaker 2: you can't move your muscles as fast.
• 38:49
  Speaker 3: So the cycling peloton, like.
• 38:52
  Speaker 2: The guys who ride the Tour de Frants, they were
• 38:55
  Speaker 2: using these to like try to optimize their fueling and
• 38:58
  Speaker 2: then they got bannedlways feel like when something is banned
• 39:01
  Speaker 2: in the night peleton, you know that works because these
• 39:05
  Speaker 2: guys are like they're looking for the one percent.
• 39:07
  Speaker 1: You know, I buy that metric, But just to say
• 39:10
  Speaker 1: it out loud, do we have any harder evidence than
• 39:14
  Speaker 1: doping bands for endurance athletes in the use of cgms.
• 39:18
  Speaker 3: Is there any harder evidence than doping bands for anything.
• 39:22
  Speaker 2: Yes, we have a little bit more harder evidence in sports.
• 39:26
  Speaker 2: So they've done some stuff in cyclists and runners who
• 39:29
  Speaker 2: are doing longer efforts, and they basically find that if
• 39:34
  Speaker 2: you give people a CGM it is helpful at optimizing
• 39:40
  Speaker 2: their carbohydrate intake so they don't drop.
• 39:43
  Speaker 3: Below seventy milligrams.
• 39:45
  Speaker 2: So it's not like there's just like a direct feedback
• 39:49
  Speaker 2: exactly the thing I describe, which is for obvious reasons,
• 39:53
  Speaker 2: if you use this to then inform your fueling, then
• 39:55
  Speaker 2: you can do better at your fueling.
• 39:57
  Speaker 1: I think it's interesting though, that like the best use
• 40:00
  Speaker 1: case maybe we've come up with so far for people
• 40:02
  Speaker 1: without diabetes or pre diabetes is not keeping your glucose
• 40:06
  Speaker 1: from getting too high.
• 40:08
  Speaker 3: It's actually from getting to lose.
• 40:09
  Speaker 1: It's like watching out from getting too low while you're
• 40:12
  Speaker 1: while you're consuming a lot of glucose in your muscles.
• 40:15
  Speaker 3: Yes, that is maybe what we learn.
• 40:18
  Speaker 2: Okay, are there any I think the last thing I
• 40:20
  Speaker 2: want to talk about here, so like to sort of
• 40:23
  Speaker 2: put a pin in that. I think the question people
• 40:25
  Speaker 2: can ask themselves is you know, what am I planning
• 40:27
  Speaker 2: to What am I planning to do with this?
• 40:29
  Speaker 3: And not everybody's going to have the like I'm running
• 40:31
  Speaker 3: for two hours.
• 40:32
  Speaker 2: Version of this, But I think there are cases for saying,
• 40:35
  Speaker 2: you know, I'm feeling really tired or really draggy in
• 40:39
  Speaker 2: different times of the day, like maybe there's some information
• 40:42
  Speaker 2: in here that could be that could you know, in
• 40:44
  Speaker 2: some way be helpful.
• 40:46
  Speaker 1: Yeah, it feels like though your your point about like
• 40:49
  Speaker 1: a two week fifty dollars investment, maybe okay, just to
• 40:54
  Speaker 1: like play around and get a sense of, you know,
• 40:57
  Speaker 1: your body, I'm not feeling like, oh yes, and therefore
• 41:00
  Speaker 1: you need the monthly subscription, And like.
• 41:02
  Speaker 3: No, I think I would never.
• 41:04
  Speaker 2: I think there's almost no case for someone to do
• 41:08
  Speaker 2: anything other than get fifty spend fifty bucks for two weeks,
• 41:11
  Speaker 2: and I think for most people there's no case for
• 41:13
  Speaker 2: that either. But the idea that you're going to endlessly
• 41:16
  Speaker 2: wear one of these, you know, I will say I
• 41:18
  Speaker 2: wore this like three days in I was like, okay,
• 41:20
  Speaker 2: I've learned something and then it, you know, a week
• 41:24
  Speaker 2: in or ten days in, it fell off when I
• 41:26
  Speaker 2: hit it with the laundry machine door.
• 41:28
  Speaker 3: And so then I just was like, now that's probably
• 41:30
  Speaker 3: enough information.
• 41:32
  Speaker 1: We should talk about some potential risks, yes, because nothing
• 41:36
  Speaker 1: is risk for free. Obviously, it's breaking the skin, you know,
• 41:40
  Speaker 1: some theoretical risk of infection, and of course there's the
• 41:42
  Speaker 1: risk of spending money, which you have other things to
• 41:44
  Speaker 1: spend your hard earned money on opportunity cost. But there
• 41:48
  Speaker 1: is a new psychological condition. It has not yet made
• 41:52
  Speaker 1: it all the way to the DSM, the diagnostics and
• 41:55
  Speaker 1: statistical manual which are all the official psychiatric conditions, but
• 41:59
  Speaker 1: it's called ortho rexia nervosa. Have you heard of this.
• 42:02
  Speaker 2: Yeah, it's like an over obsession with health. Yeah, eating
• 42:07
  Speaker 2: healthy behaviors.
• 42:09
  Speaker 1: Yeah, exactly.
• 42:10
  Speaker 2: So.
• 42:11
  Speaker 1: Orthorexia nervosa has been documented in several studies. Again, not
• 42:15
  Speaker 1: an official psychological diagnosis yet, but it's basically people who
• 42:18
  Speaker 1: become so obsessed and continuous glucose monitors can play into
• 42:22
  Speaker 1: this with like maintaining that perfectly flat line that it
• 42:26
  Speaker 1: starts to consume them and every psychological condition that does
• 42:30
  Speaker 1: end up in the DSM always has a criteria that's
• 42:33
  Speaker 1: like and it interferes with your daily life, right, Like,
• 42:35
  Speaker 1: so you know alcohol use disorder. It's like you're drinking
• 42:39
  Speaker 1: alcohol and it interferes with your daily life. And so
• 42:42
  Speaker 1: there are people for whom things like this. The cgms,
• 42:46
  Speaker 1: even sleep trackers that's called orthosomnia, like gets so obsessed
• 42:51
  Speaker 1: with kind of perfecting those metrics that their relationships suffer,
• 42:55
  Speaker 1: their job suffer. It's all they can think about. If
• 42:58
  Speaker 1: you feel like you're that type of person, do not
• 43:00
  Speaker 1: put one of these on your body.
• 43:02
  Speaker 2: I agree, And I think the other piece of this
• 43:05
  Speaker 2: is I do not think people should fear foods.
• 43:10
  Speaker 3: And there's a.
• 43:11
  Speaker 2: Little bit of a sort of space in here, and
• 43:13
  Speaker 2: you see this in the wellness influencer space. It's like,
• 43:15
  Speaker 2: you know, I wore a CGM, and I learned that
• 43:18
  Speaker 2: I can never eat rice because when you eat rice,
• 43:22
  Speaker 2: your glucose spikes. In this way, you can only eat
• 43:25
  Speaker 2: rice if you also put chicken on it. It's like,
• 43:28
  Speaker 2: it's fine to eat chicken with your rice. But I
• 43:31
  Speaker 2: don't think that. I worry that people will sort of
• 43:34
  Speaker 2: overinterpret just like basic variations in glucose that are totally normal,
• 43:39
  Speaker 2: and physiology and the basic physiology as some kind of
• 43:43
  Speaker 2: like I'm broken because you know, my blood sugar went
• 43:46
  Speaker 2: to one hundred and thirty after I ate a bowl
• 43:48
  Speaker 2: of rice, which is a totally normal, regular thing to
• 43:52
  Speaker 2: have happened.
• 43:53
  Speaker 1: Yeah, And just to say, even larger spikes, well documented
• 43:59
  Speaker 1: spikes up to one sixty one, seventy one to ninety
• 44:02
  Speaker 1: after a meal, even up to two hundred in healthy
• 44:05
  Speaker 1: individuals can be normal depending on the amount of glucose
• 44:08
  Speaker 1: that you ingest. And it doesn't mean that you're necessarily
• 44:11
  Speaker 1: insulin resistant or broken in any way. It just means
• 44:14
  Speaker 1: your body really efficiently broke down those carbohydrates and gave
• 44:18
  Speaker 1: you a bunch of glucose, and then your body's going
• 44:20
  Speaker 1: to do the thing that your body does, which is
• 44:22
  Speaker 1: take all that excess glucose and stick it in the
• 44:24
  Speaker 1: liver in the form of glycogen so that when you
• 44:26
  Speaker 1: go on your run, you don't fall down flat exactly.
• 44:30
  Speaker 2: Okay, Perry, continuous glucose monitors for non diabetic individuals, smash
• 44:36
  Speaker 2: your pass pass.
• 44:37
  Speaker 1: On this one. I think save your money. I don't
• 44:40
  Speaker 1: think you're getting much information from it. Focus on something else,
• 44:44
  Speaker 1: how about Emily.
• 44:45
  Speaker 2: I think I'm also a pass even as a consumer.
• 44:48
  Speaker 2: I think for almost no one, is this really very useful?
• 44:53
  Speaker 2: And I think a lot of the feedback that you
• 44:54
  Speaker 2: would get from it, you could actually just get from
• 44:56
  Speaker 2: paying attention to how you feel, which is actually more
• 45:00
  Speaker 2: important than what some number is on an app.
• 45:03
  Speaker 1: All right, that's it for continuous glucose monitors. Your mail
• 45:06
  Speaker 1: bag Question of the Week after the.
• 45:07
  Speaker 4: Break, Hey, Emily and Perry. This is Adam from Persipity,
• 45:16
  Speaker 4: New Jersey. I had a question for you about statins
• 45:19
  Speaker 4: and grapefruit. I've heard that you're not supposed to eat
• 45:22
  Speaker 4: grapefruit while you're taking statins, and I didn't know. Is
• 45:25
  Speaker 4: it because they won't work as well? Is it that
• 45:27
  Speaker 4: they're bad for you if you do? What's the deal?
• 45:31
  Speaker 4: Thanks so much?
• 45:32
  Speaker 1: Yeah, A lot of people always wonder, you know, it's
• 45:34
  Speaker 1: really weird that on certain medications, it's like, you know, oh,
• 45:37
  Speaker 1: take this with food, take this without food. Don't eat
• 45:41
  Speaker 1: grapefruit while you're having this medication. It feels very specific,
• 45:45
  Speaker 1: and it is, and it all has to do with
• 45:47
  Speaker 1: liver metabolism. So grapefruit and grapefruit juice contains something called
• 45:53
  Speaker 1: a ferano cumerin, which inhibits one of the enzymes in
• 45:59
  Speaker 1: your liver. It's responsible for breaking drown some drugs, including
• 46:03
  Speaker 1: some status called cytochrome P four fifty and so if
• 46:06
  Speaker 1: that enzyme is inhibited, then when you take a dose
• 46:09
  Speaker 1: of that drug, it doesn't get broken down as fast
• 46:12
  Speaker 1: and it can get to toxic levels more quickly.
• 46:15
  Speaker 2: So it's not jost or it's not that it doesn't work,
• 46:17
  Speaker 2: it's that it is actively dangerous.
• 46:20
  Speaker 1: Correct. Yeah, this is one of those things that makes
• 46:24
  Speaker 1: drug levels higher, not lower. But there are other things
• 46:27
  Speaker 1: that interact with the liver too that will increase the
• 46:31
  Speaker 1: metabolism of certain drugs. There's the most famous one of
• 46:36
  Speaker 1: those probably is the interaction between alcohol and thileanol in
• 46:40
  Speaker 1: the liver. Those are both metabolized by the same receptor,
• 46:43
  Speaker 1: leading to something called the therapeutic misadventure, which is when
• 46:49
  Speaker 1: this is kind of fastening and sad, when people try
• 46:52
  Speaker 1: to overdose or commit suicide by taking tilenol and alcohol together.
• 46:59
  Speaker 1: The alcohols can heating for the thailanol receptor in the liver.
• 47:03
  Speaker 1: The thing that breaks down the thaileanol, and it is
• 47:05
  Speaker 1: the breakdown product of thailanol that's toxic in the high doses,
• 47:08
  Speaker 1: and so by drinking while you did that, you paradoxically
• 47:12
  Speaker 1: sort of saved yourself. We see that from time to time.
• 47:14
  Speaker 3: Yikes.
• 47:15
  Speaker 1: Okay, so don't do any of these things.
• 47:17
  Speaker 2: But to get back to the statins.
• 47:23
  Speaker 1: Tangential, I'm gonna have my I'm gonna have my.
• 47:25
  Speaker 3: Thin min I think you need.
• 47:29
  Speaker 2: Does this mean you can literally like, if you go
• 47:31
  Speaker 2: on a satin for life, you're never eating grapefruit again.
• 47:33
  Speaker 1: That's well, now I'm chewing. Okay, you need to ask
• 47:39
  Speaker 1: that question longer.
• 47:43
  Speaker 2: I love grape and I never have them again if
• 47:46
  Speaker 2: I'm on a statin. Now.
• 47:49
  Speaker 1: The truth is, most of the studies of the pharmacokinetics
• 47:54
  Speaker 1: of these drugs pharmacokinetics is like the concentration that drugs
• 47:58
  Speaker 1: get to in your in your blood after you take them,
• 48:01
  Speaker 1: are based on people drinking double concentrated grapefruit juice in
• 48:05
  Speaker 1: a significant quantity, and so probably like a bit of
• 48:10
  Speaker 1: grapefruit juice here and there is not going to cause
• 48:12
  Speaker 1: a huge problem. And of course statins aren't particularly toxic
• 48:16
  Speaker 1: at higher doses anyway. So a lot of these risks
• 48:19
  Speaker 1: are more theoretical, but they are there.
• 48:21
  Speaker 2: But if you were going to plan to be honest
• 48:23
  Speaker 2: at and while also being on the grapefruit diet of
• 48:26
  Speaker 2: the nineteen seventies, which was exclusively grapefruit oriented, that would
• 48:29
  Speaker 2: be a mistake.
• 48:30
  Speaker 1: That would clearly be a mistake.
• 48:32
  Speaker 3: Okay, news, you can use people. That's it for us today.
• 48:37
  Speaker 2: Stick with us next week when we'll ask what's the
• 48:40
  Speaker 2: deal with hormone replacement therapy? Wellness Actually is produced in
• 48:47
  Speaker 2: association with iHeartMedia.
• 48:49
  Speaker 3: Our senior producer is Tamar Avishai.
• 48:51
  Speaker 2: Our executive producer at iHeart is Jennifer Bassett. Our theme
• 48:55
  Speaker 2: music is by Eric Deutsch, and our content is for
• 48:58
  Speaker 2: educational purposes only.
• 49:00
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• 49:02
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• 49:11
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• 49:14
  Speaker 1: Head over to Wellness Actually dot fm and leave us
• 49:17
  Speaker 1: a question for our mailbag or suggest a topic for
• 49:20
  Speaker 1: a future show.
• 49:21
  Speaker 3: We'll let the influencers have the last word.
• 49:23
  Speaker 4: I am not a diabetic, but I decided to get
• 49:26
  Speaker 4: my CGM because I wanted to find out what foods
• 49:29
  Speaker 4: affect me.
• 49:30
  Speaker 5: So here are some of the big things that I've
• 49:32
  Speaker 5: learned in the past.
• 49:33
  Speaker 1: Two weeks of wearing my CTM food.
• 49:35
  Speaker 5: Despite my blood sugar.
• 49:36
  Speaker 1: The most was drumroll please, sushi.