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NUTRITION411: THE PODCAST, EP. 32

The Use of Continuous Glucose Monitoring in People With Diabetes

Lisa Jones, MA, RDN, LDN, FAND

In this podcast episode, Lisa Jones, MA, RDN, LDN, FAND, interviews Rachel Stahl Salzman, MS, RDN, CDN, CDCES, and Livleen Gill, MBA, RDN, LDN, FAND, on the use of continuous glucose monitoring (CGM) in people with diabetes, including practice pearls for onboarding people with diabetes and clinicians, the role of the registered dietitian nutritionist in the patient care team, and barriers to the use of CGM and ways to overcome them.  

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TRANSCRIPTION:

Jessica Bard: Hello, and welcome to Nutrition411: The Podcast, a special podcast series led by registered dietitian and nutritionist, Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Lisa Jones: Hello, and welcome to Nutrition411: The Podcast, where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's podcast is part of a series of episodes on diabetes technology featuring a Q&A with Livleen Gill and Rachel Stahl Salzman. Welcome, Livleen and Rachel.

Rachel Stahl Salzman: Thanks so much for having us.

Lisa Jones: I'm excited about this episode. I want to take a moment to introduce each of you first. So I will start with Livleen Gill.

Livleen is the president and CEO of Apostle Group, LLC, a consulting company that provides innovative solutions to clients in healthcare, food, and nutrition. She's also the CEO of Wholesome Village company in Rockville, Maryland. Previously, she was a private practice nutrition consultant for more than 20 years, and a food and nutrition services director and outpatient dietitian at healthcare centers in Maryland. She will serve as the Academy of Nutrition and Dietetics President in the 2024 to 2025 year.

Next, I want to introduce Rachel. Rachel is a registered dietitian and diabetes care and education specialist in the division of endocrinology, diabetes, and metabolism at Weill Cornell Medicine in New York City. Rachel is passionate about empowering individuals to make sustainable lifestyle changes and leverage diabetes technology and digital health to improve their health and quality of life.

So again, welcome, Livleen and Rachel.

Rachel Stahl Salzman: Thank you.

Lisa Jones: We will start talking about our first topic, which is we want to dive into continuous glucose monitoring. So, I want to hear from Rachel, if you can explain to me, the definition of CGM technology and what specifically are the standards of care in diabetes.

Rachel Stahl Salzman: All right, so this topic is so exciting to all of us. I think we're all seeing the breadth of technology with CGMs in helping to improve care for those living with diabetes. So for those listening, a continuous glucose monitor, known as a CGM, is a device that measures and displays your glucose levels in the interstitial fluid, and it's doing that continuously. These devices consist of a sensor inserted just under the skin. Many of them are placed on the back of the upper arm. There's a transmitter and a receiver or reader or a smartphone that would display the glucose reading. Typically with a smartphone, there's a connected app based on the CGM device that's going to be through Bluetooth connection, showing the person's glucose values, showing the direction with trends and arrows, and offering so many great features and benefits for them to understand their values.

Many of these devices are typically worn for seven to 14 days, and then they're replaced, except for there's one on the market, known as Eversense E3, which is the only implantable CGM, that lasts under the skin for six months in the United States, which is pretty interesting. This topic of CGM is really exciting because the standards of care and diabetes from the American Diabetes Association just came out. In their technology chapter on CGMs, they share that it is becoming the standard of care for people with diabetes, particularly those who take insulin to manage diabetes. This is in line with many other international guidelines, including the American Association of Clinical Endocrinologists and the International Society for Pediatric and Adolescent Diabetes. So all of these organizations together are recognizing the important role that this technology has.

Lisa Jones: Wow. So it's certainly amazing, and just from the last time that you were on our podcast talking about these different diabetes technologies, I don't remember, the new one with the six months, that's just fascinating, the whole thing. And then trying to keep up with all the technology seems like a part-time job in itself. 

Rachel Stahl Salzman: It totally is. And all of these devices keep getting smarter and more accurate, more affordable. So even the companies that have been on the market for a while, every time there's a new FDA approval, this add-on, this benefit... even in the past year, two of the devices, Freestyle Libre 2 and 3, and Dexcom G7, have been approved for gestational diabetes and diabetes in pregnancy. So that was also a really exciting update.

Lisa Jones: Yes. And then with the update, that lends itself nicely to how do you then take all these different apps and technology that you're using and talk about onboarding people with diabetes to use them?

Rachel Stahl Salzman: Yeah, absolutely. It can feel very overwhelming to think about all the different options out there. And I think when it comes to onboarding the person, it's really starting with listening to them. I think about finding out what their biggest concerns are, what are their trouble points in diabetes management, and thinking about how technology could help with their individual goals.

Lisa Jones: And then I want to ask Livleen, her experience with, just listening to what Rachel was saying, with all the new technology that's coming out and how do you keep up with it with the standards of care in diabetes, but then also in your area with onboarding people, what would you say to that, Livleen?

Livleen Gill: Great question, Lisa. Keeping on top of technology, and we've been bombarded by technology–good, all good in trying to manage diabetes and to streamline care. But one of the things that for the individuals that we work with who are adults and older adults and our physician and nurse practitioners and RDs who take a while to adopt technology. So, we had to learn what our patients were coming in with, what they could do, what were their pain points in terms of medications, the number of medications they were taking, the frustrations that both the patients and the care team were seeing in being able to manage their A1C. That's kind of how we set up our protocols, our processes, to start to embed. And we started with a small advisory council, which had our team, including patients in there, so that we could see how we were going to proceed with the adoption of technology and kind of individualize the care for those people we were taking care of.

Lisa Jones: Yeah, that's fantastic. And I like the advisory council because we're not in a vacuum creating these policies by ourselves. It's always good to have other people involved in the creation of it and then the checkpoint to go back and say, "Okay, is this working? What can we modify to move forward?"

Rachel Stahl Salzman: And I would add, yeah, I love the idea too of getting that patient perspective, because that speaks volumes. And setting up the onboarding, I'm sure Livleen can agree, it's not just putting the sensor on and letting them go. There is so much learning that goes on with these technologies, and the role of the registered dietitian is so important to help support them in understanding what this data is and understanding how we're going to look at the data and how that's going to help inform care. It is such a comprehensive part of an endocrinology and primary care program for CGMs.

Lisa Jones: Yes, and I know in another episode that we had, Rachel, we were talking about the advancements and everything. But just thinking back to even 10 years ago, now there's so much data. Whereas before, you didn't have this. Just the capabilities, I just find this so fascinating. And the future, the bright future ahead, right?

Rachel Stahl Salzman: Absolutely, yeah.

Lisa Jones: But all of it can't happen without RDNs. So if we talk about the RDNs, can you highlight the role of the RDN for us, because it's such a crucial role here?

Rachel Stahl Salzman: Yeah, absolutely. The dietitian can play a key role in supporting both other clinicians in understanding technology as well as the people living with diabetes themselves. So some examples of what we've done, and our dietitians, is that we are also diabetes care and education specialists. So that is the CDCES credential, which has given us and given me personally just so much knowledge, resources, and confidence to take the lead in championing diabetes technology and understanding its application for supporting diabetes care. So we do in-services with our clinicians, we have monthly meetings on diabetes topics, and we bring in experts in the field. Now we do so much virtually. We talk on Zoom. So, we're able to get a lot of people on these meetings to stay up to the technology. And for the patients, I think just having dedicated time to educate them, support them, and follow up with them with the data to help keep them engaged.

Lisa Jones: Yes, and I love hearing that, too, because you're showing that it is that team, including the patient. Whereas before, it was like, "Oh, I have this patient," but the patient was kind of on the receiving end of it. Now the patient gets to be part of it, which I love hearing. So thank you for sharing that. And Livleen, I'm curious, how do you get primary care clinicians more comfortable using technology?

Livleen Gill: I'm going to segue into your other question a little bit towards the end with the RDN, and the RDN really is the key to all of this and bringing the team together. So the RDN has the knowledge and the skill set for working with individuals with diabetes. And one of the other things that is helpful is we have MNT, so we can be reimbursed for that medical nutrition therapy. And if you have the other program, the DSME program, you also can be able to bill if you have an RD as the lead. So in our program, we were able to get the primary care buy-in by showing them the data, showing them how, bringing in the technology, and we were able to improve the care and personalize the care of the patient.

We would do many meetings with them, we would bring in reps from outside to talk about the technology and show the data, including the RDNs and the NPs would show the data in our practice, and we would have these hands-on workshops for them to get comfortable. I also, as the CEO of the company, I'm able to leverage by making them attend conferences and some of the continuing education in these so that they start to get up to speed, but the data is the most helpful when they see their patients' A1C improving, right? That becomes the key, and they can get them off medications, and it's not just shot in the dark, just keep adding medication, but they have true data to look at. So that's part of how we were able to bring them on this journey with us.

Lisa Jones: I love that. Again, this showcases not only the RDN but the entire team. And then, of course, all the data that we have access to these days I think is incredibly helpful. So thank you for that. I do want to shift gears a little bit and talk about some barriers to the use of CGM. So Rachel, do you want to talk about some barriers to that?

Rachel Stahl Salzman: Sure, yeah. There are some barriers to using a continuous glucose monitor, and how I think about it are three different categories, and I'm sure Livleen could add on here. I think about barriers for the person living with diabetes. I think about the barriers around the healthcare professional and a systems-level kind of aspect. And so there's a lot to unpack from those three categories, but I'll just touch on a few briefly first. When I think about the person with diabetes, I think some things that I've seen in practice are there is an aspect of a fear of change. I think we could all agree on this if it ain't broke, don't fix it idea. People are comfortable with what they're doing, they think it's going well, but how can we support the use of technology to help them understand what else is out there and what more they can gather from the data?

And I also think there's a lack of device knowledge. There certainly are more commercials than ever. We could all think about the Superbowl ad with Nick Jonas with Dexcom, and magazines and other media are talking about technology. But I still think there, for a lot of people, aren't aware. They come to our office after living with diabetes. Maybe they transitioned care from somewhere else. We sit down with them, we show them, I like to give a refresher, like, "This is what's out there." Maybe they hadn't thought about insulin pump therapy in many years. Things have evolved so much in the past few years. So I think as a provider, how important it is for us to be up to speed so that way we can educate the people we work with.

Lisa Jones: I was going to say, that's such a great point with the fear of change, because if you think about even a general app when you're doing an update to your apps and you're like, "Oh, my goodness." And then you go into the interface and it looks different. You're like, "Where's that at?" So I can imagine what that's like for a patient, kind of like, "Oh, what did they change now?" Just trying to keep up with it, you need an online manual to do that. But go ahead, what were you going to say?

Rachel Stahl Salzman: Yeah, yeah. And I was just going to close with the higher level, the systems-level component barriers. I think I'm sure everyone's familiar listening, the idea of some concerns around insurance coverage the cost of some of these devices, and breaking down barriers to support more equitable access to these technologies are still barriers that we face, though improving.

Lisa Jones: Yes, cost and accessibility are high on that list. So thank you, Rachel, for that. And Livleen, what are your thoughts? As Rachel was saying, there are so many different aspects of it, the person living with diabetes, and the barriers to clinicians in primary care or assisted living, per se.

Livleen Gill:

Absolutely. And Rachel did a great job putting those three buckets there. And I'll talk about the professional side. So, one of the barriers to adoption for the clinicians, and when I say clinician, I'm talking about the physicians here, is they're not embedded. It's not easy to get the data, it's not embedded in their electronic health records. They have to go somewhere else to get the data, and that takes a lot of time. Second thing, with Rachel talking about the costs, we have a lot of prior authorization that we have to do from plan to plan, different plans, and you can't keep them straight. And that requires a lot of time.

It not only is that, but on the individual side, what we find is we deal with older adults, right? So 65 and over. 60% of our population that we see is in that. Privacy is a big issue for them. Where is this going? You put this thing on your skin, but how are you able to look? Who else is looking in there? That's a big concern for them. And the technology literacy, there are huge gaps in there for them. And so those are kinds of things that are barriers to adoption and making it mainstream for professionals and individuals living with diabetes.

Lisa Jones: Yes, there are such great points. And that kind of begs the question, since there are so many advances, and Rachel, I'm sure you can speak to this as well, is have you seen from when you first started working with early adopters of the technology to now, what would you say? Do you find that this is becoming less of a barrier? Or do you think that the curve on that has changed in any way?

Rachel Stahl Salzman:

Yes. Yeah, I do think that the curve has changed. A lot of these devices are trying to transcend barriers around digital literacy, making it easier with language, with color coding to allow more people to be comfortable with these devices. But I still think it goes back to us as registered dieticians working with people with diabetes and other clinicians to make sure we're providing the optimal support and education to make sure that they have success with the options.

Lisa Jones: Yes. I was going to ask a question about what strategies each of you used to help overcome these barriers. And Rachel, you kind of already answered some of it with the color coding. Do you want to expand a little bit on that?

Livleen Gill: Here's what we've done. So before the individual, the patient coming in for their appointment with the physician, well, we have the RD who's gone over the reports and makes the highlights, puts everything onto a note, and then pings the physician with it, and the report is downloaded in the patient's chart. So that is one way for the physician. They don't have to go looking. It's a time saver. The number two thing for the patients that we've done is we have written material. We have written material with the font size that the advisory council came up with that looks good in a format that is easy to understand.

Also, before the patient gets the CGM, they spend about an hour with our clinician, whether it's the RD or the nurse practitioner, depending on the timing of the visit. They spend about an hour with them going over every aspect of it with the written material, with feeling it, all of that. Then we set them up with daily phone calls and touch points for the first week, which has helped some of the barriers and them to adopt the technology, both on the provider side and on the individual side. So those are some of the things that we've done for this.

Lisa Jones: That's wonderful. The daily phone calls, as well as the other thing you're mentioning, but just putting yourself in a patient's perspective, it would be fantastic to get a daily call to help you. Because a lot of times, say, for example, you're discharged from a hospital and then they may call once, but the fact that it's daily, I think, is more helpful than just that one touch point. So thank you for sharing that. And then, Rachel, I want to circle back to you on is there any additional strategies that you want to share about the barriers.

Rachel Stahl Salzman: Yeah, I would just highlight to help overcome them, very similar to Livleen, we need the time to help educate them for success, so very similarly on that front. And encouraging them to have regular follow-ups is so important. Because this data is typically all through cloud-based data, we can access it in real-time. We rely on and are so fortunate to have a wonderful staff of medical assistants who send the connections to the different systems to make sure that the patient's data from the CGM is connected to our clinic, similar to Livleen, so that it's downloaded into the medical record in advance of our appointment.

Or we can look it up in-between visits. If the patient reaches out, "Hey, I'm noticing my glucose levels have been high in the morning, can you take a look at my CGM readings and see what we can do?" And that clues me in to be able to peek in in real-time. I don't have to worry about them coming into the office to drop their glucose meter to download the data. This has alleviated so much of that, which has helped make things much more efficient and get the patients the answers when they need it, rather than waiting three months later and they've already forgotten what their concern was months ago.

Lisa Jones: Yes, excellent point. That is important, the real-time data.

Livleen Gill: One of the things, Lisa, both Rachel and I haven't talked about, which is important, and I know in our earlier conversation, I know Rachel's clinic, and we do this too, that we use a professional CGM, which is when there's some hesitancy at the barriers to show how that data is going to be used with the individual, which is for a two-week period that we use it before we either transition them to their personal CGM or if there is an issue that cost is prohibitive or the insurance doesn't cover, but we at least get some data that we can see where the issues are lying. So that is one other way that we've been able to overcome some of the barriers. Right, Rachel? Would you agree?

Rachel Stahl Salzman: Yes, I completely agree. We utilize professional CGMs quite often, especially in those cases, so that way patients don't feel like we're going to be prescribing it, you're going to be wearing this all the time. Rather than, "Hey, let's try. Do a trial, and see what you like. Let's take a look at the data together." And oftentimes that unlocks so many insights for the person that they can have it. And it's also really helpful for those whose insurance doesn't cover it because the professional CGM is bought by the clinic themselves. So there really should be no cost to the patient.

Lisa Jones: Oh, wow. So then my question here would be, because many of our listeners are clinical inpatient dieticians, they may be seeing the technology more so than somebody else who's not working in that setting. Do you know what they use in the hospital for CGMs?

Rachel Stahl Salzman: That's a great question, Lisa. I spent many years as an inpatient dietician, and even in the years I was there, I would, year after year, see more diabetes devices around as they become more accessible and approved for use by people with diabetes. Right now, CGM devices are not approved by the FDA for inpatient management. Now, that doesn't mean that a person who comes into the hospital wearing it has to take it off, but in terms of needing a point-of-care glucose measurement for the nursing, for insulin dosing decisions, or hypoglycemia assessment, glycemic management through point-of-care glucose is still the preferred method. But I will say with the standards of care, there are always new updates every year, if not sooner. And the research is evolving and helping support the use of CGM in the hospital. But as it stands now, it's still not FDA-approved in inpatient.

Lisa Jones: Oh, that's good to know. Thank you. Thank you for that clarification. Are there any other comments on this topic? I would love to hear each of your top takeaways from this discussion on continuous glucose monitoring.

Livleen Gill: So to piggyback on what Rachel said about inpatient, I'm also going to say that the same issues that Rachel has outlined for the hospitals, we have the same things in long-term care facilities, nursing homes, rehab centers, and assisted living. The other challenge over there is you have an assisted living frontline staff, which are med techs. They're not trained with it. The regulations are also not, they're more for point-of-care testing. So even if the individuals go in there with these CGMs, it becomes they are still being tested. They have these CGMs, and they haven't adopted them. And then we are in this land like, "Okay, now what do we do?" Because they can't stay there with the CGM because the facility doesn't take responsibility. So some of those things have to change for the full adoption of these CGMs to be in those inpatient facilities and places of living where older adults live, too.

Lisa Jones:

All right, I appreciate that. Thank you.

Rachel Stahl Salzman:

I would add, too, Livleen, what's been helpful for us on the inpatient side is we have an inpatient glycemic management team. Of course, that takes a team, but these individuals on the glycemic management team would get consulted for any person with diabetes who's coming in on a CGM or an insulin pump that they would help evaluate to see if it's possible for them to at least continue it, even though we're still going to do the point-of-care glucose measurements, but having the patient feel comfortable, right? This insulin pump, the CGM has been something, part of their day-to-day for many years, for example. So we always want to try to help support them to continue it, but having the expertise on staff at all of those skilled nursing facilities and various places would be important to help see that through.

Livleen Gill: Agreed. Absolutely.

Lisa Jones: Yes. This has been a wonderful discussion on continuous glucose monitoring, and I will say my two takeaways are data and teamwork from this discussion. And I'm curious, Rachel, what would you say yours are?

Rachel Stahl Salzman: Yeah, I completely agree. And it's exciting for the role of the registered dietitian to be that key player in helping to unlock this data and help the person to understand and apply it to help them improve their outcomes.

Lisa Jones: Yes. And how about you, Livleen?

Livleen Gill: I agree with Rachel and you about this. Dietitians are the key to this. They have the skills, and they can be the linchpin of the team to bring it together for both the professional side, the clinician side, and the individuals living with diabetes.

Lisa Jones: And I thank you both so much for sharing your expertise on this topic with us today.

Rachel Stahl Salzman: Our pleasure. Thanks, Lisa.

Jessica Bard: For more nutrition content, visit consultant360.com.

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