From Uncertainty to Insight: How Continuous Glucose Monitors (CGMs) Are Transforming Diabetes Care During Pregnancy
Video Transcript:
Robin Loveday: Hello and welcome, everyone. My name is Robin Loveday. I'm a nurse practitioner, CDCES. And today, we're going to discuss the role of continuous glucose monitoring, or CGM, with managing diabetes. We're going to review benefits, challenges associated with this type of device, barriers to adoption, but also the unique benefits of this device in different subpopulations of patients living with diabetes. If you'll start us off and introduce yourself.
David Doriguzzi: Thanks, Robin. I'm David Doriguzzi. I'm a physician assistant. I’ve been working as a diabetes specialty PA for about 23 years. I am with a large medical group in Northern Los Angeles County in Lancaster, California. And it's a pleasure to be here today.
Dr Anita Swamy: I'm Dr. Anita Swamy. I'm a pediatric endocrinologist, and I specialize in diabetes. And I'm in the awesome city of Chicago, Illinois, and honored to be here today.
Dr Aaron King: My name is Dr Aaron King. I'm a family medicine physician in San Antonio. I've had an area of interest in diabetes now for about 20 years and enjoy taking care of full scope adults both with and without diabetes and also take care of type 1 diabetes.
Joy Ashby Cornthwaite: I'm Joy Ashby Cornthwaite, and I'm a registered dietitian and a certified diabetes care and education specialist. I lead a group of clinicians taking care of high-risk pregnancies in Houston, Texas.
So, as a dietitian in this space for a very long time—I won't tell you exactly how many years—having patients come in and, despite the pain, despite the burden, despite the stigma, despite the time-consuming checking their blood sugars, people would continue to do that. And they would do that and adjust whole medication, as well as their food choices for not only themselves but their entire family.
And to come back and only have four finger sticks that said, "I am still not succeeding," that was a huge detriment to all of the gains that had been achieved in the 2 weeks or 4 weeks between visits with them. What CGM allows patients to see is to see how their changes are impacting their glucose.
And that repeated positive reinforcement boosts self-efficacy in ways that we have come to understand through research. So, you've got motivation involved there. You've got repetition and habit-forming involved there. You also have the positive influence of everyone in the family is feeling better and you haven't made these huge changes to your entire family's grocery list and eating habits for nothing to end up being more positive.
Coming in and having a blood glucose value and having someone circle on your piece of paper in red ink to say how terrible you've done is not really a good positive motivator. But if you have an AGP and a compare from before and after that says, "I have done a better job this time—there is more green involved," it's highly motivating. And that self-efficacy is what keeps them going 12 months down the line.
And in terms of women living with diabetes and pregnancy type 1, type 2, gestational diabetes, I find that there's less of a hesitancy, especially given that there is now FDA approval for use of CGM in pregnancy as well as moms arriving to clinic saying, "I know my grandfather or a friend or a family support person lives with diabetes and they wear a CGM. There are so many things I have to do in pregnancy. I have to make sure I eat well. I have to take my vitamins. I have to sleep. I have to come to the clinic every month or every 2 to 3 weeks in the month. I don't want the added burden of finger sticks. Also, PS, I'm pregnant. And so, I'm super sensitive, and my fingers hurt. How can I get on a CGM?"
And so, I think that, more and more, if we are going to be responsive as an OB-GYN MFM community to the needs and wants of moms living with diabetes and all of the burden that comes with being pregnant period, we need to provide CGMs as a way to easily collect data and take care of moms.
And in the OB-GYN and MFM space, it's important to recognize that the standards are guided by ACOG or SMFM. And the standards of care still remain four finger sticks per day, despite FDA approval and regular utilization of CGM during pregnancy. In my opinion, I do think—and I do see, as more data is collected around outcomes and efficacy for both prenatal and maternal health in terms of things like preeclampsia prevention, improvement of glycemia during pregnancy, during delivery, also respiratory distress in babies when they're born, large for gestational age being impacted—I think all of those clinical trials are going to lead to a very different stance in the very near future from ACOG and SMFM. But we're still waiting for that. But I think it's very important to recognize that those standards currently exist. And while ADA standards are for use, ADA has recently come out with recommendations, very strong expert opinion recommendations, supported by trials for use of CGM in every mother who lives with type 1 diabetes during pregnancy. So, I think that there is some hesitancy to go against the grain right now, but I think the grain is changing.
The nice thing about Urgent Low Soon is that it's linked to both velocity or rate of change as well as directionality. And so, in pregnancy there's times where highs and lows occur. And you may not exactly know why, and they're unpredictable—because of a recent change in medication or a change of food or a food preference or nausea and vomiting. There's a whole slew of different pregnancy considerations that happen that can influence blood glucose. And so, when moms are able to see that and respond to them accordingly based on what they were experiencing, we do see a reduction of the rebound hyperglycemia or highs that come from overtreating. And we can stop the sort of diabetes roller coaster, which is that glycemic variability that's very real in pregnancy and often occurs every day.
Robin Loveday: What benefits, Joy, do you see regarding the use of Dexcom CGM in patients with gestational diabetes?
Joy Ashby Cornthwaite: So, first and foremost is frequency of checking. So, when we ask a person who's pregnant and living with diabetes, all types of diabetes, to fingerstick on top of all the other considerations and responsibilities of life and pregnancy in general, the return on that ask is sometimes a lot lower than we expect, right? So, if you've got, for example, I have a mom who is an RN. So, she knows the importance of checking her blood glucose values. But she also is an RN in an ICU setting, which means that she has to wear a lot of personal protective devices and equipment. If she goes into a patient room, when she comes out she needs to wash her hands. She can't keep her BGM supplies, needles, machine, everything on the floor with her. She has to go to her locker, unlock her locker, check her blood sugar. She's unable to do this continually every single day while she's pregnant because she's a nurse, and she has to take care of patients as well.
And so, despite her best efforts, she wasn't able to keep bringing us back the recommended four checks per day. So, you put a CGM on her and that reduces the burden, right? And now, she's able to see her glucose values. She's able to understand how stress impacts her blood glucose values. On the days that she's on for 12 hours, her numbers were significantly higher. And we're able to adjust her medications based on that than on the days when she was off of work, depending on food choices. All of these things are huge barriers to improving those outcomes that we strive for, right? So, we want to mitigate preeclampsia. We want to mitigate large pregestational age. Yet, we're wanting to depend on single-point values that don't tell us anything—that we may never get all of those values anyways. I think CGM is going to change pregnancy care. It already has.
Dr Aaron King: To that end, Joy, I'm curious on your expertise here. It seems to me like this is the prime patient that we should be using CGM in. It's almost amazing that it's taken this long to really move into becoming the standard of care and being accepted. But I'm also wondering—we've been talking about barriers both to providers and to patients. What are your patients' reactions when you suggest that? And how open are they to the technology? It seems like they'd be really ready to pick that up. I mean, every mom I know there’s nothing more important than the health of their infant. And so, can you comment on that?
Joy Ashby Cornthwaite: Yeah. So, most moms in our clinical practice that I see are really willing to try, at least first place it and experience it. And even if they're a bit hesitant, we have samples, like you were saying before. And we place it on them, and they're like, "Oh, my goodness, that didn't hurt." Initially, it's like, "Wait, there's going to be a needle and it's going to..." I'm like, "The needle's not going to be left behind. You're going to feel one single prick. And then, it's going to be on there, and you can read it to your phone." And they're like, "Okay." And so, we sit down together. I have them place it. They place it themselves or I place it for them, and it's an immediate relief.
You can see how relieving it is because they've been checking their fingers, and it hurts, and all sorts of things. And they're like, "And now, do I have to write this down? Do I have to fax it over to you? Do I screenshot it in my EHR? How do I get this number back to you?" You're like, "Well, we just put in the code, and it comes directly to the clinic." And they're like, "Oh, so I put this on every currently 10 days," soon to be 15 days, "I put this on and it shows on my phone. And then, you just get it, and I just show up at my appointment?" It's like, just like that. That's what happens. And they're like, "Okay, this is amazing."
And then, we might have a few moms who are living with diabetes before pregnancy and currently doing the BGM route. Those moms are probably the most hesitant patients that we have because of the stigma that they've lived with for their entire lives with diabetes. So, bringing in a log has always, for them, meant someone's going to judge them based on the numbers and what they have failed to achieve—not what they've achieved, but what they’ve failed to achieve. And so, their first question is, "If I put the CGM on, you will see all these values?" And then, they hesitate. And then, we remind them that, because we see what was previously unseen, we are going to be able to mitigate or reduce the risk to you and the baby. This is not a judgment about what you have failed to do, but it provides us with information to move forward.
And that's an important thing when you recognize that that's what’s holding back those particular patients, you want to speak it into reality. You want to say to them, "I understand what it is that you're trying to tell me or what you're not saying.” And then, you can move through that. “Yes, I'm going to be able to see it, but no judgment. We're going to use it to move us forward." And that conversation shifts from the patients who maybe didn't want it to a patient who is now posting on their own Instagram and their own TikTok, "If your doctor isn't using a CGM, you come find this doctor, and they'll use a CGM in pregnancy with you." And so, that's pretty amazing when you have a patient shift from maybe a person who is hesitant to a person who supports use for everyone who's going through the same condition that they are.
Dr Anita Swamy: And Joy, when we were talking earlier, you said something that really stuck with me about a week in gestation is a lifetime for that child. Can you comment on that because that really was impressive to me too.
Joy Ashby Cornthwaite: Yeah, so particularly, so one of the timeframes that's really very important in pregnancy is that third trimester. So, all through pregnancy, you're having rising placental hormones that prevent mom's body—
Dr Anita Swamy: The baby mafia.
Joy Ashby Cornthwaite: Yeah, baby mafia.
Dr Anita Swamy: Right, right. Got it, got it.
Joy Ashby Cornthwaite: So, baby's pregnancy mafia is keeping mom's insulin from working appropriately. And so, what every pregnant mom needs to do is to either produce more insulin, so two to three times more, or if a mom is already living with diabetes, they need to take two to three times more insulin at the end of their pregnancy. So, this third trimester, what happens then is that baby is adding weight in order to prepare for delivery, and baby is also having lung production towards the end of pregnancy. And you're also seeing insulin needs ramp up as well. So, it is very, very important to view the glucose values and edit accordingly your either medication changes or behavioral adjustments towards the end of pregnancy. And if you don't have continuous glucose monitoring, week 32 to 33, week 33 to 34 is a huge amount of developmental change that's happening for baby. And they only have 10 months in there. They only have 40 weeks.
So, if you are down to four finger sticks every day, weeks 30 to 40, that is very little data to act upon. And if you haven't adjusted insulin—if you have insulin therapy on board or any kind of medication therapy on board—in four weeks, at the end of pregnancy, you've hit clinical inertia and you—
Dr Anita Swamy: I was amazed at the numbers you were telling me, like 1 to 15, 1 to 20, all the way down to 1 to 1 for a carb ratio.
Joy Ashby Cornthwaite: One to one for carb ratio for some of our moms.
Dr Anita Swamy: So, I think that's something unique that I wasn't aware of. So, thank you.
Dr Aaron King:
I wonder also, you mentioned the importance of the third trimester. Maybe comment a little bit, do you see a lot of fatigue from moms? They're in that home stretch before delivery. They've been asked to check their glucoses maybe since the beginning, but certainly since 20 weeks or so when they're screened. I would think a lot of things going on, obviously the pregnancy may be becoming more difficult at that time. Do you see or have you seen clinically that maybe some of those finger checks fall off, and do you see a place where CGM really helps that?
Joy Ashby Cornthwaite: think anecdotally doing anything for—I mean, I've been pregnant three times—doing anything that is painful and arduous for 40 weeks straight, there's going to be a point in time where you're like, "I just want to sleep." Moms are making a whole human. That is a whole job in and of itself. And so, CGM, you're placing it at the appropriate interval, and that's going to continue to give you information. You don't have to worry about, "Well, do I feel like taking it three times or four times today, or do I need to take it eight times?" Because, remember, values are changing pretty frequently. So, sometimes you are going to have to check more than the recommended four times in the third trimester.
But moms who are wearing CGMs, what I find is that the behavioral changes and the habits that have formed throughout the beginning of pregnancy get reinforced in that third trimester. So, even if you're tired, a 10-minute walk helps to lower your glucose value. So, just seeing that, even if you're fatigued, you're like, "Okay, well, I'm going to eat my lunch now. And I'm going to walk for 10 minutes, and it doesn't hurt. It's—my doctor approves my movement. I can do this all the way up until delivery." If it's unseen and you don't feel like pricking your finger and it hurts too much, what are the chances that you're going to maintain movement and menu modifications in the third trimester?
David Doriguzzi: And the way you described it earlier as far as it being not about judgment, but in terms of, "Hey, there may be a risk that your baby's exposed too that we don't know about. But now, we can be aware of it, and we can mitigate that risk." That must change everything for your patients.
Joy Ashby Cornthwaite: It does. It does change a lot of things. One of the mental health sort of responses that my patients give me is—in the very beginning, when they're diagnosed with GDM or when they find out that they're pregnant and they're living with diabetes—is not the initial response of like, "I am pregnant. I am so excited." It is like, “What have I done?" So, patients begin to go through this sort of grieving period followed by a lot of guilt. And that's reinforced by, "I don't know how to fix this because, no matter what I've tried, my numbers—when I prick my finger one time—still say this. And I don't know what's happening in the middle." And so, there's a lot of uncertainty there between clinic visits, between finger sticks. So, you find people responding in different ways. Either they'll use up all their strips early because they're checking pre- and post-meal fasting whenever they feel differently, and then they're getting a refill-too-soon error. And then, we're having to do a prior authorization or a quantity override or something like that.
None of that is supportive to mom's mental health because now she's like, "Well, I'm trying to do more. But I can't do more because my insurance says I can't have it. And I still don't know what's going on with my baby. And I'm fearful that everything that I put in my mouth is not great." And then, there's—I mean, I could go on days and days about what it does to a person not to know what's going on. But I think the greatest fear and negative outcomes come from not knowing. And you can't be involved and engaged if you don't know.
David Doriguzzi: Now that CGM is becoming more well-known and there's greater awareness of it in the public space, do you find that many moms come in asking you about a Dexcom on their own as opposed to you having to convince them? Because, anecdotally, I've noticed that a lot of times in several of my type 1 patients, the best they ever do is while they're pregnant, because all of a sudden it's not just about them anymore. And they get way more intense and more involved. And it's very motivating when the choices that they make, the doses that they either accept or skip, suddenly affect somebody else, and the motivation goes up really high. What's been your experience in that regard?
Joy Ashby Cornthwaite: Yeah, I think moms are intrinsically motivated to protect the baby. And so, a lot of moms are coming in, and they're telling us that they saw this amazing device that lets them see their glucose values and control it. And they actually seek our clinics out because we are the clinics who regularly order CGMs for moms. They may have switched—some of them have switched providers to our clinic because they know that it's an embedded system of CGM use. I think more and more with the advent of Dexcom in the media, Dexcom online, there's now whole pregnancy handouts that show moms living in pregnancy with diabetes and using CGMs. There is a large community of moms who are supporting one another. And patients are coming in and saying, "I want my diabetes care to include CGM. Are you on board with it?"
Robin Loveday: So, numerous studies have observed an increased risk of depression in pregnant women with gestational diabetes. And we all know, of course, what anxiety and stress can do to our glucose levels, right? So, patients with gestational diabetes—we've heard you talk about that—can benefit from tools like this, allows for that greater level of control over their glucose levels. So, Joy, how can CGM offer additional support for pregnant women with gestational diabetes to help just reduce that overall psychological component of pregnancy and diabetes?
Joy Ashby Cornthwaite: So, CGM use—and particularly Dexcom for moms who already live with diabetes and take medications before pregnancy—is something that we don't oftentimes talk about. But we have pre-pregnancy counseling services as well at our clinic. And so, moms know that pre-pregnancy it's really important to begin to manage your glucose values and bring them in range so that you provide an environment that is the most welcoming and nurturing for your baby. And so, CGM use before pregnancy can set you on the right path to managing glucose during pregnancy. And then, during pregnancy, you can see the changes and respond to them accordingly. All of these things benefit mental health for moms, being able to take the power from the gatekeepers that see you very little in your life. So, we have appointments with patients. Even if it's an hour-long appointment with a diabetes educator, the remaining 23 hours is with yourself, right?
And so, I like to think about CGM as taking the power away from people who aren't you and putting it into your hands. And that's an important component of feeling confident in self and being able to move forward in self. I'm not a mental health specialist by any stretch of the imagination, but I know for myself, I feel better when I'm in the driver's seat, right? So, if someone's sitting next to me in the car and saying, "Put your foot on the brake, put your foot on the gas, put your foot on the brake," that makes no sense whatsoever. If I can see on my odometer how fast I'm going, then I can put my foot on the gas or release and put my foot on the brake. I get that control. That's why some people prefer to drive.
Robin Loveday: It's a great analogy. Thank you all so much for your time and your expertise. This has been an absolute pleasure and thank you so much for joining us.