#54 – Kevin Sayer, CEO of Dexcom: Continuous glucose monitors – impact of food, sleep, and stress on glucose, the unmatched power of CGM to drive behavioral change, and the exciting future of CGM
Kevin Sayer, CEO of Dexcom, discusses CGM benefits for diabetes and general wellness. Peter Attia shares insights on sleep, stress, and glucose, highlighting CGM's power to drive behavioral change and future advancements.
Deep Dive Analysis
15 Topic Outline
Introduction to Kevin Sayer and Dexcom's Mission
How Peter Attia and Kevin Sayer Met
Kevin Sayer's Career Path to Dexcom CEO
Mechanism of Continuous Glucose Monitor (CGM) Technology
Challenges and Opportunities in US Healthcare System
Dexcom's Partnership with Verily for Future Products
Evolution of CGM: Performance, Patient Experience, Cost
Accuracy and User Experience of Dexcom G6
Behavioral Change Driven by Real-Time CGM Feedback
Future of Type 1 Diabetes: Automated Insulin Delivery
Software Improvements for Type 2 Diabetes Management
Dexcom's Position Against Competitors and Non-Invasive Options
Cost, Prescription Requirements, and OTC Potential for CGM
Smartwatch Integration and Bluetooth Technology
Future Applications of CGM: Hospitals, Nutrition, Wellness
5 Key Concepts
Continuous Glucose Monitor (CGM)
A device that measures glucose levels in the subcutaneous tissue using a thin wire coated with special membranes. This wire generates an electrochemical signal, which an algorithm in the transmitter converts into a real-time glucose value, providing continuous insights into blood sugar trends.
Hypoglycemia Unaware
A condition where individuals with diabetes do not recognize when their blood sugar levels are dangerously low. CGM devices are critical for these patients as they provide alerts and alarms, and can even share data with caregivers to prevent severe hypoglycemic events and hospitalizations.
ICGM (Interconnected CGM)
A new regulatory category created by the FDA for continuous glucose monitoring systems. This designation sets specific accuracy standards and facilitates easier integration with other medical devices, such as insulin pumps and automated insulin delivery algorithms, by streamlining regulatory pathways for connected products.
Algorithm Engineering
The process of developing sophisticated software that converts raw electrochemical signals from a CGM sensor into accurate glucose readings. Advanced algorithms can also identify inaccurate fingerstick calibrations and are being developed to provide decision support for insulin dosing or predict future glucose trends.
Open Architecture Platform
A system design where a company provides Application Programming Interfaces (APIs) to allow other software platforms to access and utilize its data. Dexcom uses this to enable third-party applications to analyze glucose values and potentially develop better care models or integrate with nutrition apps.
7 Questions Answered
A CGM sensor uses a small wire inserted subcutaneously, coated with special membranes, to generate an electrochemical signal. This signal is then converted by an algorithm in a transmitter into a glucose value, providing continuous, real-time blood sugar readings.
The G6 features an automated, quicker insertion process, new membrane technology, and an improved algorithm, all contributing to enhanced accuracy and a more consistent, reliable performance without the need for fingerstick calibrations.
Despite making common sense, insurance coverage can be cyclical and vary by payer and region, often requiring extensive documentation or specific criteria (like documented hypoglycemic events) for approval, especially for type 2 diabetes patients or those without intensive insulin use.
Currently, CGM devices are classified as Class II medical devices by the FDA, primarily because they display real-time glucose values that can be used for insulin dosing. To be sold over-the-counter, the device would likely need to be re-categorized and potentially have its functionality or real-time feedback limited to prevent its use for diabetes treatment without medical supervision.
Preliminary studies suggest it might be possible to estimate how quickly insulin reacts and how much is produced based on the slope of glucose curves. However, this would likely require more frequent measurement intervals than current 5-minute readings and further algorithm development.
Future applications include use in hospitals (especially ICUs) to manage hyperglycemia and improve healing, obtaining a label for gestational diabetes, and integration with nutrition and wellness apps for general health optimization, potentially offering insights without direct insulin dosing recommendations.
While previous Dexcom models like the G5 could show falsely elevated glucose readings with acetaminophen use, the Dexcom G6 has been extensively studied and does not have a contraindication for acetaminophen, meaning its accuracy is not affected by the drug.
15 Actionable Insights
1. Use CGM for Behavioral Change
Utilize continuous glucose monitoring (CGM) for real-time feedback on how activities, especially food, impact your glucose levels. This immediate data can drive significant behavioral changes, helping you avoid choices that lead to undesirable glucose spikes, as demonstrated by the host’s experience with trail mix.
2. Optimize Type 1 Diabetes Management
For individuals with Type 1 diabetes, using a CGM can lead to significantly better glycemic control, with reported average A1C drops of 0.5 to 1.0 percentage points and a reduction in hypoglycemic events. This enables tighter management, moving from a ’normal’ A1C of 7.5% to 5.6% without hypos, as seen in pediatric patients.
3. Leverage CGM for Hypoglycemia Unawareness
If you experience hypoglycemia unawareness, use a CGM with alert and alarm features to be notified of low blood sugar. The system’s ‘share’ feature can also alert caregivers, potentially preventing hospitalizations that can cost $10,000 to $30,000.
4. Manage Evening Cortisol for Glucose
Pay attention to the role of evening cortisol levels on your nighttime glucose, as high cortisol can raise glucose levels even after a normal dinner. Tracking this correlation can help you understand and mitigate unexpected morning glucose elevations.
5. Identify Food-Specific Glucose Spikes
Use CGM to discover how specific foods, even seemingly healthy ones like grapes or trail mix, can cause unexpected and significant glucose spikes. This real-time information allows you to make informed dietary adjustments to avoid such reactions.
6. Understand Exercise Impact on Glucose
Observe how exercise transiently raises your blood glucose (e.g., a 30-point spike during a workout) but subsequently lowers your average glucose for the rest of the day (e.g., 10 points lower). This insight helps in understanding the overall benefits of physical activity on glycemic control.
7. Monitor Stress and Sleep for Glucose
Recognize the significant impact of stress and poor sleep on your glucose levels. High stress and crappy sleep can lead to higher glucose readings, highlighting the importance of managing these lifestyle factors for better metabolic health.
8. Calibrate G6 Daily for Accuracy
Even though the Dexcom G6 doesn’t require daily calibration, consider calibrating it once a day to potentially achieve even greater accuracy. The host notes this practice often results in readings that are within 3% of fingerstick measurements.
9. Wash Hands for Accurate Blood Glucose
Always wash your hands thoroughly before performing a fingerstick glucose test. Food residue on your hands can cause false elevations in your glucose readings, leading to inaccurate measurements.
10. Allow Children to Experience Failure
As a parent, don’t be afraid to let your children fail, as learning from failures can be as valuable, if not more so, than successes. This approach helps them develop resilience and motivation to achieve great things.
11. Improve Strategic Communication
In professional settings, ensure you are better prepared and more thoughtful in delivering your messages, especially when presenting strategic ideas to decision-makers. This increases the likelihood of your proposals being accepted and avoids ‘beating your head against the wall’ in futile efforts.
12. Recognize When to Disengage
Learn to identify situations where your efforts are not yielding results and be willing to disengage if the situation isn’t going to work out. This can prevent prolonged misery and open doors to better opportunities.
13. Build an Engaged Team
Recognize that your success is highly dependent on the people around you. Cultivate a team that is committed, works hard, and is deeply engaged in their work, as this collective dedication is crucial for achieving company goals.
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5 Key Quotes
I consider it to be one of the two most important devices that I wear, and I wear it pretty much all the time.
Peter Attia
My fingers have not felt like this for 15 years. And that's how long I've had diabetes.
Dexcom Patient (recounted by Kevin Sayer)
Trail mix will spike you as fast as anything you can eat.
Kevin Sayer
The biggest disservice that I think has been done to this field, and this is hyperbolic, I mean, there have been many disservices, it's the fact that we refer to them both as diabetes.
Peter Attia
We can't be afraid to let our kids fail. Everybody getting a ribbon and everybody getting a trophy. I once told a coach to cut my son so he would learn something.
Kevin Sayer
1 Protocols
Automated Insulin Delivery (Tandem Pump System)
Kevin Sayer- An insulin pump is worn on the body, containing an insulin cartridge and software.
- A small infusion set, usually on the abdomen, delivers insulin.
- A Dexcom sensor, placed elsewhere on the body, reads glucose signals.
- The pump's software receives sensor signals and information about delivered insulin.
- If glucose levels go too low, the pump automatically shuts off insulin delivery for a period.
- Insulin delivery is turned back on when the sensor detects an upward trend in glucose.