A top endocrinologist reflects on what he got wrong about the future of diabetes care

This edition of Second Opinion is brought to you by our sponsor StrideMD, which specializes in integrating remote patient monitoring, telehealth, and in-person care. Licensed in 50 states with a team of over 100 telehealth physicians and an endocrine practice within Florida, it has served over 75,000 patients nationwide.

Predictions are fun to read, but one of the big problems with them is that we too rarely reflect on whether they come true. So when Dr. Aaron Neinstein, a San Francisco-based endocrinologist, texted me about his own bold prediction from 2019, I was eager to take a trip down memory lane.

In that piece for CNBC, which I personally helped edit, he mused that blood sugar tracking via continuous glucose monitors would be ubiquitous amongst people with diabetes within the next 5 years.

In his own words:

So was he right? Well, I’d say yes and no.

There is certainly more use of CGMs than there were in 2019. The American Diabetes Association recommends this form of monitoring for anyone with Type 1 or Type 2 diabetes who takes insulin. Neinstein, who also now works at a technology company called Notable, said that there is better coverage for it across commercial payers and Medicare. Medicaid, he said, is spotty. “In some places, we see as high as 40% penetration amongst people with diabetes; in others it’s more like 10% and it’s state by state, driven by factors like insurance,” he said.

Neinstein doesn’t think that in 2024, people should still be relying on finger sticks to track their blood sugar levels. And yet, that’s still the case across much of America. “It’s the story of health care,” he said. “The future is here; it’s just not evenly distributed.”

How About For The Healthy?

What did he get right? Well, the use of CGMs for people who do not have diabetes. What has emerged since 2019 is the rise of companies like Levels Health, backed by venture firms like a16z, that offer blood sugar tracking via minimally invasive CGMs.

To their credit, the makers of CGMs, including Abbott and Dexcom, have created devices that are so barely noticeable and easy to set up that people without diabetes saw an opportunity to use them for insights into their health. This trend has been going on for a while amongst bio-hackers in the technology community but has continued to grow.

For a period of time, I was one of those people. I recall back in 2020 finding a FreeStyle Libre on eBay and using it for a few months. I’ll be honest with you all that the results were not particularly surprising, and backed up what I already suspected about my health. Alcohol tended to spike my blood sugar levels and disturb my sleep. Exercise had a positive impact. Plenty of the obvious foods and beverages — sugary coffees, white rice, certain sweet breakfast cereals - were also triggers. I recall giving Dr. Neinstein a ring at the time and walking him through my numbers, and he gave me some thoughts about how to integrate the data and use it to make better lifestyle decisions. I incorporated a few of them, but I still enjoy a glass of wine from time to time.

There were a few surprises though, namely in the form of how many prepared foods are actually filled with added sugar (pasta sauces, yogurts, healthy-looking granola bars - TLDR you cannot trust packaging)!

To that end, why are people without diabetes tracking their blood sugar - and will that result in new innovations? One pursuit amongst research labs and companies for decades now has been a kind of tracking that’s “non-invasive and continuous,” meaning no needles. It’s possible we will never achieve that kind of breakthrough, or even if we need something like that given today’s CGM’s are so easy to use and painless.

Neinstein says some of the momentum has also slowed down - at one point, companies like Samsung, Apple and Alphabet were all reportedly chasing this goal. Alphabet, for instance, was working for a number of years on a contact lens to track people’s blood sugar levels before halting the project.

Neinstein doesn’t have a super positive perspective on healthy people tracking their blood sugar. In his view, this isn’t “the right population” that should be benefiting from these devices. “I have yet to see evidence that it benefits people who are metabolically healthy,” he said. For people who are not metabolically healthy - even those who do not take insulin, but do have pre-diabetes or diabetes - he thinks there is some benefit though in the form of biofeedback to learn and improve habits. 

The Rise of GLP-1s

What Neinstein truly could not have anticipated is quite how rapidly GLP-1 medications exploded into the market, and the impact these drugs have had on metabolic health. “We are seeing more and more evidence come with stronger and stronger benefits, and larger effect sizes,” he said.

In the past few years, this category of medicines has rapidly expanded beyond weight loss and blood sugar reduction to cardiovascular and kidney disease risk reduction. Because these drugs have substantial benefits for swathes of the population, there’s going to be some vying for coverage in his opinion between the CGMs and the weight loss drugs. He has a sense of where that will end up. “You’ll probably see your Ozempic covered before your CGM if you’re on Medicaid,” he suggests.

Where he does see opportunities is in programs that provide a combination of the weight loss medications and the CGM devices for those who qualify. That could build a “positive feedback cycle,” he said, where people have access to a whole new toolkit that builds their confidence. In his experience, actually seeing the data trend in a positive direction can be a major psychological boost for patients.

Of course, I had to ask him for his next prediction:

“GLP-1s will continue to dominate the story,” he said. “The newest ones are achieving up to 30% weight loss, so it’s also a story that’s still being written.”

Another hot take? “Blood sugar was often a distraction in the larger metabolic obesity crisis,” he said. Lowering blood sugar is important, but reducing macrovascular disease was too often an afterthought.” Neinstein said the GLP-1 drugs for people with obesity and metabolic disease are reducing the risk of heart attacks and strokes, while lowering blood sugar in the process.

My last question to Neinstein was about his new company, Notable, which sits at the intersection of AI and health care operations. How can he connect his work as an endocrinologist, where he treats patients with chronic conditions, with a company focused on the work that happens behind closed doors (the stuff that patients typically don’t see).

He responded without hesitation:

“In my opinion the two biggest problems in our system right now are obesity, and health care’s massive administrative burden,” he said. “I’m fortunate to get to work on both.”

A few additional thoughts from an endocrinologist on the front lines

Dr. Disha Narang is one of the most thoughtful endocrinologists I know so I asked her if she had any additional thoughts on the big CGM question. Her take? These devices have been “highly invaluable in the world of diabetes,” she said, with more people now being aware of how certain foods and behaviors are impacting their blood sugars. 

But they can be variable. 

In her words:

“For patients who have a much lower Hemoglobin A1C, for example in the pre-diabetes range (<6.5%), blood sugar averages are usually <120. At lower blood sugar averages, we tend to see greater false low blood sugars in our current CGM's. This may happen overnight or during a period of increased activity. The CGM alerts the user, so being woken up in the middle of the night to a blood sugar of 60 is often alarming, and quite disconcerting to users. This often leads to more panicked phone calls and messages to the doctor's office, which as we know, are often understaffed these days. Add this to a culture that highly publicizes low-carb or keto diets, patients may show increased anxiety over any blood sugars that go above what their expected range may be. I often see patients become terrified to see any blood sugar excursions, thinking they must maintain as flat a line as possible on their CGM trends. This leads to a lot of anxious conversations, and in some cases, recommendations to stop CGM use, because it becomes anxiety-provoking for certain patients.”

I found that fascinating so thought I’d include her thoughts here. As I’ve been reminded countless times by physician friends over the years, more data without context isn’t necessarily a good thing. 

Some exciting news!!

I have two major updates for you this week!

• The first is that I have a new job at Manatt, an integrated legal and consulting firm. I’ll be working mostly on the health tech side of the house, focusing my advisory practice on emerging companies in digital health. Manatt also has an internal venture fund, and I’ll be advising on that. My new Manatt email is [email protected] if you’d like to catch up on any of the above. I’ll be joining the firm alongside some very familiar faces, including Tom Cassels, Melindah Sharma and Shami Feinglass (Endpoints has the scoop on the new folks!). Manatt has a lot of smart health care minds on the team, and I’m cleared to add some of their voices as featured experts on regulatory, policy, business strategy and more.

• I’ll continue to write my Second Opinion column as per usual, because this work could not be more important to me. It is my overriding belief that a key lever to transform health care is through communications.

• Secondly, Second Opinion is getting a long awaited NEW PODCAST!!! HECK YES!!! In partnership with our friends at Turpentine Media. I’ll be interviewing some of the featured experts in these posts in more depth, and we’ve got an incredible line up to come. My guest hosts are Luba Greenwood and Dr. Ash Zenooz, who I’ve known now for close to a decade. Luba brings a biotech/life sciences perspective to the group, while Ash is an industry operator and physician. Our upcoming topics include biosecurity, the latest in telemedicine, whether AI is overhyped and more.

• Here’s a sneak peak of our first episode, featuring guests like Parsley Health’s Robin Berzin, Cherish Health’s Sumit Nagpal, and top private equity investor/nurse Meghan Fitzgerald. Follow Second Opinion on Spotify, YouTube, Apple or whatever you get your podcasts.

Lastly, a reflection on my own mortality…

You may recall that I invited a group of eight doctors to duke it out on the topic of whole body MRI a few months back, asking them the question of whether it’s advisable for patients or not.

For those not familiar, these scans can look for an array of medical issues including cancer and brain aneurysms. But they can also uncover some potential false positive results, where patients will opt for additional tests they don’t need. That has doctors feeling highly conflicted about whether they’d recommend them or not.

After publishing the piece, I heard from the CEO of Ezra Emi Gal. He suggested I try it for myself, and not just write about it in a purely theoretical way, and sent me a code. So I went ahead and booked my appointment at the nearest facility in Queens, NY and filled out the paperwork required to get started.

Here’s how it went…

On the day itself, I marked off a few hours on my schedule and took a 20-minute Uber over to the facility. After signing in at the front desk, I changed into my Ezra cotton pajamas and stashed away my belongings.

What followed was a series of two scans, one short and one long. The long one was honestly tough for me because I do get somewhat claustrophobic. Word to the wise: If you do not like the idea of being confined in small spaces then I’d suggest getting mentally prepared ahead of time. I found that the blanket, the music and the ear plugs helped me to zone out, but the entire time I still found myself fixating on the idea of an itch on my head or my nose I couldn’t reach.

Those who get really anxious can and should talk to their doctor about it beforehand, and it may be possible to request to take breaks. It does take close to an hour, which is actually quite a long time to be with your thoughts. It’s not particularly peaceful or meditative though, because the machine is loud, so it would take a true zen master to get into a truly mindful place.

After I was wrapped up, I grabbed a car ride home and promptly received a note from Ezra to expect the results within a week or two. I didn’t feel particularly nervous about the wait, because I wasn’t expecting the scan to find much given that I’m generally healthy (as far as I know) and in my mid-thirties. 

The results

The report arrived on time and I opened them up as soon as it hit my Inbox. 

So what did I learn?

Well, probably the most actionable part of it is that my hormonal IUD is apparently in the wrong place. So I immediately scheduled a visit with my gynecologist, particularly as I had reason to believe that this finding is accurate. I won’t go into the details but I had suspected that it was out of place for a while.

Secondly, I learned about a thyroid nodule to keep an eye on. I reached out to an endocrinologist friend, however, who advised me it’s likely not anything to worry about. 

Then I read on about a few things I already suspected or knew about. I was not surprised to read about the minor scoliosis, because my anesthesiologist pointed that out while I was getting my two c-sections. But there were a few other interesting details, so I called up two of the surgeons in my network – Dr. Rohan Ramakrishna and Dr. Jonathan Slotkin - to ask about some of the other results. 

Both weren’t particularly concerned, but did ask me about whether I had experienced discomfort in my back or more generally. I have certainly had some aches and pains, so they recommended regular exercise - particularly in the form of strength training. Both couldn’t stress this enough, particularly for women. Weight lifting yields a number of benefits includes everything from better sleep to improved posture. Women are prone to avoiding it, thinking it’ll make them too buff (this is typically more myth than reality).

Another interesting finding: I did have some scarring in the lungs due to a post-viral infection. My theory is that this is related to being one of the first people to get Covid, as I was had a horrible, persistent cough and fever in the weeks following that highly suspicious J.P. Morgan conference in early 2020. Of course, I can’t know that for sure as no test existed at the time.

There wasn’t much else worth reporting on beyond that. 

Bottom line?

What I liked about the report was how it was organized into findings that felt most important to relay, and a series of recommendations about what the best next steps should be. Nothing in my case felt urgent, outside of the IUD, so Ezra recommended in most cases that I speak with my primary care doctor at my next visit.

In my case, I was fortunate enough to have a few physicians in my life I could send the report to for an additional assessment. 

While I wouldn’t say the results were earth shattering or life changing, it did prompt me to reflect a bit on my longevity. Dr. Ramakrishna, the practicing brain surgeon and digital health entrepreneur that I spoke to, reminded me that there’s value in feeling motivated to do more from a wellness/lifestyle perspective.

Would I repeat the scan? Probably. It’s unlikely I would do it again anytime soon, but I would certainly consider it in about five years time as an investment in my long-term health.

Were there any downsides? I can understand the concern that many physicians have about false positives. There’s true liability associated with informing a patient that a result is “probably not a big deal.” Fortunately I have people in my life who will do that, knowing it’s friendly advice versus what they’d tell me if I was sitting in the office across from them. 

So that’s my caveat: It can be hard to both give people access to their own health information, and prevent them from jumping to their own conclusions. If you’re taking a test like Ezra, consider beforehand who you might call upon for the medical “real talk” version of the report readout.

Needless to say, if you’re concerned about something and Ezra flags it or you have questions about Whole Body MRI, talk to your doctor. 

That’s a lot for this week’s edition, folks! New podcast, new job and lots more to come. Stay tuned.