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How Do CGMs Work? [+CGM Accuracy and Tips for Calibration]

March 30, 2022
Written by
Team NutriSense

Continuous glucose monitors, or CGMs, are among the most important breakthrough developments in recent biomedical tech. In a nutshell: they're sensors that allow you to track glucose trends in real-time in a minimally invasive way. Compared with the more conventional blood glucose meters (BGMs), they provide a painless assessment of glucose trends. 

Using a CGM is typically as easy as putting it on the right part of your body (more on that later) and letting it track your activity and habits. But before you get started, let’s address the technology itself and discuss how to ensure that you are getting the most accurate readings possible with your new tech. 

If you want to make the most of your CGM, it's helpful to know how to use it correctly. This involves learning more about what the device is, how to calibrate it if you ever need to, and what precision and accuracy mean in regards to it. As with all technology, it’s possible to see minor discrepancies when it functions, which can feel frustrating. 

Let’s discuss why you might experience this and what you can do about it.

Understanding the CGM

A CGM is a small device you wear on your body that continuously tracks your glucose levels in real-time. If you have access to an app like the one NutriSense offers with its CGM Program, you can track daily activity to see how food, sleep, exercise, and stress impact your glucose. You scan the device on your phone to see real-time glucose changes in response to various factors. It shows you how your body responds to these different factors, which can help you optimize your health.

The FDA allows CGM devices and finger-prick devices to have some variation from what you would receive from a blood test at a physician’s office. So, remember, readings from both types of devices can fluctuate! The only way to ensure a perfectly accurate reading is by getting a blood glucose test from a lab. 

The most important thing to consider when using a CGM is the relative change in data and the pattern of trends over time, instead of the absolute values or exact numbers. There may be variabilities in absolute value, but CGMs read relative changes in your blood glucose very accurately.  

Think of It Like This

 CGM readings are like videos. With the continuous readings, you can get a good overview of how your glucose levels change over time and in reaction to different foods, activities, sleeping trends, etc. We can view trends as opposed to focusing on one specific value.

Finger-prick tests are like a photo of your glucose—they capture a single moment. So, those readings will be based on your choices shortly before pricking your finger.

BGMs versus CGMs: What’s the Difference?

Although BGMs and CGMs are both designed to measure the glucose level in the body, they are not the same. Let's take a look at some of the key differences. 

The Blood Glucose Monitor (BGM)

First of all, BGMs measure the glucose concentration in the blood, which means that it requires finger pricks, leading to local pain and discomfort. BGMs can also only deliver one measurement at a time, making it challenging to identify glucose trends. However, when it comes to absolute values, BGMs are more precise than CGMs.

The Continuous Glucose Monitor (CGM)

The main advantage of CGMs is the ability to measure glucose levels continuously, allowing you to monitor your glucose trends easily. Glucose trend information gives you the power to track the behavior of glucose concentration in real-time. Also, CGMs don’t require finger pricking, which significantly improves the user experience.

How to Choose Between Them

CGMs are great to measure glucose evolution over the day, offering real-time monitoring in a minimally invasive way. However, when compared with BGMs, CGMs present a lower accuracy with a higher response delay. 

It's because sensors measure glucose concentration in the interstitial fluid (ISF), and glucose can take a while to diffuse from the blood to this fluid. So, you can use BGMs when accurate glucose measurements are required, while CGMs work best with glucose trend monitoring. 

Both measurements are important for health tracking: you can use accurate measurements for diagnostics and device calibration, while glucose trend monitoring can detect sudden spikes in glucose, correlate patient behavior with glucose levels, and help with nutritional decision-making. 

Also, it is possible to obtain different measurements from a BGM and a CGM simultaneously, as blood responds faster to glucose variation than the interstitial fluid. A good practice is to measure glucose behavior using a CGM device and then use a BGM sensor to double-check any abnormal readings.

There Are Different Types of CGMs

The three most common manufacturers of CGMs are Abbott, Dexcom, and Eversense. At NutriSense, we use the Abbott Freestyle Libre CGM. The FDA has approved the use of the Freestyle without backup readings from a finger stick device, as it is factory calibrated. 

That said, we also allow our members extra quality assurance when calibrating the sensor manually instead of relying solely on factory calibration.

Now that you know more about the CGM, let's focus on calibration. Both CGMs and BGMs measure the glucose level using electrochemical sensors. 

Remember that these sensors have a limited lifespan, so most will have an expiration date. You have to replace the sensor after its expiry date due to a drop in accuracy and precision (the Abbott Libre Freestyle, for instance, has an expiration date of four months). 

The second thing to note is that readings can vary because of temperature, body location, manufacturing variations, and other external factors. CGM calibration can help correct these errors by relating the raw readings with actual glucose measurements taken from more reliable techniques. The two main reference methods for calibration are:

1) Using a Lab Value

Laboratory glucose tests use venous blood to measure the glucose level. Venous blood assessment can provide more accurate results due to the higher quality of the sample, with a larger quantity of blood, intact cells, and biomarkers. So, laboratory tests are the gold standard for glucose evaluation. 

Here's more about the procedure for lab test calibration:

  • Book a lab test with your doctor to test your fasting glucose level.
  • Compare your lab value to your fasting (no food for around eight or more hours) glucose reading in the NutriSense app. You can do this by scanning your CGM after waking up and before eating, drinking, or exercising.
  • If you notice a discrepancy in your CGM reading of around five points or more from the reference lab value, you should try to adjust it. In the NutriSense app, you can go to settings>sensor>manual calibration and adjust it accordingly, refreshing the app to see the changes reflected.

2) Using a Glucose Meter (Finger-Prick)

You can also use a finger-prick glucometer to calibrate your CGM. Although less accurate than laboratory tests, finger-prick or fingerstick tests are much more convenient and easier to perform, using just a drop of capillary blood from your finger. 

To calibrate your CGM using finger-prick devices, follow these steps:

  • Take a fasting (no food for eight or more hours) fingerstick test an hour after waking up before food, coffee, or exercise. Ensure your glucose strips have not expired and that your fingers are clean.
  • Compare your reading on the CGM at roughly the same time. Note that there is a 15-45 minute lag between blood glucose and interstitial glucose measurement (which is what your CGM measures). 
  • During non-fasted times, we need to account for this lag more specifically, but on a fasting comparison, it may not be as necessary. It’s one reason we recommend only making adjustments to the graph in comparison to fasting glucose values when your glucose is most stable.
  • If you notice a discrepancy in your CGM reading of around five points or more from the reference lab value, you should try to adjust it. In the NutriSense app, you can go to settings>sensor>manual calibration and adjust it accordingly, refreshing the app to see the changes reflected.

*Remember to wait for 12-24 hours before you decide to calibrate, as your CGM will be using that first day you are wearing it as “warm-up” time. 

One thing to consider is the delay between blood glucose readings from a finger stick and the interstitial glucose readings that the CGM reads, as explained in the BGM versus CGM section. 

One way to look at it is by using an analogy of a train. Your glucose levels are the train, where the front of the train is the blood glucose reading, which is instantaneous and taken at that moment. At the end of the train is the interstitial readings. 

If the train is going up a hill, then the front of the train passes this spot before the caboose, but the caboose still passes by the same spot. So: the two tests take the same reading but with a 15 to 45-minute delay. 

What are the FDA Requirements for Commercial CGMs?

A visual representation of the FDA requirements for commercial CGMs

At first, the FDA classified CGMs as class III devices, so they were required to pass through a full pre-market approval (PMA) process before release. These included clinical trials and thorough studies about sensitivity, accuracy, and precision. After 2018, however, the FDA defined integrated CGMs (iCGMs) as class II devices, which are cleared from the PMA process and can be approved through the 510(k) submission.

The overall iCGM accuracy required by the FDA demands that at least 85 percent of the glucose measurements must have errors lower than 20 percent. What this means is that it’s not unusual to find weird deviations in your CGM device since errors going up to 20 percent in the absolute value can be expected.

The BGM regulation, on the other hand, states that more than 95 percent of the measurements must present errors lower than 15 percent, which is significantly lower than the CGM error. It means that we can expect more precision and accuracy from BGMs when compared to CGMs. 

However, iCGM devices must comply with trend accuracy, which defines how well the device follows a change in the glucose level. This requirement states a maximum error allowed for the rate of glucose change in time. In other words, if your glucose level rises, the CGM measurement value must increase similarly. This change of rate is often more important than absolute values in CGMs since the goal here is to obtain a picture of the evolution of glucose over time.

What CGM Should I Use?

A woman reading a book outside wearing a CGM

There are currently three major CGM manufacturers: Abbott, Dexcom, and Eversense. They are very similar in terms of the functioning principle. Still, they present some key differences in terms of placement and accuracy. 

The table below compares the wear time, body site, and MARD of a few different devices. MARD stands for Mean Absolute Relative Difference, a metric of statistical dispersion of the CGM measurement and the actual body glucose level. So, if the MARD is large, the statistical dispersion is also large, and, consequently, the accuracy is low. 

Description of wear time, body site and MARD for three CGM types: Abbott, Dexcom and Sensonics

We can see that the accuracies are similar for the three CGMs, so the advantages come from the device specifications. For instance, the Abbott FreeStyle Libre Pro presents the lowest price per sensor. In contrast, the Eversense has the longest wear time. However, the Eversense CGM requires surgical insertion and removal, significantly more invasive than its counterparts. 

Between the minimally invasive CGMs, the Abbott FreeStyle shows a longer wear time than the Dexcom. The Dexcom CGM has the advantage of abdomen installation, which is interesting since it gives users the option of a more discreet application. 

Another note is that these studies compared the CGMs with the Dexcom G5. The most recent market version of the Dexcom is the G6 version, which provides factory calibration, a 10-day wear period, and an overall MARD of nine percent [2].

Location Matters

A woman applying her CGM

The application site of the CGM sensor varies by manufacturer. Still, they are usually restricted to the upper arm and the abdomen. It's because the biochemical structure of the body, such as the fat and muscle percentage and water content, changes with the location, including the interstitial tissue used to detect glucose. For instance, a CGM placed on your foot will give different readings from a CGM on your upper arm. 

Since the manufacturer expects the CGM to be on the recommended location, especially in factory-calibrated devices, improper placement can cause issues. Different sites on the same person can give different absolute readings. Studies have even found variations between the left and right arms. 

Since most commercial CGM devices are FDA-approved only for specific locations, following the manufacturer’s instructions for the application site is crucial to get the best performance from your CGM.

There May Be Other Reasons You’re Getting an Abnormal Reading

You may notice a spike in your CGM reading that seems out of place and may appear to be an error on the technology’s part. There are a few reasons this could be happening—and it’s not because your CGM is broken or unreliable!

  1. Your CGM is inserted into a muscle. People who are very lean with little body fat often have to manually calibrate the sensor to a greater degree than others. The probe in the sensor needs to be completely bathed in interstitial fluid. While this may affect the absolute calibration, it will not affect the relative changes in glucose levels over time.
  2. You take high doses of vitamin C. High doses of vitamin C can cause a “false spike” in your data. Vitamin C affects your interstitial fluid and not your blood glucose levels in this case. If you think you may be able to decrease your dose of Vitamin C, speak with your doctor.
  3. You take certain medications. Drugs like Tylenol/acetaminophen can also cause a false spike. It’s due to the acetaminophen’s interaction with the electrodes in your CGM. Remember that if you take higher doses of this medication, you may see higher spikes from two to eight hours after ingestion.

If you aren’t sure what might have caused a given glucose response, reach out to a specialist. The Nutrition Specialists (registered dietitians or nutritionists) at NutriSense are trained to help you troubleshoot these situations.

Learn More About CGMs and How to Optimize Your Health with NutriSense

NutriSense utilizes CGM technology to identify individual glucose trends over time. Our mission is to help you determine what choices affect your blood glucose levels and how. This information gives you (and our registered dietitians) information to help guide decisions about achieving your unique health goals. While the CGM technology NutriSense utilizes is approved by the FDA, our app is not. Because of this, the app is not meant to provide targeted medical treatment but to educate you to make better decisions in your daily life.

CGMs can be valuable tools for those who want to optimize their health and focus on glucose control, those with diabetes, those who want to reach weight loss goals, and anyone who wants to learn more about their body’s needs. 

To get the most out of your CGM, it’s a good idea to work closely with your assigned dietitian or nutritionist to get to know the technology and learn how to calibrate it properly. We encourage you to ask questions and keep an open channel of communication.

Our team is here to help you every step of the way! 

References

[1] Jafri, Rabab Z., et al. "A three-way accuracy comparison of the Dexcom G5, Abbott Freestyle Libre Pro, and Senseonics Eversense CGM devices in an outpatient study of subjects with type 1 diabetes." Diabetes 67.Supplement_1 (2018).

[2] Dexcom. “Discover Dexcom Continuous Glucose Monitoring (CGM) Technology” https://provider.dexcom.com/dexcom-cgm

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How Do CGMs Work? [+CGM Accuracy and Tips for Calibration]
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Can You Donate Blood if You Have an Autoimmune Disease?
Can You Donate Blood if You Have an Autoimmune Disease?

Donating blood can save a life, and these donations are needed more often than you may think. Read on to learn how autoimmune conditions affect your eligibility to donate.

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8
min
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Postpartum Nutrition: A Guide to Healthy Eating After Giving Birth
Postpartum Nutrition: A Guide to Healthy Eating After Giving Birth

As a new mom, you may be eager to regain your pre-pregnancy body, but it's essential to take things slow and follow postpartum diet guidelines. Read on to discover dietitian recommended postpartum guidelines to losing weight.

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13
min
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9 Natural Supplements to Lower Your Blood Sugar
9 Natural Supplements to Lower Your Blood Sugar

Alongside a healthy diet, adding certain nutrients can help with achieving optimal blood glucose levels. Here are nine supplements that help your body do just that!

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12
min
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14 Common Health Myths Debunked by Dietitians
14 Common Health Myths Debunked by Dietitians

We asked our Nutrition Team to help us debunk 14 popular nutrition and lifestyle myths. Here's what our dietitians—and the research—say about these age-old myths. 

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8
min
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Is Oatmeal Really That Healthy?
Is Oatmeal Really That Healthy?

You may have always considered oatmeal to be a healthy breakfast option, but is it really that good for you? Let’s break down the different components of oatmeal and find out.

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14
min
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Summer Soup Recipes: An Expert Weighs in on 13 Healthy Soup Options
Summer Soup Recipes: An Expert Weighs in on 13 Healthy Soup Options

To help you make the most of the warmer weather, we asked Carlee Hayes, RDN, CD, and Nutrition Manager here at NutriSense, to share a few of her favorite summer soup recipes.

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9
min
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9 Ways to Improve Insulin Sensitivity
9 Ways to Improve Insulin Sensitivity

Insulin resistance can create a variety of health issues and lead to type 2 diabetes. Here are nine effective ways to improve insulin sensitivity for improved metabolic health.

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8
min
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Improve Gut Health to Improve Brain Function
Improve Gut Health to Improve Brain Function

Did you know your gut influences how well your brain functions? Here are our top dietitian approved tips to boost gut health for improved cognitive functioning.

Podcast
42
min
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A Simple & Effective Tool To Help Balance Your Hormones Stat
A Simple & Effective Tool To Help Balance Your Hormones Stat

Catherine Staffieri discusses the impact of glucose on hormones, perimenopause and menopause, weight loss and the incredible benefits of using a CGM as a tool to help you feel your best.

Podcast
43
min
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The Benefits of Using CGMs in Your Health Coach Practice
The Benefits of Using CGMs in Your Health Coach Practice

To discuss how a health coach can incorporate this in their practice, Health Coach Academy invited Carlee Hayes to the show.

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12
min
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20 Mental Health and Wellness Podcasts Recommended by Dietitians
20 Mental Health and Wellness Podcasts Recommended by Dietitians

This week, we’ve compiled some of our favorite podcasts that go beyond nutrition. Here are 20 wellness-focused podcasts to add to your queue.

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12
min
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Are BCAAs Worth It? The Bottom Line on Branched-Chain Amino Acids
Are BCAAs Worth It? The Bottom Line on Branched-Chain Amino Acids

Are BCAAs worth it? This post digs into 30+ years of research to answer this question. The answer may surprise you.

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8
min
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Science Backed Tips for Menopause-Related Weight Gain
Science Backed Tips for Menopause-Related Weight Gain

Menopause can be a difficult journey, so we've compiled some of the most effective, science backed tips to help you with menopause-related weight gain.

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8
min
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Help Dad Stay Healthy this Father's Day
Help Dad Stay Healthy this Father's Day

Father’s Day is around the corner, and whether you’re celebrating your dad, a father figure, or another cherished loved one, helping them take care of their health can be the ultimate gift.

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10
min
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11 Great Low-Carb Snacks to Add to Your Diet [+ 5 Recipes our Dietitians Love]
11 Great Low-Carb Snacks to Add to Your Diet [+ 5 Recipes our Dietitians Love]

Here's a helpful list of some of our favorite low-carb snacks that can help you keep your diet varied and full of healthy nutrients.

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7
min
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Low Glycemic Index Recipe Ideas Everyone Will Enjoy
Low Glycemic Index Recipe Ideas Everyone Will Enjoy

Whether you're looking for low GI summer snacks or healthy sweet treats, this post has got you covered. Here are tasty low glycemic index recipes everyone will enjoy!

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8
min
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Do Grapes Raise Blood Sugar Levels?
Do Grapes Raise Blood Sugar Levels?

Wondering if grapes are safe for people with diabetes to include in their diet? Read on to find out.

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7
min
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The Relationship Between Cholesterol and Blood Sugar
The Relationship Between Cholesterol and Blood Sugar

Cholesterol plays a very important role in the human body, contributing to the structure of the cells, helping with vitamin D synthesis, and also promoting the production of steroid and sex hormones, like cortisol, aldosterone, testosterone, and estrogen. But how exactly is cholesterol connected to blood glucose levels?

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11
min
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20 Questions to Ask Your CGM Provider (with Kara Collier)
20 Questions to Ask Your CGM Provider (with Kara Collier)

We sat down with Kara Collier, our co-founder and VP of Health here at NutriSense, to take a closer look at how CGMs work and what you need to know about these devices before using one.

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7
min
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Are Carbs and Sugar the Same? 
Are Carbs and Sugar the Same? 

Are carbs and sugar the same? In this post, we break down the key differences between the two and share the benefits of complex carbohydrates.

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9
min
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Best Recovery Breakfasts to Beat Post-Workout DOMS
Best Recovery Breakfasts to Beat Post-Workout DOMS

Read on to learn more about DOMS, how long it can last, and then pick from our list of the best breakfasts to help beat that post-workout soreness, support muscle building, and encourage fat loss.

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13
min
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7 Plant-Derived Supplements to Help Lower Blood Sugar
7 Plant-Derived Supplements to Help Lower Blood Sugar

When it comes to lowering blood sugar levels, not all supplements are created equal. From ginseng to aloe vera, here are some of the best supplements to help avoid high blood sugar and encourage blood sugar control.

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8
min
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Is Bloating After Surgery Normal?
Is Bloating After Surgery Normal?

Bloating that results from a surgery can sometimes be an unexpected part of the recovery process. Is there anything you can do to reduce bloating or prevent it from happening? And what causes this bloating anyway? Read on to find the answer to these questions and much more to help you combat your post-surgery swelling. 

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9
min
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Is Fiber a Carb? 
Is Fiber a Carb? 

Learn why fiber is classified as a carb and how to increase your intake of this health promoting nutrient.

Story
9
min
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Living with Autoimmune Conditions: Parkinson’s Disease 
Living with Autoimmune Conditions: Parkinson’s Disease 

Did you know Parkinson’s disease is the second most common neurodegenerative disease? Read on to learn what it's like living with PD plus discover treatment options.

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10
min
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An Expert Breaks Down 11 Viral Health Trends
An Expert Breaks Down 11 Viral Health Trends

From rosemary water to dry scooping, should you be trying every new trend that hits TikTok? How can you tell which ones may help and which ones to steer clear of?

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8
min
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Does Eating Too Much Sugar Affect Your Skin?
Does Eating Too Much Sugar Affect Your Skin?

As great as sugar tastes, including too much of it in your diet can lead to certain health problems. Read on to learn more about the role sugar plays in keeping your skin healthy.

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9
min
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14 Health and Nutrition Podcasts Recommended by Dietitians
14 Health and Nutrition Podcasts Recommended by Dietitians

Read on to see which podcasts our dietitians recommend if you’re interested in learning more about nutrition and health.

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7
min
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Does Nicotine Affect Blood Glucose?
Does Nicotine Affect Blood Glucose?

Nicotine is a chemical in tobacco that can affect your health in various ways. Read our article to learn how it impacts blood sugar levels and insulin sensitivity.

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9
min
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Why Everyone, Including Healthy People Should Use CGMs
Why Everyone, Including Healthy People Should Use CGMs

CGMs are now an excellent tool for anyone who wants to optimize their metabolic health. Read on to find out more about the benefits CGMs can have for healthy people!

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10
min
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Why Do People Need to Lose Weight Before Bariatric Surgery?
Why Do People Need to Lose Weight Before Bariatric Surgery?

Although bariatric surgery can be an effective way to lose weight and improve health for people who are obese, it’s a major decision. Find out what lifestyle changes you need to make before going under the knife.

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8
min
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NutriSense Dietitians Recommend: Favorite Grilling Recipes
NutriSense Dietitians Recommend: Favorite Grilling Recipes

Excited to fire up the grill this summer? Read on to learn if grilling is healthy for you plus check out the NutriSense Nutrition Team's favorite grilling recipes for the season.

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9
min
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How a Healthy Gut Improves Blood Sugar
How a Healthy Gut Improves Blood Sugar

Did you know that your gut health can impact your blood glucose levels? Explore ways to improve your gut health for optimal glucose levels.

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8
min
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Living With Autoimmune Conditions: Rheumatoid Arthritis
Living With Autoimmune Conditions: Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory autoimmune disease that can cause swelling and joint pain. Learn more about how it develops and how other health conditions affect its onset.

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10
min
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13 Best Weight Loss Apps to Consider
13 Best Weight Loss Apps to Consider

We’ve hand-picked the best weight loss apps available. Here are the thirteen best weight loss apps.

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8
min
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What is Red Light Therapy?
What is Red Light Therapy?

An emerging treatment, red light therapy promises to prevent and treat the signs of aging and other skin issues. Read on to find out more.

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9
min
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Diets People are Most Likely to Give Up On [+Tips to Stick with Them]
Diets People are Most Likely to Give Up On [+Tips to Stick with Them]

Struggling to stick with a health-promoting diet? Here’s how to make it enjoyable so you can reap the benefits.

Podcast
85
min
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Kara Collier on Optimal Health Through Blood Sugar Regulation
Kara Collier on Optimal Health Through Blood Sugar Regulation

VP of Health and co-founder of NutriSense Kara Collier discusses reaching optimal health through blood sugar regulation, what a continuous glucose monitor is, and who might benefit from using it.

Podcast
16
min
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How to Turn Your Idea into a 120 Person Team with Dan Zavorotny
How to Turn Your Idea into a 120 Person Team with Dan Zavorotny

In this episode of Zero to CEO, Jason Sherman talks to Dan Zavorotny about how to turn your idea into a 120 person team in 2.5 years.

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7
min
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A Breakdown of Body Mass Index (BMI)
A Breakdown of Body Mass Index (BMI)

Body mass index is a term you may have seen tossed around quite a bit in the health world. You may know that it’s a way to measure body fat, but with so many new tests for measuring overall fitness and health, is BMI still reliable?

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8
min
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Glucose-Friendly Recipes to Enjoy This Memorial Day
Glucose-Friendly Recipes to Enjoy This Memorial Day

If you're watching your glucose levels, traditional BBQ staples may not be the best choice. Here are some recipes that will help you enjoy a Memorial Day meal without a blood sugar spike.

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8
min
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Taking Mental Health Online: Tips & Tools for Self-Care
Taking Mental Health Online: Tips & Tools for Self-Care

Mental health has a significant impact on your overall health; here are tips, tools, and apps to improve your mental wellbeing.

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8
min
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Can You Check Your Blood Sugar at Home Without a Meter
Can You Check Your Blood Sugar at Home Without a Meter

Living with diabetes can be a challenge, especially when it comes to keeping your blood sugar levels regulated. Learn if you can check your blood sugar at home without a meter.

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10
min
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NutriSense Dietitians Recommend: Best Sunscreen for all Skin Types
NutriSense Dietitians Recommend: Best Sunscreen for all Skin Types

With summer right around the corner, it’s time to make sure you have the tools you need to protect yourself from sunburn and sun damage. But how do you choose the right one for adequate sun protection?

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8
min
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Japanese Water Therapy & Weight Loss: What’s the Deal? 
Japanese Water Therapy & Weight Loss: What’s the Deal? 

Learn how Japanese water therapy can help with weight loss, energy levels, and detoxification.