Adoption of Diabetes Technology in Denmark: Continuous Glucose Monitor as Time-Machine

ABSTRACT

Health technologies to monitor glucose values are an important part of daily diabetes self-care. Based on 12 months of fieldwork in Denmark with 14 people with type 2 diabetes, I explore people’s experience of living with Continuous Glucose Monitoring. This new technology automatically measures glucose levels throughout the day but is not yet common in type 2 diabetes treatment in Denmark. In this article, I capture the social shaping of Continuous Glucose Monitoring, employing the concept of time. I show how adoption of the technology is embedded in a form of biographical time. This refers to people’s use of the technology linked to their stories about themselves. Drawing on a notion of habitus, people’s embodied past experiences and future prospects come to shape its use, I propose. My main claim is that while people with diabetes implement the technology into their lives in unique ways, adapting it to their circumstances and social conditions, practice of Continuous Glucose Monitoring reproduce social structures. This is evinced, I argue, in people’s tinkering with the technology and the frames of reference used to inform it. I introduce the term “tinkering in time”, highlighting the introduction of new health technology within the frame of lived human time.

KEYWORDS:

• Denmark
• habitus
• health technologies
• temporality
• tinkering
• type 2 diabetes

You’re lucky; you can hardly remember when there were no mobile phones can you? Imagine, when I was a kid, there were only landlines, so as soon as you left the house, you couldn’t reach each other When the computers came, I remember that it was absolutely crazy. I got my first computer when I was about 30. And then I started flying, so I’ve also had access to it because I’ve flown so much abroad, and I’ve been to so many places where they were further ahead than Denmark … So of course, for me it has been piece of cake (practicing Continuous Glucose Monitoring) … I’ve fiddled a lot with electronics, so I can easily figure it out. It makes sense to me how all such things are built in the same way (Frits).

Sixty-six-year-old Frits, as I call him for the sake of anonymity, is describing how he uses the new technology, Continuous Glucose Monitoring (CGM), as a tool to manage his type 2 diabetes (T2D). CGM is a time-machine: it measures the person’s glucose levels once every five minutes. Yet it is a time-machine in another sense as well: my ethnographic findings from research in Denmark with people with T2D suggests that people’s use of this technology is embedded in their experiences of time. Understanding how new technologies for glucose measurement are used, demands, I argue, that we place these technologies within their users’ “temporal” experience. In making this argument, I build on previous anthropological studies of health technologies which have shown how people “tinker” with technology, adopting it to circumstances and social conditions (Kingod 2020; Mol et al. 2010). I point to the importance of temporal experiences for the forms that tinkering takes. Accordingly, I approach CGM as a practice in and of time connected to a form of “habitus” (Bourdieu 2000).

As with Frits, the people I met would often refer to previous life experiences when describing present-day use of CGM and draw in expectations of the future. This has led me to approach this new health technology as a matter of lived human time.

The study

Diabetes technology in a Danish setting

In Denmark, approximately 325,000 people live with T2D (Diabetesforeningen 2023), a number which is estimated to rise to around 420,000 by 2030 (Carstensen, Rønn, and Jørgensen 2020). In biological terms, T2D is a chronic disease resulting from the body’s ineffective use of insulin (International Diabetes Federation 2023), caused by genetic factors, socioeconomic determinants, and so-called “lifestyle behaviors” (Stringhini et al. 2013). The cornerstone of diabetes self-care is healthy eating and exercise, most often combined with medication (International Diabetes Federation 2023). People with diabetes must self-monitor glucose levels in order to adjust food intake, exercise, and the dose of insulin in correlation with glucose levels prior to meals, at bedtime, before exercise, and when they suspect high or low blood sugar. This is facilitated by diabetes technology.

In diabetes, the use of health technologies, such as glucometers and, more recently Continuous Glucose Monitoring (CGM), is a crucial part of self-care to keep track of glucose levels. For this study, CGM was provided by Dexcom and involves the G6 model (which was the newest model at the beginning of this study, there now exists the G7 model). Dexcom is a company that produces CGM technology and is one of the leading providers globally. The Dexcom G6 technology involves a small disposable sensor attached to the skin on the abdomen that automatically measures interstitial glucose levels every five minutes. The sensor must be changed at home every tenth day. A reusable transmitter is attached to the sensor transferring the glucose information via Bluetooth to the original receiver from Dexcom or on an app on the phone that displays and stores this information (Dexcom 2024).

Incorporating self-monitoring technology into the treatment of type 1 diabetes (T1D) has proven benefits for biomedical parameters but is generally not used in the treatment of T2D in Denmark yet. Limited studies have explored the use of the technology in T2D. In places like Germany, France, Austria (Kröger, Fasching, and Hanaire 2020), and North America (Beck et al. 2017) biomedical studies of self-monitoring technology have indicated a positive effect on glycemic outcomes for people with T2D. Dexcom G6 is only available with a medical prescription and is currently not accessible for people with T2D in Denmark (only for people with T1D). Recently, a similar technology, Freestyle Libre, designed by the other leading CGM provider, Abbott, has become available for purchase for people with T2D in Denmark (Diabetesforeningen 2022). Contrary to Dexcom’s model, Freestyle Libre users need to scan the sensor with a receiver or an app on the phone when in need of glucose value information. It is not yet common among this group, not least because of its high cost for the Danish health care system. Equipment to self-monitor glucose values is paid for by the Danish healthcare system for people with diabetes treated with insulin, and this now includes the Freestyle Libre model if approved by the local municipality.

An ethnography of CGM

In this article I utilize research conducted as part of a larger project, conducted in collaboration between the Department of Anthropology at the University of Copenhagen, Health Promotion Research, Diabetes Technology Research, and the T2D outpatient clinic at Steno Diabetes Center Copenhagen (SDCC). The larger project included a 12-month randomized control trial (RCT) investigating the effect of CGM on T2D glycemic variables. The influence of peer groups during the trial was also explored. The trial was led by a diabetes nurse with whom I collaborated, as well as an associated research group of anthropologists, diabetes nurses and diabetologists. A total of 96 participants were recruited from the T2D outpatient clinic at SDCC. Participants were randomized into three different groups: (1) those living with CGM, (2) those living with CGM and attending peer groups, or (3) those continuing to live as they used to. People living with CGM and attending peer groups were my focus for this article, as agreed by the research group. 14 participants ended up being part of my study – which was undertaken between January 2020 and July 2022 – from the total group of 15, of whom 6 were women and 8 were men between the ages of 50 and 77. One person in the group declined to participate further after the first interview.

The empirical data mainly consists of semi-structured interviews with my informants, who were sometimes accompanied by family members. Methodologically, I applied a phenomenological approach inspired by Michael Jackson (2011). Understanding is thus reached in the encounter with the world, as an “emergent and perpetually renegotiated outcome of social interaction, dialogue, and engagement” (Jackson 2011:xiii). Consequently, I often deviated from my pre-conceived interview guides, or did not use it at all, in order to pursue what my informants found important. I conducted a minimum of three interviews with all informants, before, during and after the trial, all of which were audio recorded and/or transcribed. All interviews were conducted in Danish. Translations were agreed upon by the author and a native English-speaking colleague. The interviews are supplemented by audio recordings from clinical encounters between my informants and their health care professionals during the trial, and fieldnotes based on participant observation. Fieldnotes were made shortly after attending the field, at home or at my office, although brief notes were sometimes scribbled down in the field. Fieldnotes and interviews alike are anonymized and stored on a secure computer drive. Specific geographic places are rarely mentioned, and life details are blurred when possible.

Tinkering, temporality, and habitus were not initial analytical ideas. Following from a phenomenological approach, I wanted to remain open toward my informants’ concrete practicing of CGM, to reach an intersubjective understanding in a specific situation and in relationships with others (Jackson 2011). Inspired by the rich body of literature on everyday life (e.g., de Certeau 2011; Lefebvre 1987; Smith 1987; Wolf-Meyer 2019), and particularly interested in people’s organization of day-to-day routines and habits, the primary aim of my fieldwork was to learn how the people in this study used CGM in their daily living. However, different temporalities were highly present in all my informants’ stories and became increasingly apparent to me during the process, and I quickly noticed the various ways they incorporated the technology into their lives as I got to know them. This spiked my interest into their different circumstances and social conditions connected to their individual approaches and expectations to the technology. Creating a form of iterative process, these analytical ideas also came to inform further questions during fieldwork, focusing more on how people’s CGM practice was linked to past experiences with everyday life technologies (technologies as understood by my informants) and views on the future. Through analyzing my data, I, in retrospect, found the concepts of tinkering, temporality, and habitus useful in understanding my informants’ unique adoption of CGM. I employ these terms as “loose concepts” (Pols 2015) to guide the analysis, so, they do not constitute a comprehensive theory but are highly empirically informed. For this article, I have chosen to explore the cases of Frits and Mark. These cases offer exemplary illustrations of the divergent ways people with diabetes in my sample practice CGM, and in their stories the link between past, present, and future is particularly apparent. It is important to note that the experiences of Frits and Mark are not universal, yet, the analytical themes were identified across the material as empirical trends. Frits and Mark in many ways represent two extremes, while the remaining participants are to be found on a continuum between the two subject positions. Other voices from the sample are included in the analysis to support my overall findings.

Analytical framework: Tinkering as a matter of time

Comprehending CGM as temporal practice

A large body of literature within the social sciences have demonstrated a link between technologies and its social context. The field, formalized by Bijker et al. (2012), highpoint that technologies are shaped by the people using it. In medical anthropology, several studies have investigated how people come to live with medical prosthetics, adjusting to new embodied changes, and adapting the technology to their social worlds (e.g., Friedner 2022; Manderson 2016; Messenger 2010). Comprehending living with CGM, I build on this literature exposing the subjectivity of health technologies. For people whose lives are disrupted by chronic illness, adaptation to such bodily changes is hard work (Manderson 2016). Scholars within the field of medical prosthetics have opted for various kinds of subject positions in use of health technologies and moving beyond approaching the binary use and nonuse (Friedner 2023). Therefore, it is paramount to investigate what kinds of tinkering (Kingod 2020; Mol et al. 2010) CGM allows for. Technologies are dependent on people being willing to “adapt their tools to a specific situation while adapting the situation to the tools, on and on, endlessly tinkering” (Mol et al. 2010:15). People with diabetes must then undergo work of negotiating between technology, bodies, and daily lives, e.g., experimenting with how and where to place diabetes technology on the body, and individualizing settings for glucose level patterns on diabetes technology (Kingod 2020). The concept of tinkering has received much attention in medical anthropology as an important situated and contextual form of knowledge, yet existing literature on tinkering is closely tied to that on care and focusing on day-to-day adaptation of technologies. Knowledge on how tinkering relates to temporality and broader notions of time has hardly been reflected upon.

Within anthropology, there is an increasing interest in working with an analytical focus on temporality (e.g., Bear 2016; Bourdieu 2000; Gammeltoft 2013; Good 1993). Building on this lineage, I focus on peoples’ subjective and embodied experience of time. In medical anthropology, studies point to how different temporalities are at stake in the experiences of people living with illness contrary to a linear time flow characterizing a clinical domain (Hardin 2015; Messenger 2010; Pols 2015). Lived time “do[es] not add up to a ‘whole’ or a clear linear time with a beginning and an ending. The different temporalities are folded into one another” (Pols 2015:101). This suggests the importance of exploring what temporalities mean in their particular situation. Only a few studies have examined daily diabetes self-care practices through the lens of temporality, and limited research has explored the temporal experience of health technologies.

Mathieu-Fritz and Guillot (2017) have demonstrated a link between CGM and time in that CGM use fosters new forms of temporalities for people with diabetes. Access to data on glucose values in the short-term past shown as trends and following possibilities of anticipating and acting on this data in the short-term future, facilitates regulation of fluctuations in glucose levels. While this study shows how CGM may transform the illness experience through the concept of time, I suggest extending the analytical scope of temporality in attending to how people’s adoption of CGM is informed by time. In doing so, I address not only the here-and-now and short-term pasts and futures but also long-term experiencing of past and future dimensions. In understanding people’s future expectations, I extend on Wolf-Meyer and Callahan-Kapoor’s work (2017) in their attention to the future in self-care of people with diabetes through medical prognostication. Prognostic technologies, they suggest, rely on medical understandings of people’s futures, and motivate self-care practices aimed at avoiding future health risks. I propose that the people with diabetes who are part of this study pull in their anticipated futures when practicing CGM, yet, instead of biomedical understandings of anticipated futures, I turn to people’s own expectations concerning their futures. In understanding people’s pasts, I am inspired by ethnographic research by Rayna Rapp (1999) arguing for the use of health technologies as highly dependent on people’s backgrounds. I also draw on Hardin (2015), whose study shows how evangelical temporality is privileged over biomedical temporality for people living with diabetes in Samoa in daily diabetes self-care practices. While Hardin’s research concerns biomedical time in relation to evangelical time, I am interested in broader notions of time. The opening vignette from my fieldwork indicates how people’s biographies shape the adoption of CGM in important ways. I explore CGM practicing within a form of biographical time (Dalsgård 2021), in the sense that I understand people’s CGM use in connection to their narratives about themselves.

Tinkering in time

At the intersection of the concepts tinkering and temporality, I introduce the notion of “tinkering in time.” Løvschal-Nielsen, Andersen, and Meinert (2021) explore how children in a Danish pediatric oncology ward take control of time to establish existential agency in a response to the time-constraints of the treatment. They show that children “tinker with time,” adapting it to their situations and vice versa (Løvschal-Nielsen, Andersen, and Meinert 2021:217). From foregrounding people’s practices as embedded in notions of time, I suggest interpreting people’s use of CGM as a practicing in time and of time. In this context, I draw on (some of) Pierre Bourdieu’s (2000) theoretical apparatus to unravel human time. In Pascalian Meditations, Bourdieu addresses practice as temporalization. He criticizes a deterministic perception of time as previous and external to practice. Bourdieu proposes reconstructing the perspective of the acting agent “thereby revealing that practice is not in time but makes time (Bourdieu 2000:206). Practice as temporalization, according to Bourdieu, takes place between people’s expectations formed by previous experience and the social world, in other words, between habitus and structures as “objective chances” (Bourdieu 2000:213). This way, people’s practices involve past, present, and future dimensions. In exploring people’s practices around CGM as temporal experiencing, I show how day-to-day practicing of the technology is embedded in people’s past experiences with everyday life technologies and future expectations to life with diabetes. This analytical perspective is a lens to approach how a new health technology may be adopted in different ways, revealing, in turn, how my informants’ different circumstances and social conditions influence the ways they make use of CGM.

The CGM experience: A timely practice

In different ways, past experiences permeated the present adoption of CGM by the people with diabetes I spent time with. For some, this was a new and challenging experience, for others it acted as a natural continuation of their already technologically-guided everyday lives. Insecurity and uncertainty about what the future diabetes self-care might look like was also present in stories of the here-and-now experience of CGM.

CGM and the weaving into people’s biographies

The first time I talked to Frits, I asked him where he was born, about his family, what kind of work he had, when he was first diagnosed with diabetes, and other important life events that had shaped his biography. During this time, I began to form an initial sense of Frits’s life; from his birth in Sweden, to growing up in a suburb in Copenhagen, studying engineering after high school, then taking flying lessons alongside his studies until he decided to become a pilot. After flying for 20 years, he was now working as head of a department that provided pilots with background information on fuel, takeoff weights, maps, routes, and navigation. Frits agreed to talk to me again, although he did not really understand my anthropological perspective. But he was happy to support it in exchange for being part of the biomedical RCT, he told me. “I’m more technically oriented myself, so the other part interests me more,” he elaborated.

Well into the trial year with CGM, I arranged to meet with Frits at a café in a mall on his route from his home to his job at the airport. At this point in time, I already knew how much Frits enjoyed novel technological devices, or “gadgets” as he called them. His wife sometimes called him a “technology freak” he told me. One of the first things he did after getting the CGM device, was to order an Apple Watch. The watch enabled him to constantly monitor his glucose values just by looking at his left arm. Frits told me that he had already been looking into how to order the CGM device online from Germany if he was not allowed to keep the device after the trial period. “A revolution,” he called it, compared to the old way of measuring his glucose levels by a drop of blood from his finger. After talking for a couple of hours, Frits and I agreed to finish up, and as we passed an electronics retailer from the Danish chain Elgiganten on the way to the exit, Frits told me that he would have a look inside, before heading to work. I asked him if he was interested in anything in particular; “no, I just like to have a look,” he told me. Like Frits, all the people that I talked to during fieldwork found CGM helpful in managing diabetes in their daily life. However, during this process, I got the growing sense that they all possessed their unique and particular approach to practicing CGM and ways of fitting the technology into their presents and everyday circumstances. “Technology freaks” like Frits possessed valuable technological experiences and skills to draw upon, thus shaping how CGM was adopted.

With CGM, Frits was able to constantly monitor his glucose levels shown as a number along with an arrow pointing either horizontally, up, or down, as well as a graph of the last 24 hours of values. This way, Frits was aware of not only the glucose proportion inside his body as a momentary snapshot but also what to expect in the following minutes and hours, as well as an overview of the fluctuations leading up to the present time. This new kind of technology was useful in Frits’ busy life in that it helped him react in the moment and make decisions concerning his treatment. It also made Frits aware of how his body reacted to what he did hours ago, such as what he ate and if he was watching TV or gardening.

You could, of course, do a lot of measurements from a prick in the finger, but I have a busy daily life and sometimes I forget it, and with this device you can really see what is going on. With this device you are in control; now the glucose value is low, and it is not rising at the moment – no arrows – then it’s now that I could allow myself to eat that piece of cake, and not a few hours later when the glucose value is high and rising. That kind of calculation can be difficult to really get a grasp of, but this device visualizes it; now I should hold back a bit, now is the time to eat something. And you learn how much to eat. I can see what happens if I eat a small portion or a large portion.

Many of my informants used fast-working insulin periodically when eating carbohydrates. However, some of my informants forgot that this was an option, or their stock of insulin was not regularly renewed, and some were also reminded by health care professionals that this approach resulted in extra calories and therefore was not recommended to avoid weight gain. Accordingly, CGM provided an additional way of managing the glucose values here-and-now.

As I have sought to illustrate through the case of Frits, the CGM experience takes place in time and is thus embedded in peoples’ presents and the daily rhythms and routines that constitute everyday life of people with diabetes. This shows the interrelatedness of the individual and the context; in other words, I would suggest, CGM is practiced in the matrix between a form of habitus of people with diabetes and their social world. This process is elaborated in the following.

During my fieldwork, I also met Mark, who was 52 years old. Whenever we met, we would go for a walk outside, as Mark has PTSD stemming from when he was in prison and therefore had difficulties concentrating on our conversations when sitting still. This particular day, however, a couple of months in, we agreed that I should see where he lived, and Mark had the opportunity to end the interview if he felt overwhelmed. Mark used to work as a butcher and later as a porter, and the hard physical work took its toll on his body. Since he got out of prison a couple of years ago, he had not been able to find work and was now living on welfare subsidies. Mark enjoyed my company and having someone to talk to, he told me. Mark lived with his brother in a small town just outside Copenhagen, an area where he had spent most of his life. His brother also had T2D, but as he hardly ate and did not take his medications, he occasionally had to be admitted to the hospital. When I asked Mark how this affected him, he told me that he tried not to worry and focused on living his own life. On this day, we ended up talking for a couple of hours while eating lunch. The radio played ’80s pop to drown out the tinnitus in Mark’s ears. Mark had just returned from a vacation in Spain, where he was shooting a pornographic film with a friend, he told me. This was an interest of his and was something he did for pleasure. I asked him how he had been. “Great,” he answered with a big smile, as he always did. I asked him about the practicing of CGM. “It’s all good. I haven’t worn it for the last four days though, as I was making a film,” he told me. “I think it’s a bit ugly to look at,” he explained. This was not the first time; he usually took it off when he was acting in a film. He then removed the small disposable sensor from his body and threw it away as trash and kept the receiver from Dexcom in his drawer when he left his home. He put on a new one when the work was over, leaving an interval of somewhere between four hours and several days where he did not use the device. In the adoption of CGM, Mark had found a way to fit the technology into his everyday life so that it did not prevent him from doing what he wanted. To Mark, wearing the device was not compatible with acting in pornographic films as it stuck out when placed on his body.

Throughout my year of fieldwork, my informants told me about their various ways of practicing CGM to fit it into their everyday lives, from when and where to wear the device on the body, to turning the alarms on and off when needed. People’s tinkering was, I noticed, connected to the concept of time. Beatrice, one of my informants, a 70-year-old now retired but former social and health care assistant, thought about the visibility of CGM: “if I was younger, I would have to consider whether to place it on the stomach or on the side or where to place it.” Beatrice at her current age did not particularly care if people looked at the device but imagined that her younger self would have found it difficult when people looked at it. She, on the other hand, greatly appreciated the alarm function as an elderly woman, comparing her situation to a friend also with diabetes and around the same age, living alone and always in fear of losing consciousness due to low glucose value. Another of my informants, Ralf, 52, and working as a specialist technician with purification plant, told me of how he left CGM on the desk in front of him when at work to remind him of his daily insulin injections at lunch. Due to his busy work schedule, he would often forget it, but CGM made it easier for him to remember. Like Beatrice and Ralf, people’s stories made me think of the timeliness of the CGM experience in that people’s presents determined how CGM fitted in. When Mark took off the device for a period of time to be able to make the films he loves, or when Frits bought new technological gadgets to monitor his glucose levels just by looking at his left arm, they were both, too, in their own way, tinkering with the device to make it part of their biography. Through practical and pragmatic engagement, all my informants adopted CGM on their own terms I pursue the significance of people’s pasts for their particular adoption of CGM as a timely practice further in the following section.

The past reaching into the present

Well into the trial period, I arranged to meet Mark once more. This time, he wanted to show me the shelter run by volunteers where he spent a lot of time. But first Mark invited me to join a meeting with a social worker at the municipality where Mark went frequently. Inside, an older woman came to get us. She and Mark seemed to know each other well. When we sat down, she asked me if I knew about the “system.” She then drew a pyramid and carefully explained to me the way from a flexi-job at the bottom of the pyramid and all the way up to approval for early retirement benefits at the very top. Mark was not able to work due to his PTSD. “If I am not approved (for early retirement), I will rob a bank, then at least I know that I have a safe place to sleep,” he said smiling, yet in a serious tone. At the shelter, two young volunteers were about to fire up the barbecue and prepare the lunch. The live band that was going to play after lunch was setting up its gear, and more people arrived until the tables were all filled. By this point, Mark’s glucose levels had dropped significantly. I asked Mark why he thought this had happened, wondering to myself whether CGM use might have contributed to this development. “It’s the Jardiance,” he said, “this new medication that I’m on. My pee smells different; I’m peeing a lot of sugar out.” I asked Mark if he thought CGM played any part in his glucose level drop. “Yes, this thing has showed me that this medication works for me,” he answered. “Before Jardiance I could see the glucose values would rise in the middle of the night, and I eat nothing after 7pm, so I was totally confused.” Using the technology gave Mark insights into the effect of the new medication and confirmed that it worked well for him. As the technology visualizes the glucose level 24 hours back in time, he could see that the levels were stable even during the night, a valuable piece of knowledge to him that the finger-stick method could not have provided.

When I asked Mark to bring the everyday technology that he used the most, he pulled out his phone: “That is the only technology that I use. Except for an electric toothbrush, and my TV, but I didn’t want to bring a 55-inch flat screen.” I asked Mark what popped into his head when I said, “everyday life technologies.” “It is very nice to have, it’s like having won the lottery,” he explained. “It’s like having won the lottery?” I repeated. “Yes, if I won, I would buy a new phone, and a new TV, my TV is from prison, I bought it from a co-inmate, and my phone is eight years old. I have nothing new. Everything I own, I have found at recycling stations and other places.” “So, would you say that you are technologically interested or not?” I was curious.

No, I am not. I just want it to work whenever I push the on button. And my phone, it asks for a new password all the time. I think I have around four million passwords, and none of them work. I could probably learn it, but I just call my nephew regarding technology, whenever something doesn’t work … Since Nokia 3210 I have been completely lost.

“And why are you not technological interested yourself, do you think?’ I asked. “That’s because of the year I was born,” Mark replied and continued:

When I had computers in primary school, it had a screen the size of a fist, and the computer was the size of a house. And you had to type in two A4 pages to be able to play just one game about throwing bombs at skyscrapers. And I’m dyslexic. That was when I realized that I was probably born in the wrong year; it was boring. I could probably learn it though, I think, but it would take lots of time as I’m dyslexic … Some of my friends found it interesting. But I had a hard time concentrating in school as I couldn’t understand what was going on. Nonetheless we can’t all become computer programmers, there need to be butchers as well.

In the above excerpt, it is striking how Mark linked his self-perception as a technologically uninterested person to when he was born and his early childhood memories as a dyslexic – these experiences existing as a form of embodied temporality (Dalsgård 2021). All my informants carried with them such embodied past life experiences that in different ways suffused their presents with CGM. When I asked Scarlett, another of my informants, a 65-year-old now retired porter, if she had developed any new self-care routines or habits as part of the CGM experience, she told me of how the progressive development in her diabetes was directly connected to social conditions and the circumstances she had found herself in. When her husband died 11 years ago, she suddenly started needing daily insulin injections. Before her body was exposed to this “shock,” she had been able to manage her diabetes simply through being mindful of what she ate combined with oral medications. From the CGM use, she realized that she often experienced low glucose levels during the night, a side effect from the insulin injections. From that point on she kept chocolate by her bed at night to deal with the low glucose levels announced by the CGM alarm.

Highlighting Mark’s experiences compared to those of “technology freaks” like Frits, I want to draw attention to how the stories of people with diabetes that I have met during fieldwork saturate individual ways of using CGM. Ellen, an informant of mine, 75 years old and a retired occupational therapist, similarly perceived herself as “computers and technology stupid.” This was an obstacle for her in everyday life, such as going to the bank where “they only want to guide you on the phone,” whereas she preferred to “look people in the eye.” To Ellen, CGM was a “wonder machine” in that it helped her in her “battle” against the high glucose levels by always providing measurements. However, she lacked an “overview” of the development. The nurse conducting the RCT at one point suggested that Ellen could install a program, Dexcom Clarity, on the computer or as an app on the phone, providing reports with elaborate information on patterns and trends on glucose levels back in time. “Now you lost me,” Ellen responded, and raised concerns of who might have access to this kind of information. So, this was not a satisfactory solution to Ellen, and Ellen continued to struggle with this for the remainder of the RCT. Nolan, an 80-year-old former engineer now retired, often linked his engineering background to his use of CGM. “Educated to optimize, minimize, and maximize, I try to optimize my diabetes. From this (CGM use) I have learned a lot about how to act. If I eat this, it goes this much up. When I go to bed and the curve (of glucose levels) is steeply downward, I must eat something, if the curve is flat around 5–6 (in the Danish measuring unit mmol/mol), then I can go to bed.” Such things had always interested Nolan. One day at home in bed with a fever when he was around five years old, his parents wanted to cheer him up and asked him what he wanted. “A toolkit,” he replied. Even though Nolan had not worked as an engineer for many years, engineering was still very much a part of his self-understanding. To me, these are other examples of how people’s previous experiences with technologies are intimately linked to their practice of CGM, in turn eliciting Bourdieu’s concept of habitus, where “social agents are endowed with habitus, inscribed in their bodies by past experiences” (Bourdieu 2000:138). Past experiences with everyday life technologies thus linger on in the minds and bodies of people with diabetes. The pasts of the people that I talked to during fieldwork consequently came to affect how the present situation unfolded, resulting in different ways of approaching CGM connected to embodied experiences with technologies. In the following section I explore the association between what I, within a Bourdieuan framework, conceptualize as people’s habitus and their future imaginings of CGM.

Glimpses of the future

From the very beginning, almost all my informants raised the question: what will happen after the trial period? Can I keep access to CGM? Grace, a 61-year-old librarian, even wrote a long letter addressed directly to the CGM technology itself after the trial period, wishing for it to come back into her life. This is only a short excerpt: “To CGM: … You wanted to stay my friend, but the day came that we had to say our goodbyes, and we haven’t seen each other since. I miss you a lot and hope that we can become friends again soon. Take care, CGM – we may meet again. Your dear friend, Grace.”

By the end of the one-year trial period, I met with Frits in the T2D outpatient clinic. We met by the welcome desk, where Frits was about to upload his glucose level data from the CGM device to the online communication platform Diasend (now called Glooko) so that the health care professionals can access this shared information. The nurse who was conducting the RCT was there as well. Frits got straight to the point: “What now?” He had been doing some calculating at home:

Finger-sticks for measuring with the glucose meter are eight Danish Kroner a piece, and then you need the glucose meter, the fluid for calibrating, and so on. So, that will be 13,000 Danish Kroner (approx. US $ 1900) a month in total. And this device (CGM), if I buy it for three months at a time, it will be 15,000, and if I buy it for one year it will be 12,000 a month in total. So, it’s practically the same price (for the Danish health care system, not Frits). So who should I talk to to get this device?

The nurse urged Frits to apply for a similar technology, Freestyle Libre, at the local municipality and said they would talk to his doctor about recommending to the municipality that this would be a good idea for Frits. “It’s a problem that now I’m being used to living with this technology, and if it’s suddenly taken away … ” he lamented. We were then called in to the doctor’s office. “So, I cannot read off your device today,” the doctor began. “But I just uploaded my device out by the machine,” Frits said pointing toward the door. “Yes, but my password doesn’t work at the moment, so I cannot access your data,” the doctor replied. “I’m afraid I cannot help you,” interrupted Siri on Frits’s iPhone. “But maybe you can tell me yourself about what the device has shown lately, because I can see that your long-term glucose level is sky-high?” the doctor said and continued: “how often do you scan with the device?” “Scan?” Frits looked confused, “oh but I don’t scan, this device measures automatically every five minutes.” “Do you look at it?” the doctor wanted to know. “Yes, I have the glucose levels right here, on my watch,” he said showing his left arm, “so I look all the time.” “But it’s now time to take it off, the sensor, what do you think of that?” the doctor asked. Frits took the CGM device – the device that was no longer his – out from his chest pocket and placed it on the table. I could see that it had been used, it had small scratches on it, and I could still see Frits’s fingerprints on it. It looked so different in the white and sterile office, like it did not belong. “I’m not happy about that, because I really think it’s been good. I really want to keep it,” Frits said. “You know that’s not possible,” the doctor answered and continued, “you can of course apply to the municipality, but you have a bad case. “But can you write that it will be beneficial for my future, and that I will be more motivated?” Frits asked the doctor. “No, I can’t do that, and they don’t care anyway,” the doctor replied.

The satisfaction that Frits expressed about the device counts for very little; contrary to Frits’ own opinion, the message was clear: “you do not benefit from this device.” So, there exists a schism between what the doctor is reviewing and imagine for Frits’s future and Frits own expectations for his future. Regardless of the doctor’s judgment, Frits stuck with his imagined future which includes the CGM technology, and when I spoke with him again a couple of months later, he was still trying to figure out if he could buy the technology himself outside Denmark. In the meantime, he struggled to return to his former and now almost forgotten diabetes self-care routines and habits. Many days, he told me, he completely forgot to measure his glucose value with his old device. Studies of post-trial experiences with medical devices have suggested that participants may have difficulty returning to post-trial life that does not have the same psychological and emotional benefits and suddenly feel deskilled in relation to pre-trial self-care routines (Lawton et al. 2019). What this points to is the importance of addressing the ethical dimension of participating in the RCT of this study without any promise of access to CGM afterward (for more on this discussion, see e.g., Elliott 2018; Petryna 2009). So, even after the CGM experience, Frits’s imaginings of his future with CGM were pulled into his present.

After the trial period, Mark and I met for lunch together. I asked him how his glucose levels were, “They’re amazing, at 5.5 (mmol/mol) every morning. I only measure it in the morning because I know it’s too high during the day. My sugar doctor says she wants it to be even lower, so I tell her, ‘you are aware that I have diabetes, right?’” I asked him if he had tried measuring it during the day. “Yes, it’s too high, it rises to around 20. But then again, it drops to 5 the next morning, so I think it’s great.” Mark elaborated. “I tremble and feel bad whenever the glucose is below 5, so I feel like this is good for me. It’s my body after all.” “Do you miss CGM?” I asked him. “No,” he said. “Are you in fact happy to get rid of it?” I wanted to know. “Yes, actually. I checked my glucose levels too many times. And I could see that it was too high; that made me feel guilty. So, it’s easier to live without it,” he said. The transition from CGM back to the former way of measuring glucose levels was less challenging for Mark. He saw the benefits of returning to his old way of living – to an “easier” life.

In Pascalian Meditations (2000), Bourdieu points to the intimate relationship between expectations of life and possibilities of fulfilling them. As people have different positions depending on their habitus, according to Bourdieu, expectations are adapted to what he refers to as objective chances. Thus, temporal experiencing is not equally dispersed among people. Temporal practicing takes place between a habitus and the social context, “between the dispositions to be and to do and the regularities of a natural and social cosmos (or a field)” (Bourdieu 2000:208). What Bourdieu proposes is that people tend to adjust their future expectations to their possibilities. Practicing, says Bourdieu, means playing “a game,” and in this game “the good player” is the one who places him or herself not where the ball is but where it is about to land (Bourdieu 2000:208). What facilitates the link between people’s expectations and possibilities, is in Bourdieu’s terms “the forth-coming” (Bourdieu 2000:208). The forth-coming is what people anticipate shaped by past experiences. Practice as temporalization thus in turn risk reproducing social structures. Uncertain futures were a central theme in all my informants’ accounts of living with CGM. The concept of “subjunctivity” has been used in previous studies to frame uncertainty in illness experiences and is closely tied to Bourdieu’s concept of the forth-coming. Susan have Whyte employed the concept of subjunctivity in a health care setting (2005). The idea of subjunctivity may be defined as individuals acting with “doubt, hope, will, and potential” (Whyte 2005:251). According to Wolf-Meyer and Callahan-Kapoor, “chronic subjunctivity means always anticipating particular futures wrought through medical technologies and expertise, but never knowing which future will manifest” (Wolf-Meyer and Callahan-Kapoor 2017:93). The concept of subjunctivity thus illuminates how technology elicit an attentiveness toward time.

Mark and Frits expect and anticipate their futures, I suggest, according to their respective habitus and enacted in their different CGM experience. Mark, although younger than Frits, explains that he was born too late to fully appreciate technology, whereas Frits after many years of experience with technologies has a hard time imagining a future without CGM. Frits had a highly analytical approach to living with CGM. This way of living was familiar to Frits as he was used to dealing with numbers through his past experiences and deployed practical knowledge and technical skills to adopt the technology in a specific way. In the case of Mark, his way of practicing CGM showed another approach to the technology in his wish to retain his daily habits and routines. And after the trial period, Mark wanted to return to his former ways of diabetes self-care. To Mark, the CGM experience constituted an experience in time, appreciating the sociality in being part of an experiment, “to get out” and “seeing other people,” was one of the main reasons he decided to enroll in the RCT in the first place, but not a way of living that he wanted to continue. Seeing CGM practicing as temporal, reveals in turn how it is socially experienced. People’s present adaptation of CGM to their circumstances is, as I have argued, the product of previous experiences and future anticipation. CGM use thus risks reproducing social structures as things to do and things to be done are defined by the relationship between structures of hopes and expectations and structures of probabilities (Bourdieu 2000). To sum up, a form of biographical time shapes the CGM experience, as, in Bourdieu’s terminology, people’s “habitus is that presence of the past in the present which makes possible the presence in the present of the forth-coming” (Bourdieu 2000:210).

Concluding remarks

The ethnographic material from which this article stems, exposed many individual ways of practicing CGM, illustrative of its social shaping. In medical anthropology, previous studies have shown how people come to live with medical prosthetics through adaptation to their social worlds. Diabetes self-care and the use of health technologies are subjects rarely studied through the lens of temporality. Taking as my point of departure how practices are temporal, paying attention to the coinciding temporalities in living with CGM for people with T2D, revealed how CGM use is embedded in people’s biographies. Through an analytical focus on time, I argue that in approaching the lived experience of CGM we have a window to consider how people’s embodied past experiences with technologies and their possibilities, hopes, and future imaginings shape the practicing of CGM. Building on existing literature within the field, I have extended the analytical scope of the concept of temporality in attending to not only the here-and-now but also people’s pasts and futures. I have shown here how people, in pragmatic engagement with world, tinker with CGM to fit the technology into their lives, adopting it to their circumstances and social conditions. Expanding on the concept of tinkering, I have introduced the idea of tinkering in time – a tinkering informed by people’s experiences in and of time. Practice of CGM, I suggest, thus risks reproducing social structures, in that a notion of habitus permeates its use. In more general terms, I suggest that a focus on the concept of temporality may expand on anthropological analysis of the relations between people’s biographies and the growing use of health technologies. This points to how the projected possibilities of CGM converge with human everyday life. In the setting of daily life, use of the technology unfolds in many ways where the pasts of people with diabetes intersect with the present and pull in the future, reflective of a biographical time. Studying the use of CGM hence function as an opening to understand the introduction of new health technologies within the frame of lived human time – linking the use of technologies to people’s narratives about themselves. Of practical implications, I highlight the importance of awareness of past experiences with technologies among new potential users of CGM as people have different prerequisites, and hence individual needs and expectations.

Acknowledgments

I thank my PhD supervisors Tine Gammeltoft and Bryan Cleal for valuable comments on the manuscript along the way, and three anonymous Medical Anthropology reviewers. I am grateful to the people with T2D who participated in the research for sharing their experiences and reflections with me.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Astrid Andrea Anesen

Astrid Andrea Anesen is an anthropologist and PhD student at the Department of Anthropology, University of Copenhagen, and Health Promotion Research, Steno Diabetes Center Copenhagen.