Evaluating Time-Series Foundation Models and Multimodal Dietary Context for CGM Forecasting

Continuous glucose monitoring (CGM) provides high-frequency measurements of glucose dynamics and enables short-term glucose forecasting for diabetes management. Although time-series foundation models have shown strong general forecasting ability, their effectiveness for CGM prediction and the added value of multimodal dietary context remain unclear. We conduct a comprehensive empirical study using eight public CGM datasets spanning Type 1 diabetes, Type 2 diabetes, and non-diabetes populations. Under a unified protocol across multiple context lengths and prediction horizons, zero-shot foundation models did not consistently outperform strong task-specific baselines such as Elastic Net and PatchTST. In contrast, lightweight fine-tuning substantially improved forecasting performance. For example, fine-tuned Chronos-Bolt reduced RMSE by 6.5%-18.4% in the T1D cohort and by 8.6%-18.2% in the non-diabetes/T2D cohort, with comparable improvements in both in-distribution and out-of-distribution test settings. We further evaluate multimodal dietary context using CGMacros, which provides temporally aligned CGM signals, food images, and macronutrient records. A residual-based fusion framework reduced overall RMSE by approximately 3% and postprandial RMSE by approximately 15% relative to the CGM-only baseline. Moreover, Chronos-based CGM representations were more strongly correlated with observed postprandial glucose increments than representations from LSTM and CatBoost, even after those models incorporated additional dietary modalities, suggesting that pretrained temporal representations better preserve meal-induced excursion patterns. These findings show that foundation models require CGM-specific adaptation for reliable forecasting and that dietary context provides clinically meaningful signals beyond CGM alone, especially during postprandial periods.