Improving the Clinical Value and Utility of CGM Systems: Issues and Recommendations: A Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group

How to Use Continuous Glucose Monitoring Efficiently in Diabetes Management: Opinions and Recommendations by German Experts on the Status and Open Questions

Today, continuous glucose monitoring (CGM) is a standard diagnostic option for patients with diabetes, at least for those with type 1 diabetes and those with type 2 diabetes on insulin therapy, according to international guidelines. The switch from spot capillary blood glucose measurement to CGM was driven by the extensive and immediate support and facilitation of diabetes management CGM offers. In patients not using insulin, the benefits of CGM are not so well studied/obvious. In such patients, factors like well-being and biofeedback are driving CGM uptake and outcome. Apps can combine CGM data with data about physical activity and meal consumption for therapy adjustments. Personalized data management and coaching is also more feasible with CGM data. The same holds true for digitalization and telemedicine intervention ("virtual diabetes clinic"). Combining CGM data with Smart Pens ("patient decision support") helps to avoid missing insulin boluses or insulin miscalculation. Continuous glucose monitoring is a major pillar of all automated insulin delivery systems, which helps substantially to avoid acute complications and achieve more time in the glycemic target range. These options were discussed by a group of German experts to identify concrete gaps in the care structure, with a view to the necessary structural adjustments of the health care system.

Effects of Continuous Glucose Monitoring on Glycemic Control in Type 2 Diabetes: A Systematic Review and Meta-Analysis

As the prevalence of diabetes is rapidly increasing, the use of continuous glucose monitoring, which is effective in improving glycemic control in type 2 diabetes, is increasing.

METHODS

Systematic review was performed according to PRISMA criteria. The search was conducted for articles published until 31 May 2023 in PubMed, CINAHL, Cochrane Library, EMBASE, ClinicalKey, etc. The meta-analysis involved the synthesis of effect size; tests of homogeneity and heterogeneity; trim and fill plot; Egger's regression test; and Begg's test for assessing publication bias.

RESULTS

491 studies were searched, of which 17 studies that met the selection criteria were analyzed. The overall effect on HbA1c was -0.37 (95% CI, -0.63~-0.11, p < 0.001), with HbA1c decreasing significantly after CGM interventions. Sub-analyses showed that the study was statistically significant in those aged 60 years or older, when rt-CGM was used and when the study was performed in multiple centers.

CONCLUSION

The results of this study showed that intervention using CGM was effective in reducing HbA1c in type 2 diabetes. The factors identified in this study can be used as guidelines for developing future CGM intervention programs.

Improving Care for People Living With Dementia and Diabetes: Applying the Human-Centered Design Process to Continuous Glucose Monitoring

People with Alzheimer's disease or related dementias and diabetes mellitus (ADRD-DM) are at high risk for hypoglycemic events. Their cognitive impairment and psychosocial situation often hinder detection of hypoglycemia. Extending use and benefits of continuous glucose monitoring (CGM) to people with ADRD-DM could improve hypoglycemia detection, inform care, and reduce adverse events. However, cognitive impairment associated with ADRD presents unique challenges for CGM use. This commentary proposes applying the human-centered design process to CGM, investigating design solutions or interventions needed to integrate CGM into the health care of patients with ADRD-DM. With this process, we can identify and inform CGM designs for people with ADRD-DM, broadening CGM access, increasing detection and treatment of the silent threat posed by hypoglycemia.

Roadmap to the Effective Use of Continuous Glucose Monitoring: Innovation, Investigation, and Implementation

For 25 years, continuous glucose monitoring (CGM) has been evolving into what it is now: a key tool to both measure individuals' glycemic status and to help guide their day-to-day management of diabetes. Through a series of engineering innovations, clinical investigations, and efforts to optimize workflow implementation, the use of CGM is helping to transform diabetes care. This article presents a roadmap to the effective use of CGM that outlines past, present, and possible future advances in harnessing the potential of CGM to improve the lives of many people with diabetes, with an emphasis on ensuring that CGM technology is available to all who could benefit from its use.

Key indices of glycaemic variability for application in diabetes clinical practice

Near normal glycaemic control in diabetes consists to target daily glucose fluctuations and quarterly HbA1c oscillations in addition to overall glucose exposure. Consequently, the prerequisite is to define simple, and mathematically undisputable key metrics for the short- and long-term variability in glucose homeostasis. As the standard deviations (SD) of either glucose or HbA1c are dependent on their means, the coefficient of variation (CV = SD/mean) should be applied instead as it that avoids the correlation between the SD and mean values. A CV glucose of 36% is the most appropriate threshold between those with stable versus labile glucose homeostasis. However, when near normal mean glucose concentrations are achieved a lower CV threshold of <27 % is necessary for reducing the risk for hypoglycaemia to a minimal rate. For the long-term variability in glucose homeostasis, a CVHbA1c < 5 % seems to be a relevant recommendation for preventing adverse clinical outcomes.

Glucose variability: a new risk factor for cardiovascular disease

AIMS AND DATA SYNTHESIS

Glucose variability (GV) is increasingly considered an additional index of glycemic control. Growing evidence indicates that GV is associated with diabetic vascular complications, thus being a relevant point to address in diabetes management. GV can be measured using various parameters, but to date, a gold standard has not been identified. This underscores the need for further studies in this field also to identify the optimal treatment.

CONCLUSIONS

We reviewed the definition of GV, the pathogenetic mechanisms of atherosclerosis, and its relationship with diabetic complications.

Healthcare Professionals' Knowledge of and Attitudes Towards the Use of Time in Range in Diabetes Management: Online Survey Across Seven Countries

INTRODUCTION

Time in range (TIR) is a metric of glycaemic target management derived from continuous glucose monitoring (CGM) data. This study aimed to understand knowledge of and attitudes towards use of TIR among healthcare professionals (HCPs), and gain insights into benefits and barriers to its use in clinical practice.

METHODS

An online survey was disseminated across seven countries. Participants were sampled from online HCP panels and were aware of TIR (defined as amount of time in, below, and above target range). Participants were HCPs classified as specialists (SP), generalists (GP), or allied HCPs (AP; diabetes nurse specialists, diabetes educators, general nurses, nurse practitioners/physician assistants).

RESULTS

Respondents included 741 SP, 671 GP and 307 AP. Most HCPs (approximately 90%) agreed TIR is likely/somewhat likely to become the standard of diabetes management. Perceived benefits of TIR included helping to optimise medication regimen (SP, 71%; GP, 73%; AP, 74%), giving HCPs the knowledge and insights to make informed clinical decisions (SP, 66%; GP, 61%; AP, 72%), and empowering people with diabetes with information to successfully manage their diabetes (SP, 69%; GP, 77%; AP, 78%). Barriers to wider adoption included limited CGM access (SP, 65%; GP, 74%; AP, 69%) and lack of HCP training/education (SP, 45%; GP, 59%; AP, 51%). Most participants considered integration of TIR into clinical guidelines, recognition of TIR by regulators as a primary clinical endpoint, and recognition of TIR by payers as a parameter for diabetes treatment evaluation as key factors for increased use.

CONCLUSIONS

Overall, HCPs agreed on the benefits of using TIR for diabetes management. Besides raising awareness among HCPs and people with diabetes, more training and healthcare system updates are needed to facilitate increased TIR use. In addition, integration into clinical guidelines and recognition by regulators and payers are needed.

Porous Colorimetric Microneedles for Minimally Invasive Rapid Glucose Sampling and Sensing in Skin Interstitial Fluid

Though monitoring blood glucose (BG) is indispensable for regulating diabetes, the frequent pricking of the finger by the commonly used fingertip blood collection causes discomfort and poses an infection risk. Since glucose levels in skin interstitial fluid (ISF) correlate with blood glucose levels, monitoring glucose in the skin ISF can be a viable alternative. With this rationale, the present study developed a biocompatible porous microneedle capable of rapid sampling, sensing, and glucose analysis in ISF in a minimally invasive manner, which can improve patient compliance and detection efficiency. The microneedles contain glucose oxidase (GOx) and horseradish peroxidase (HRP), and a colorimetric sensing layer containing 3,3',5,5'-tetramethylbenzidine (TMB) is on the back of the microneedles. After penetrating rat skin, porous microneedles harvest ISF rapidly and smoothly via capillary action, triggering the production of hydrogen peroxide (H₂O₂) from glucose. In the presence of H₂O₂, HRP reacts with TMB contained in the filter paper on the back of microneedles, causing an easily visible color shift. Further, a smartphone analysis of the images quickly quantifies glucose levels in the 50-400 mg/dL range using the correlation between color intensity and glucose concentration. The developed microneedle-based sensing technique with minimally invasive sampling will have great implications for point-of-care clinical diagnosis and diabetic health management.

Costs and Outcomes Comparison of Diabetes Technology Usage Among People With Type 1 or 2 Diabetes Using Rapid-Acting Insulin

BACKGROUND

Does initiation of a continuous glucose monitor (CGM) or insulin pump lower health care utilization and/or costs?

METHODS

Distinct cohorts of people with type 1 diabetes (T1D) or type 2 diabetes (T2D) using a blood glucose monitor (BGM), CGM, pump, or CGM with pump were identified from a large claims database. Patients ≥40 years old with 12 months of continuous enrollment before and after the device start date qualified for the study. Outcomes included one-year medical utilization and costs (minus device) for events such as hospitalizations and office visits. Generalized linear models were fitted, controlling for numerous baseline covariates. The Holm method corrected for the multiplicity of hypotheses tested.

RESULTS

Of the 8235 total patients, the BGM control group was the largest, had the lowest percentage of patients with T1D, and was significantly different from the device groups in most baseline categories. Formally, only two comparisons were statistically significant: Compared with BGM, the pump cohort had greater adjusted first-year total medical and office visit costs. Other secondary outcomes such as days hospitalized, emergency department visits and labs, favored pump. Most endpoints were favorable for CGM. Results for CGM with pump generally were intermediate between CGM and pump alone.

CONCLUSIONS

During a one-year follow-up, unadjusted medical costs of both CGM and pump appear lower than BGM, but multivariable modeling yielded adjusted savings only for CGM use. Economic benefits might be observable sooner for CGMs than for pumps. Generalized linear models fitted to health care utilization event rates produced favorable results for both CGM and pump.

Effects of a Diabetes Self-Management Education Program on Glucose Levels and Self-Care in Type 1 Diabetes: A Pilot Randomized Controlled Trial

(1) Background: Several factors have been associated with the success of health education programs, such contact time, with better results being obtained from more intensive programs and early outcome measurement. Nurses play an essential role in educating patients with diabetes both in disease-management, therapeutic education, and healthy lifestyles promotion as well as emotion management. The objective was to evaluate the effectiveness of a nurse-led educational program based on patients with type 1 diabetes; (2) Methods: An experimental, two-group comparison design, 69 patients participated in the intervention group and 62 in control group. The control group received routine health education and follow-up. The intervention group received intensive educational program led by nurses. The effects were evaluated after 1 and 3 months of intervention; (3) Results: The differences between groups in sensor usage, knowledge, and diabetes self-care three months after the educational program were significant; (4) Conclusions: The program could help type 1 diabetes patients to improve the control rates for blood glucose. The continuous glucose monitoring sensor allowed knowing which parameters improved one and three months after the intervention. The hypothesis of the influence of the emotional state on glucose levels was confirmed.

Time-in-range: a promising glycemic control metric for bariatric surgery

As a complication of obesity, type 2 diabetes (T2D) is a chronic disease that is difficult to manage. However, bariatric surgery makes it possible to alleviate T2D. While the existing generic index glycosylated hemoglobin (HbA1c) is a powerful tool for examining overall blood glucose levels, it still has some limitations as a daily measure of blood glucose levels and as a judge of the effectiveness of bariatric surgery. Using the time-in-range (TIR) measurement and its derivatives is a better way to evaluate short-term blood glucose fluctuations and can be used as a supplement to HbA1c. In this article, we discuss the utility and limitations of HbA1c and other indicators used during surgery. In addition, we mentioned TIR as a novel metric that can act as an accurate predictor of the risk of T2D complications and an index of preoperative risk assessment in bariatric surgery. In contrast to previous indicators, TIR has the advantage that it cannot be affected by caloric restriction to better reflect the patient's glucose level and the level of pancreatic islet function. On this basis, TIR is a promising indicator for both the diagnosis of diabetes and the preoperative and postoperative prediction and evaluation.

Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.

Historical aspects of diagnosis and control of diabetes mellitus

Diabetes mellitus is a group of metabolic diseases affecting carbohydrate, lipid, and protein metabolism. This pathology has a long history, and it was considered a disease of the kidneys until the middle of the 19th century. Descriptions have been found in Egyptian papyri, in ancient Indian and Chinese medical literature, in the writings of ancient Greek and Arab doctors. Aretaeus of Cappadocia gave the first accurate description of the disease, coining the term diabetes. Thomas Willis first differentiated diabetes from other causes of polyuria by the sweet taste of urine. Matthew Dobson proved the presence of glucose in urine by evaporation. Claude Bernard demonstrated that hyperglycemia contributes to glucosuria. This is how the concept of the renal threshold appeared. In domestic practice, the term "renal threshold" was introduced by endocrinologist V.G. Baranov. The development of qualitative tests for determining glucose in the urine, the creation of test strips and glucometers has significantly improved the quality of life of patients with diabetes. The current stage of development of glucometry includes the determination of fasting plasma glucose, postprandial glycemia, glycated hemoglobin, as well as continuous glucose monitoring. Continuous glucose monitoring systems make it possible to estimate the time in target range, show the rate of rise or fall of glucose levels. It affects the rate and degree of carbohydrate metabolism compensation and allows for maximum control of the disease.

Simulation Platform Development for Diabetes and Technology Self-Management

BACKGROUND

Specialized education is critical for optimal insulin pump use but is not widely utilized or accessible. We aimed to (1) test the usability and acceptability of A1Control, a simulation platform supporting insulin pump education, and (2) determine predictors of performance.

METHOD

Rural adult insulin pump users with type 1 diabetes (T1D) participated in a mixed methods usability study in 2 separate rounds. Participants navigated 3 simulations (ie, infusion site occlusion, hypoglycemia, exercise). Net Promoter Score (NPS) and Systems Usability Scale (SUS) were administered. Semi-structured interviews and direct observation were used to assess perceived usability, acceptability and performance. Synthetic Minority Oversampling Technique was used to fit predictive models for visualization of patterns leading to good or poor A1Control performance.

RESULTS

Participants (N = 13) were 28-70 years old, 10 used automated insulin delivery and 12 used continuous glucose monitoring (CGM). Mean NPS was 9.5 (range 9-10) and positive sentiment during interviews indicated very high acceptability. SUS (mean 88.5, range 70-100) indicted a high perceived usability. CGM percent wear ≥ 94%, time spent in hypoglycemia ≤ 54 mg/dl of <0.01%, and <70 mg/dl of 0.5% predicted successful site-occlusion scenario performance with 100% accuracy. BOLUS score ≥ 2, TDD ≥ 34, and technology brand predicted exercise scenario success with 100% accuracy. There were an insufficient number of failed hypoglycemia scenarios to assess predictors.

CONCLUSION

A1Control shows potential to increase access and frequency of self-management and technology education. Additional study is needed to determine sustained engagement and benefit.

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Role of continuous glucose monitoring in diabetic patients at high cardiovascular risk: an expert-based multidisciplinary Delphi consensus

Background

Continuous glucose monitoring (CGM) shows in more detail the glycaemic pattern of diabetic subjects and provides several new parameters (“glucometrics”) to assess patients’ glycaemia and consensually guide treatment. A better control of glucose levels might result in improvement of clinical outcome and reduce disease complications. This study aimed to gather an expert consensus on the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk or with heart disease.

Methods

A list of 22 statements concerning type of patients who can benefit from CGM, prognostic impact of CGM in diabetic patients with heart disease, CGM use during acute cardiovascular events and educational issues of CGM were developed. Using a two-round Delphi methodology, the survey was distributed online to 42 Italian experts (21 diabetologists and 21 cardiologists) who rated their level of agreement with each statement on a 5-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with any given statement.

Results

Forty experts (95%) answered the survey. Every statement achieved a positive consensus. In particular, the panel expressed the feeling that CGM can be prognostically relevant for every diabetic patient (70%) and that is clinically useful also in the management of those with type 2 diabetes not treated with insulin (87.5%). The assessment of time in range (TIR), glycaemic variability (GV) and hypoglycaemic/hyperglycaemic episodes were considered relevant in the management of diabetic patients with heart disease (92.5% for TIR, 95% for GV, 97.5% for time spent in hypoglycaemia) and can improve the prognosis of those with ischaemic heart disease (100% for hypoglycaemia, 90% for hyperglycaemia) or with heart failure (87.5% for hypoglycaemia, 85% for TIR, 87.5% for GV). The experts retained that CGM can be used and can impact the short- and long-term prognosis during an acute cardiovascular event. Lastly, CGM has a recognized educational role for diabetic subjects.

Conclusions

According to this Delphi consensus, the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk is promising and deserves dedicated studies to confirm the experts’ feelings.

Chy NU, Alam N, Rana MM, Chowdhury NA, Hasan MM. The relationship between medical comorbidities and health-related quality of life among adults with type 2 diabetes: The experience of different hospitals in southern Bangladesh

Objective

Health-related quality of life (HRQoL) is a critical determinant to assess the severity of chronic diseases like diabetes mellitus. It has a close association with complications, comorbidities, and medical aid. This study aimed to estimate the prevalence of medical comorbidities and determine the relationship between comorbidities and HRQoL among type 2 diabetic patients of southern Bangladesh.

Method

This study was a cross-sectional study conducted through face to face interviews using a pre-tested structured questionnaire and by reviewing patient’s health records with prior written consent. The study was conducted on 2,136 patients with type 2 diabetes attending five hospitals of Chattogram, Bangladesh, during the tenure of November 2018 to July 2019. Quality of life was measured using the widely-used index of EQ-5D that considers 243 different health states and uses a scale in which 0 indicates a health state equivalent to death and 1 indicates perfect health status. The five dimensions of the quality index included mobility, self-care, usual activities, pain or discomfort, and anxiety or depression.

Results

Patients with three comorbidities and with four or more comorbidities had a higher probability of reporting “extreme problem” or “some problem” in all five dimensions of the EQ-5D index compared with those without comorbidity (Odds ratio: mobility, 3.99 [2.72–5.87], 6.22 [3.80–10.19]; usual activity, 2.67 [1.76–4.06], 5.43 [3.28–8.98]; self-care, 2.60 [1.65–4.10], 3.95 [2.33–6.69]; pain or discomfort, 2.22 [1.48–3.33], 3.44 [1.83–6.45]; anxiety or depression, 1.75 [1.07–2.88], 2.45 [1.19–5.04]). The number of comorbidities had a negative impact on quality of life.

Conclusion

Prevalent comorbidities were found to be the significant underlying cause of declined HRQoL. To raise diabetes awareness and for better disease management, the exposition of comorbidities in regards to HRQoL of people with diabetes should be considered for type 2 diabetes management schemas.

Effect of the New Nordic Diet compared with usual care on glucose control in gestational diabetes mellitus: Study protocol for the randomized controlled trial intervention with new Nordic DIet in women with GestatiOnal diabetes mellitus (iNDIGO)

BACKGROUND

Gestational diabetes mellitus (GDM) is a pregnancy complication associated with short- and long-term health consequences for mother and child. First line treatment is diet and exercise but there is a recognized knowledge gap as to what diet treatment is optimal. A healthy Nordic diet has been associated with improved health but no studies in women with GDM exist. The New Nordic Diet (NND) is an initiative with the purpose to develop a healthy Nordic diet including foods with the potential to grow in Nordic countries; including fruit, berries, vegetables, whole-grain cereal products, nuts, fish, and rapeseed oil. The purpose of the intervention with new Nordic DIet in women with GestatiOnal diabetes mellitus (iNDIGO) is to test if the NND compared with usual care improves glucose control in women with GDM.

METHODS

The iNDIGO study is a randomized parallel controlled trial where 50 women with GDM will be randomized to either an NND or usual care for 14 days (30-32 weeks of gestation). Participants in the NND group will receive menus and food bags containing foods to be consumed. Primary outcome is glycemic control (time in target) measured using continuous glucose monitoring. Compliance to the dietary intervention will be tested using dietary biomarkers and adherence questionnaires.

CONCLUSION

Diet treatment represents first line treatment in GDM but it remains unclear what type of diets are effective. iNDIGO is an efficacy study and will provide evidence as to whether a healthy Nordic diet can improve glucose control in women with GDM.

TRIAL REGISTRATION

ClinicalTrials.gov registration Number: NCT04169243. Registered 19 November 2019, https://clinicaltrials.gov/ct2/show/NCT04169243.

Randomized comparison of self-monitored blood glucose (BGM) versus continuous glucose monitoring (CGM) data to optimize glucose control in type 2 diabetes

AIMS

Evaluate whether structured BGM testing (BGM) or real-time CGM (CGM) lead to improved glucose control (A1c). Determine which approach optimized glucose control more effectively. METHODS-MULTI-ARM PARALLEL: trial of three type 2 diabetes (T2D) therapies ± metformin: (1) sulfonylurea (SU), (2) incretin (DPP4 inhibitor or GLP-1 agonist), or (3) insulin. After a baseline CGM, 114 adult subjects were randomized to either BGM (4 times daily) or CGM (24/7) for 16 weeks with therapies adjusted every 4 weeks.

RESULTS

A1c means decreased from 8.19 to 7.07 (1.12% difference) with CGM (n = 59) and 7.85 to 7.03 (0.82% difference) with BGM (n = 55) (p < 0.001). BGM and CGM groups showed significant improvements in time in range and glucose variability-with no significant difference between the two groups. Clinically important hypoglycemia (<50 mg/dL) was significantly reduced for the CGM group compared with BGM (p < 0.01), particularly in subjects taking insulin or therapies with higher hypoglycemic risk (SU).

CONCLUSION

In T2D, structured, consistent use of glucose data regardless of device (structured BGM or CGM) leads to improvements in A1c control. CGM is more effective than BGM in minimizing hypoglycemia particularly for those using higher hypoglycemic risk therapies.

Does introduction of continuous glucose monitoring at diagnosis of type 1 diabetes increase uptake in children and adolescents?

OBJECTIVE

To assess whether introduction of continuous glucose monitoring (CGM) at diagnosis of type 1 diabetes (T1D), leads to greater uptake and continuation at 12 and 24 months, in a population-based pediatric diabetes clinic.

RESEARCH DESIGN AND METHODS

All T1D children and adolescents diagnosed in the 12 months following full government subsidization of CGM were offered CGM from diagnosis at Women's and Children's Hospital, SA (Cohort 1). Uptake and continuation of CGM was compared to those diagnosed in the preceding year, who were started on CGM after diagnosis, but otherwise had identical diabetes management (Cohort 2). Demographic and clinical data were collected prospectively. The primary outcome variable was CGM wear >75% of the time at 12 and 24 months.

RESULTS

In Cohort 1, 84% were started on CGM at diagnosis. 88% had commenced CGM by 12 months and 90% by 24 months. In Cohort 2, CGM was started on average 10 months after diagnosis (range 1-25 months), with 81% started on CGM within 24 months of subsidization. At 24 months, 78% of Cohort 1 and 66% of Cohort 2 were wearing CGM >75% of the time (p = 0.26), higher than the WCH Clinic as a whole (58%). There was no difference in HbA1c between cohorts.

CONCLUSION

Starting CGM at diagnosis of T1D is feasible and well received by families, with high uptake across all ages. Although CGM continuation (wearing CGM >75% of the time) was slightly higher in Cohort 1 than Cohort 2, this did not reach statistical significance.

Time-in-range and frequency of continuous glucose monitoring: Recommendations for South Asia

BACKGROUND AND AIM

The prevalence of diabetes is on its rise and South Asia bears a huge burden. Several factors such as heterogeneity in genetics, socio-economic factors, diet, and sedentary behavior contribute to the heightened risk of developing diabetes, its rapid progression, and the development of complications in this region. Even though there have been considerable advances in glucose monitoring technologies, diabetes treatments and therapeutics, glycemic control in South Asia remains suboptimal. The successful implementation of treatment interventions and metrics for the attainment of glycemic goals depends on appropriate guidelines that accord with the characteristics of the diabetes population.

METHOD

The data were collected from studies published for more than the last ten years in the electronic databases PubMed and Google Scholar on the various challenges in the assessment and achievement of recommended TIR targets in the SA population using the keywords: Blood glucose, TIR, TAR, TBR, HbA1c, hypoglycemia, CGM, Gestational diabetes mellitus (GDM), and diabetes.

RESULTS

The objective of this recommendation is to discuss the limitations in considering the IC-TIR Expert panel recommendations targets and to propose some modifications in the lower limit of TIR in older/high-risk population, upper limit of TAR, and flexibility in the percentage of time spent in TAR for pregnant women (GDM, T2DM) for the South Asian population.

CONCLUSION

The review sheds insights into some of the major concerns in implementing the IC-TIR recommendations in South Asian population where the prevalence of diabetes and its complications are significantly higher and modifications to the existing guidelines for use in routine clinical practice.

Time in range: new parameter to evaluate blood glucose control

Continuous glucose monitoring became more common in everyday clinical practice. New parameters have been created as a standard for assessing the degree of control for people with diabetes and can be used more clearly than glycated haemoglobin. The new parameter time in range represents a significant benefit not only for diabetologists, but also an important tool to help the patients in their daily lives with diabetes.

Automated Insulin Delivery Systems: Today, Tomorrow and User Requirements

Automated insulin delivery (AID) is the most recent advance in type 1 diabetes (T1D) management. It has the potential to achieve glycemic targets without disabling hypoglycemia, to improve quality of life and reduce diabetes distress and burden associated with self-management. Several AID systems are currently licensed for use by people with T1D in Europe, United States, and the rest of the world. Despite AID becoming a reality in routine clinical practice over the last few years, the commercially hybrid AID and other systems, are still far from a fully optimized automated diabetes management tool. Implementation of AID systems requires education and support of healthcare professionals taking care of people with T1D, as well as users and their families. There is much to do to increase usability, portability, convenience and to reduce the burden associated with the use of the systems. Co-design, involvement of people with lived experience of T1D and robust qualitative assessment is critical to improving the real-world use of AID systems, especially for those who may have greater need. In addition to this, information regarding the psychosocial impact of the use of AID systems in real life is needed. The first commercially available AID systems are not the end of the development journey but are the first step in learning how to optimally automate insulin delivery in a way that is equitably accessible and effective for people living with T1D.

Different frequencies of active interruptions to sitting have distinct effects on 22 h glycemic control in type 2 diabetes

BACKGROUND & AIMS

Whether the frequency of interruptions to sitting time involving simple resistance activities (SRAs), compared to uninterrupted sitting, differentially affected 22 h glycemic control in adults with medication-controlled type 2 diabetes (T2D).

METHODS & RESULTS

Twenty-four participants (13 men; mean ± SD age 62 ± 8 years) completed three 8 h laboratory conditions: SIT: uninterrupted sitting; SRA3: sitting interrupted with 3 min of SRAs every 30 min; and, SRA6: sitting interrupted with 6 min of SRAs every 60 min. Flash glucose monitors assessed glycemic control over a 22 h period. No differences were observed between conditions for overall 22 h glycemic control as measured by AUC_total, mean glucose and time in hyperglycemia. During the 3.5 h post-lunch period, mean glucose was significantly lower during SRA6 (10.1 mmol·L^-1, 95%CI 9.2, 11.0) compared to SIT (11.1 mmol·L^-1, 95%CI 10.2, 12.0; P = 0.006). Post-lunch iAUC_net was significantly lower during SRA6 (6.2 mmol·h·L^-1, 95%CI 3.3, 9.1) compared to SIT (9.9 mmol·h·L^-1, 95%CI 7.0, 12.9; P = 0.003). During the post-lunch period, compared to SIT (2.2 h, 95%CI 1.7, 2.6), time in hyperglycemia was significantly lower during SRA6 (1.5 h, 95%CI 1.0, 1.9, P = 0.001). Nocturnal mean glucose was significantly lower following the SRA3 condition (7.6 mmol·L^-1, 95%CI 7.1, 8.1) compared to SIT (8.1 mmol·L^-1, 95%CI 7.6, 8.7, P = 0.024).

CONCLUSIONS

With standardized total activity time, less-frequent active interruptions to sitting may acutely improve glycemic control; while more-frequent interruptions may be beneficial for nocturnal glucose in those with medication-controlled T2D.

Diabetes Self-Care in Older Adults With Type 1 Diabetes Mellitus: How Does Cognition Influence Self-Management

With increasing knowledge and improvements in options for glycemic control, the life-expectancy of patients with type 1 diabetes mellitus (T1DM) has increased considerably over the past decades. Whereas this is undeniably positive for patients, aging is related to natural decline in cognitive functions. As patients with T1DM across the life-span are susceptible to cognitive deterioration, an interaction with aging may be expected and the risk of development of dementia might be increased. As achieving glycemic control depends on a set of diabetes self-management behaviors, it is imperative to understand how cognitive functions are involved in the upkeep of these behaviors and how cognitive impairment may affect them. In this narrative review, we set out to understand the relationship between cognition and T1DM self-care by first reviewing the glycemic targets in older adults, what treatment options are available, and what cognitive functions they draw upon. We will then review the cognitive literature in older adults that is available and then link both together. Lastly, we finish with clinical recommendations and suggestions for future research.

Evolving Use of Continuous Glucose Monitoring Beyond Intensive Insulin Treatment

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) use in individuals with type 1 diabetes and type 2 diabetes (T2D) who are treated with intensive insulin therapy. A growing body of evidence suggests that CGM use may also confer similar glycemic benefits in T2D individuals who are treated with less-intensive therapies. Investigators are also exploring the potential use of CGM as an aid in weight management. This article reviews the continuing evolution of CGM, focusing on how CGM may be used to improve glycemic control and promote adoption of desired health behaviors within broader T2D and prediabetes populations.

Technology in the management of type 2 diabetes: Present status and future prospects

The growing incidence of type 2 diabetes (T2D) is a significant health concern, representing 90% of diabetes cases worldwide. As the disease progresses, resultant insulin deficiency and hyperglycaemia necessitates insulin therapy in many cases. It has been recognized that a significant number of people who have a clinical requirement for insulin therapy, as well as their healthcare professionals, are reluctant to intensify treatment with insulin due to fear of hypoglycaemia, poor understanding of treatment regimens or lack of engagement, and are therefore at higher risk of developing complications from poor glycaemic control. Over the past decade, the rise of diabetes technologies, including dosing advisors, continuous glucose monitoring systems, insulin pumps and automated insulin delivery systems, has led to great improvements in the therapies available, particularly to those requiring insulin. Although the focus has largely been on delivering these therapies to the type 1 diabetes population, it is becoming increasingly recognized that people with T2D face similar challenges to achieve recommended glycaemic standards and also have the potential to benefit from these advances. In this review, we discuss diabetes technologies that are currently available for people with T2D and the evidence supporting their use, as well as future prospects. We conclude that there is a clinical need to extend the use of these technologies to the T2D population to curb the consequences of suboptimal disease management in this group.

Time in Range as a Research Outcome Measure

Time in range (TIR) is gaining ground as an outcome measure in type 1 diabetes trials. However, inclusion of TIR raises several issues for trial design. In this article, the authors begin by defining TIR and describing the current international consensus around TIR targets. They then expand on evidence for the validity of TIR as a primary clinical trial outcome before concluding with some practical, ethical, and logistical implications.

Standardized Hybrid Closed-Loop System Reporting

The hybrid closed-loop (HCL) system has been shown to improve glycemic control and reduce hypoglycemia. Optimization of HCL settings requires interpretation of the glucose, insulin, and factors affecting glucose such as food intake and exercise. To the best of our knowledge, there is no published guidance on the standardized reporting of HCL systems. Standardization of HCL reporting would make interpretation of data easy across different systems. We reviewed the literature on patient and provider perspectives on downloading and reporting glucose metric preferences. We also incorporated international consensus on standardized reporting for glucose metrics. We describe a single-page HCL data reporting, referred to here as "artificial pancreas (AP) Dashboard." We propose seven components in the AP Dashboard that can provide detailed information and visualization of glucose, insulin, and HCL-specific metrics. The seven components include (A) glucose metrics, (B) hypoglycemia, (C) insulin, (D) user experience, (E) hyperglycemia, (F) glucose modal-day profile, and (G) insight. A single-page report similar to an electrocardiogram can help providers and patients interpret HCL data easily and take the necessary steps to improve glycemic outcomes. We also describe the optimal sampling duration for HCL data download and color coding for visualization ease. We believe that this is a first step in creating a standardized HCL reporting, which may result in better uptake of the systems. For increased adoption, standardized reporting will require input from providers, patients, diabetes device manufacturers, and regulators.

Continuous Glucose Monitoring Devices: Past, Present, and Future Focus on the History and Evolution of Technological Innovation

The concept of implantable glucose sensors has been promulgated for more than 40 years. It is now accepted that continuous glucose monitoring (CGM) increases quality of life by allowing informed diabetes management decisions as a result of more optimized glucose control. The focus of this article is to provide a brief overview of the CGM market history, emerging technologies, and the foreseeable challenges for the next CGM generations as well as proposing possible solutions in an effort to advance the next generation of implantable sensor.

Variation in hypoglycemia ascertainment and report in type 2 diabetes observational studies: a meta-epidemiological study

INTRODUCTION

Observational studies constitute an important evidence base for hypoglycemia in diabetes management. This requires consistent and reliable ascertainment and reporting methodology, particularly in studies of type 2 diabetes where hypoglycemia risk is heterogeneous. Therefore, we aimed to examine the definitions of hypoglycemia used by observational studies of patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted a meta-epidemiological review of observational studies reporting on hypoglycemia or evaluating glucose-lowering medications in adults with type 2 diabetes. MEDLINE and Google Scholar were searched from January 1970 to May 2018. The definitions of non-severe, severe and nocturnal hypoglycemia were examined.

RESULTS

We reviewed 243 studies: 47.7% reported on non-severe hypoglycemia, 77.8% on severe hypoglycemia and 16.9% on nocturnal hypoglycemia; 5.8% did not specify. Among 116 studies reporting non-severe hypoglycemia, 18.1% provided no definition, 23.3% used glucose values, 38.8% relied on patient-reported symptoms, 17.2% accepted either glucose values or patient-reported symptoms and 2.6% relied on International Classification of Disease (ICD) codes. Among 189 studies reporting severe hypoglycemia, 11.1% provided no definition, 53.4% required symptoms needing assistance, 3.7% relied on glucose values, 14.8% relied on ICD codes, 2.6% relied on ICD codes or glucose values and 15.9% required both symptoms needing assistance and glucose values. Overall, 38.2% of non-severe and 67.7% of severe hypoglycemia definitions were consistent with the International Hypoglycemia Study Group.

CONCLUSIONS

The marked heterogeneity in how hypoglycemia is defined in observational studies may contribute to the inadequate understanding and correction of hypoglycemia risk factors among patients with type 2 diabetes.

Impact of Switching from Intermittently Scanned to Real-Time Continuous Glucose Monitoring Systems in a Type 1 Diabetes Patient French Cohort: An Observational Study of Clinical Practices

Aim: Assess the impact of switching from intermittently scanned (FreeStyle Libre [FSL]) to real-time (Dexcom G4 platinum [DG4]) continuous glucose monitoring systems on glycemia control in type 1 diabetes (T1D) patients with high risk of hypoglycemia and/or elevated glycated hemoglobin (HbA1c). Methods: We conducted an observational study in 18 T1D adults with poor glycemic control on FSL. Ambulatory glucose profile data were collected during the last 3 months of FSL use before inclusion (M0 period), during the first 3 months (M3 period) and the last 3 months (M6 period) of DG4 use. Data were then expressed as 24-h averages. Biological HbA1c was measured for all three periods. Patients were their own-controls and statistics were performed using paired t-test or Wilcoxon for matched-pairs. Results: The switch to DG4 at M3 resulted in a higher time-in-range (TIR) 70-180 mg/dL (median [Q1;Q3], 53.1 [44.5;67.3] vs. 41.5 [28.5;62.0], P = 0.0008), and a lower time-below-range <70 mg/dL (TBR mean ± standard deviation (SD), 5.4 ± 3.7 vs. 10.9 ± 7.1, P = 0.0009) and in the glucose % coefficient of variation (%CV mean ± SD, 40.1 vs. 46.9, P = 0.0001). Mean (SD) changes were +10.3 (8.0) percentage points for TIR, -5.5 (5.8) percentage points for TBR, and -6.8 (5.8) percentage points for %CV. These results were confirmed at the M6 period. Conclusions: Switching from FSL to DG4 appears to provide a beneficial therapeutic option without changing insulin delivery systems, regardless of the origin of the patient's initial glycemic issue.

Use of ambulatory glucose monitoring and analysis of ambulatory glucose profile in clinical practice for diabetes management; a position statement of the Arab Society of Paediatric Endocrinology and diabetes

BACKGROUND AND AIM

Diabetes mellitus imposes a significant burden around the world generally and in the Middle East and North Africa specifically. Glucose monitoring is a cornerstone of diabetes management.

METHODS

Glycated haemoglobin has always been the main metric for assessing glycaemic control, but its use is linked with multiple pitfalls. As an alternative, continuous glucose monitoring is becoming a standard of care in many countries. Intermittent scanning glucose monitoring (isCGM) has acquired a worldwide popularity and has been proven to improve glycaemic control, hypoglycaemia detection and prevention, and quality of life.

RESULTS

The most recent International Society of Paediatric and Adolescent Diabetes practice. guidelines recommended its use in young people with diabetes observing Ramadan to ensure safe fasting. At a meeting in Abu Dhabi in November 2019, the Arab Society for Paediatric. Endocrinology and Diabetes brought together a number of regional diabetes experts, patient. representatives and international expert advisors to review the evidence for isCGM and propose. guidelines for its use in the Middle East and North Africa region.

CONCLUSION

In this paper, the authors strongly recommend the use of isCGM for patients in MENA and present general recommendations and compressive specific guidance for physicians and patients, which they believe will also have wider resonance.

Evaluation of the SPECTRUM training programme for real-time continuous glucose monitoring: A real-world multicentre prospective study in 120 adults with type 1 diabetes

AIMS

Comprehensive knowledge, specific skills and data-analysis competences are prerequisites for the successful use of continuous glucose monitoring (CGM) systems. SPECTRUM is a structured training programme for real-time CGM (rtCGM) consisting of a web-based introduction and six group sessions of 90 min each. The 'CGM-TRAIN study' evaluated the efficacy and acceptance of SPECTRUM and rtCGM systems among adults with insulin therapy.

METHODS

Participants (n = 120) were recruited from 10 German diabetes centres in which they were treated under usual care conditions. Outcome measures were rtCGM knowledge, practical skills, satisfaction with the training programme, satisfaction and acceptance of rtCGM system and glycaemic control. Data were collected at study entry, after training completion and at 6-month follow-up.

RESULTS

All participants were diagnosed with type 1 diabetes (56% women, mean age 42.4 ± 13.4 years, diabetes duration 21.6 ± 11.6 years), 110 participants completed the course. After training completion, rtCGM-specific knowledge had improved by 43% (scale: 0-40 points) from 21.2 ± 7.6 to 30.4 ± 4.5 points; p < 0.001. The knowledge-level persisted until follow-up (29.4 ± 4.5). Participants were able to master nearly all the practical requirements of the technology. In addition, rtCGM was highly accepted, and participants were motivated to use their systems continuously. HbA_1c improved slightly from 61 ± 14 mmol/mol (7.7 ± 1.3%) before training to 60 ± 14 mmol/mol (7.6 ± 1.3%) at follow-up (p = 0.04). The training programme itself was favourably rated by participants.

CONCLUSIONS

Under usual out-patient daily care conditions, the training programme SPECTRUM improved knowledge and skills about rtCGM in adults with type 1 diabetes. This was associated with a reduced HbA_1c , high satisfaction and acceptance of rtCGM (Clinical Trials Registry no.: DRKS00014380).

Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel

Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA_1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA_1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA_1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.

Time-in-range as a target in type 2 diabetes: An urgent need

Time-in-range emerged as a valuable blood glucose metric, 'beyond HbA1c' for a deeper insight into glycemic control in people with diabetes. It denotes the proportion of time that a person's glucose level remains within the desired target range (usually 70-180 mg/dL or 3.9-10.0 mmol/L). Though clinical targets in the current recommendations for type 1 and type 2 diabetes are close enough, their clinical profiles and prevalences are quite different. Type 2 diabetes is the commonest form of diabetes. Many clinical trials have challenged the usefulness of HbA1c as a glycemic target for Type 2 diabetes mellitus. On account of the higher prevalence and complications of type 2 diabetes, more outcomes-based studies are needed to associate time-in-range with its ongoing risk. These studies strongly support the dependability of time-in-range to identify patients with elevated risk in type 2 diabetes. We discuss the utility of time-in-range, a new metric of continuous glucose monitoring as an outcome measure to correlate with type 2 diabetes risks and complications and to analyze the effectiveness of type 2 diabetes management. This approach may support the use of time-in-range as a metric for long-term health outcomes in the type 2 diabetes population.

Glucose Variability and Time in Range in Type 2 Diabetes Treated with U-500R by Pump or Injection: CGM Findings from the VIVID Study

Background: The EValuating U-500R Infusion Versus Injection in Type 2 Diabetes Mellitus (VIVID) study compared two methods of U-500R insulin delivery, continuous subcutaneous insulin infusion (CSII) and multiple daily injection (MDI), for 26 weeks in people with type 2 diabetes (T2D) requiring high doses of insulin. To assess glycemic variability (GV) and time in range (TIR), a subset of participants performed masked continuous glucose monitoring (CGM). Methods: VIVID participants were adults who had insulin requirements of >200 but ≤600 U/day and A1C 7.5% to 12%. Participants performed masked CGM for seven consecutive days on each of three occasions: before weeks 0 (baseline), 14, and 26. The primary objective was to compare GV between CSII and MDI groups, based on change from baseline of within-day standard deviation (SD_w) of CGM glucose. Results: Of 54 participants enrolled, 41 with evaluable data were analyzed (17 and 24 in CSII and MDI groups, respectively). The CSII group had a significantly greater reduction from baseline in mean SD_w of glucose (45.0 to 38.2 mg/dL [-8.1 mg/dL]) compared with the MDI group (47.0 to 45.8 [-0.4 mg/dL]; P = 0.047). TIR 70-180 mg/dL glucose increased significantly from baseline in the CSII group only, from 59.8% to 73.1% (change +12.9%, P < 0.05), but was not significantly different between groups. There were no significant between-group differences in the endpoint mean glucose or A1C. Conclusions: In the VIVID CGM substudy of U-500R in people with T2D requiring high doses of insulin, participants using CSII significantly reduced GV compared with MDI. CSII also significantly increased TIR with no difference between groups.

Glycemic Variability, Oxidative Stress, and Impact on Complications Related to Type 2 Diabetes Mellitus

Chronic hyperglycemia is an established risk factor for the development of complications in both type 1 and type 2 diabetes, but glycemic variability has emerged as a possible independent risk factor for diabetes complications, possibly through oxidative stress. In this review, methods to access glycemic variability and oxidative stress, as well as their correlations, are discussed. Non-pharmacological and pharmacological strategies are also debated to achieve better glycemic control, not only by HbA1c target but also with reduced glycemic fluctuations, possibly minimizing the risk of diabetes complications.

Review of the veteran affairs diabetes trial: Lessons learned

Despite robust evidence linking long-term hyperglycemia with cardiovascular complications, several large randomized trials found only modest benefits from intensive compared to standard glucose control. Of these trials, the Veteran Affairs Diabetes Trial (VADT), offers a unique long-term perspective in that there were analyses of outcomes at the end of the intervention trial, 5-years post-trial, and after 10-years post-trial. From the VADT and other large trials, we draw several valuable lessons that are relevant to the care of patients with type 2 diabetes. Intensive glucose control reduces development of nephropathy and retinopathy but not neuropathy, though evaluations of neuropathy are less consistent and conclusions regarding outcomes less reliable. While the VADT did not demonstrate reduction in cardiovascular outcomes at completion of the glucose lowering intervention, it did demonstrate a 17% reduction 5-years post-trial, which waned by 10-years post-trial observation. Of interest, the 5-year post trial period included 3 additional years of HbA1c separation between treatment groups which suggests that longer-term glucose control may be needed before benefits are seen. Other factors including hypoglycemia and increased glucose variation are also associated with cardiovascular events and are more prevalent during intensive glucose control, potentially lessening the benefit of lowering average glucose levels. Finally, intensive glucose control requires substantial effort from both the patient and clinician perspective. All of these factors must be kept in mind when considering the benefits of aggressive glucose control for each patient.

Simple Post-Processing of Continuous Glucose Monitoring Measurements Improves Endpoints in Clinical Trials

BACKGROUND

Continuous glucose monitoring (CGM) is a powerful tool to be considered both in clinical practice and clinical trials. However, CGM has been criticized for being inaccurate for many reasons including a physiological delay. This study sought to investigate the current delay issue and propose a simple post-processing procedure.

METHOD

More than a million hours of the Dexcom G4 CGM from 472 subjects investigated in a state-of-the-art clinical trial were analyzed by time shifting the CGM measurements and comparing them to plasma glucose (PG) measurements. The resultant CGM measurements were then assessed in relation to real-world clinical research endpoints.

RESULTS

A CGM time shift of -9 minutes was optimal and reduced mean absolute relative difference (MARD) statistically significantly with 1.0% point. The MARD reduction resulted in better clinical research endpoints of hypoglycemia and postprandial glucose increments.

CONCLUSIONS

The delay in CGM is still an issue. The delay in this study was identified to be 9 minutes compared to PG. With a simple post-processing approach of time shifting the CGM measurements with -9 minutes, it was possible to obtain a statistically significantly lower MARD and subsequently obtain clinical research endpoints of improved validity.

Impact of provision of optimum diabetes care on the safety of fasting in Ramadan in adult and adolescent patients with type 1 diabetes mellitus

BACKGROUND

All diabetes and Ramadan guidelines advice against fasting for people with type 1 diabetes, however, many insist on fasting. Consequently, this causes a challenge due to the risk of hypoglycaemia, hyperglycemia ± diabetic ketoacidosis.

AIM

To assess the impact of optimum care, which includes Ramadan-focused education, flash glucose monitoring, dietary advice and treatment adjustment on the safety of Ramadan fasting in people with type 1 diabetes.

METHODS

Thirty persons with type 1 diabetes who insisted to fast during Ramadan were recruited to the study. At pre-Ramadan visit, all patients received Ramadan focused education and Freestyle Libre (FSL) sensor insertion and training. Patients used the sensor for 6 weeks (pre-Ramadan and during Ramadan). The physical and biological parameters were collected 2-4 weeks before and after Ramadan.

RESULTS

22 patients on basal bolus insulin and 2 on an insulin pump had FSL data. Average number of days fasted were 24. Learning benefits was reported by 95% of patients following pre-Ramadan educational session. There was no clinically significant change in physical and/or biological data between pre and post-Ramadan. 63% reported making insulin dose adjustments in Ramadan. Flash glucose monitoring data showed 46.7% of patients had more than 10 hypoglycemic episodes in the 2 weeks prior to Ramadan compared to 29.2% during Ramadan. However, none of the data were statistically significant apart from HbA1c which reduced from prior to RamadanHbA1c of 8.2% to 7.9% post Ramadan (P 0.010). There was one DKA on 2nd day of Ramadan, reported due to missing insulin dose to avoid hypoglycemia.

CONCLUSION

Optimal care of selective patients with type 1 diabetes with a low complication rate may allow Ramadan fasting with improvement in glycemic control and without an increase in hypoglycemia, biometric or metabolic parameters. Larger, randomized controlled trials are required to be able to generalize this as a recommendation.

A systematic review on clinical implication of continuous glucose monitoring in diabetes management

Objective

The aim of this systematic review was to evaluate the clinical implications of continuous glucose monitoring (CGM) among patients with diabetes mellitus using variables that include glycated hemoglobin (HbA1c), estimated A1c, glucose variability, and users' perspectives.

Materials and Methods

This study analyzed 17 articles that were identified and studied according to the research question criteria. PRISMA guidelines were used for identification and screening of the literature. The required data were searched using Medscape, PubMed, PROSPERO, Wiley Library, Scopus, Clinical Trial Registry, and Trip.

Results

The articles reviewed were on the use of CGM in type 1 and type 2 diabetes mellitus, which showed significant improvement in the levels of HbA1c as compared to non-CGM. The application of CGM on acute sudden onset type of adverse drug reactions (i.e., hypoglycemia) is better than fasting blood sugar or self-monitoring of blood glucose or capillary blood glucose (random blood glucose monitoring). CGM is beneficial for use in patients with type 2 diabetes mellitus including elderly patients as it gives information regarding glucose variability as well as HbA1c levels. The health-care providers require full spectrum of patients' CGM data to design a better therapeutic plan. However, the patients experienced inconvenience on wearing the device on the body for longer periods. The findings also stated the fact that more education and training is required for the patients to interpret their own glycemic data using CGM and modify their lifestyle accordingly. Use of CGM along with HbA1c has also been used to achieve better glycemic results and it allows the health care professional to guide patients in terms of their glucose level; whether they are hypoglycemic or hyperglycemic, however its use has some controversies that minimize its application.

Conclusion

The study concluded that CGM has significant potential in the management of not only patients with type 1 diabetes mellitus but also patients with type 2 diabetes mellitus in spite of the few limitations that are being improvised in the upcoming years. However, limited literature of CGM among patients with type 2 diabetes mellitus and pregnant women reduces the practice scope.

Continuous Glucose Monitoring in Adults with Type 1 Diabetes: Real-World Data from the German/Austrian Prospective Diabetes Follow-Up Registry

Background: To analyze key indicators of metabolic control in adults with type 1 diabetes (T1D) using real-time or intermittent scanning continuous glucose monitoring (rtCGM/iscCGM) during real-life care, based on the German/Austrian/Swiss Prospective Diabetes Follow-up (DPV) registry. Methods: Cross-sectional analysis including 233 adults with T1D using CGM. We assessed CGM metrics by gender, age group (18 to <30 years vs. ≥30 years), insulin delivery method (multiple daily injections vs. continuous subcutaneous insulin infusion [CSII]) and sensor type (iscCGM vs. rtCGM), working days versus weekends, and daytime versus night-time using multivariable linear regression models (adjusted for demographic variables) or Wilcoxon signed-rank test. Results: Overall, 79/21% of T1D patients used iscCGM/rtCGM. Those aged ≥30 years spent more time in range (TIR [70-180 mg/dL] 54% vs. 49%) and hypoglycemic range <70 mg/dL (7% vs. 5%), less time in hyperglycemic range >180 mg/dL (38% vs. 46%) and had a lower glucose variability (coefficient of variation [CV] 36% vs. 37%) compared with adults aged <30 years. We found no significant differences between genders. Multivariable regression models revealed the highest Time In Range (TIR) and lowest time with sensor glucose >250 mg/dL, CV and daytime-night-time differences in those treated with CSII and rtCGM. Glucose profiles were slightly more favorable on working days. Conclusions: In our real-world data, rtCGM versus iscCGM was associated with a higher percentage of TIR and improved metabolic stability. Differences in ambulatory glucose profiles on working and weekend days may indicate lifestyle habits affecting glycemic stability. Real-life CGM results should be included in benchmarking reports in addition to hemoglobin A1c (HbA1c) and history of hypoglycemia.

Glycemic variability: adverse clinical outcomes and how to improve it?

Glycemic variability (GV), defined as an integral component of glucose homoeostasis, is emerging as an important metric to consider when assessing glycemic control in clinical practice. Although it remains yet no consensus, accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. In this review, we summarize the adverse clinical outcomes of GV and discuss the beneficial measures, including continuous glucose monitoring, drugs, dietary interventions and exercise training, to improve it, aiming at better addressing the challenging aspect of blood glucose management.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Relationships between Thigh and Waist Circumference, Hemoglobin Glycation Index, and Carotid Plaque in Patients with Type 2 Diabetes

BACKGROUND

This study investigated the relationships of thigh and waist circumference with the hemoglobin glycation index (HGI) and carotid atherosclerosis in patients with type 2 diabetes.

METHODS

This observational study included 3,075 Korean patients with type 2 diabetes, in whom anthropometric measurements and carotid ultrasonography were conducted. HGI was defined as the measured hemoglobin A1c (HbA1c) level minus the predicted HbA1c level, which was calculated using the linear relationship between HbA1c and fasting plasma glucose levels. Carotid atherosclerosis was defined as a clearly isolated focal plaque or focal wall thickening &gt;50% of the surrounding intima-media thickness.

RESULTS

The frequency of a positive HGI decreased with increasing thigh circumference in men and increased with increasing waist circumference in women after adjusting for potential confounding variables. Thigh and waist circumference had a combined augmentative effect on the likelihood of positive HGI, which was dramatically higher in patients in higher waist-to-thigh ratio quartiles (adjusted odds ratios for the highest compared to the lowest quartile: 1.595 in men and 1.570 in women). Additionally, the larger the thigh circumference, the lower the risk of carotid atherosclerosis, although in women, this relationship lacked significance after adjustment for potential confounders.

CONCLUSION

HGI was associated with thigh circumference in men and waist circumference in women. In addition, the combination of low thigh circumference and high waist circumference was strongly associated with a higher HGI in Korean patients with type 2 diabetes. In particular, thigh circumference was associated with carotid atherosclerosis in men. However, further longitudinal studies are warranted.

Assessment of factors that determine the mean absolute relative difference in flash glucose monitoring with reference to plasma glucose levels in Japanese subjects without diabetes

The Abbott FreeStyle Libre flash glucose monitoring system (FGM) is a recently introduced, but widespread continuous glucose monitoring system. While its mean absolute relative difference (MARD) value indicating its accuracy is acceptable with reference to the self-monitoring of blood glucose (SMBG) levels, few reports have examined the MARD in sensor glucose values of FGM (FGM-SG) with reference to plasma glucose (PG) levels and the factors determining it. We performed oral glucose tolerance tests (OGTTs) in 25 Japanese subjects without diabetes. Parkes error grid analyses showed that FGM-SG with either SMBG or PG levels as a reference met International Organization for Standardization criteria. The MARD in FGM-SG with reference to SMBG levels was 10.9 ± 4.1% during OGTTs. Surprisingly, the MARD in FGM-SG with reference to PG levels was 20.3 ± 10.3% during OGTTs, revealing a discrepancy in the accuracy of FGM-SG compared with that of PG levels; moreover, the MARD showed negative correlations with fasting blood sugar level, homeostasis model assessment insulin resistance index, and body mass index (BMI). Multiple regression analyses revealed that BMI contributed the most to the MARD when FGM-SG and PG level were compared, as lean individuals have a greater MARD regardless of glucose levels. Inaccurate FGM data could potentially increase the risk of inappropriate treatment; consideration of such factors is critical to ensure reliable FGM values.

Clinical Recommendations for the Use of the Ambulatory Glucose Profile in Diabetes Care

BACKGROUND

The ambulatory glucose profile (AGP) uses the wealth of data that are generated by continuous glucose monitoring, including flash glucose monitoring technologies, to provide a visual representation of glucose levels over a typical standard day of usually the most recent two weeks for a person with diabetes and helps to identify patterns and trends in glucose control. The AGP allows certain patterns of glucose levels to be identified and analyzed, such that treatment adjustments can be made, and new individual treatment goals can be defined. This helps to ensure increased treatment satisfaction and adherence, quality of life, and an improvement in metabolic management for people with diabetes.

OBJECTIVE

To date, a range of approaches exists for interpreting the information contained in an AGP, with different priorities given to identifying and targeting patterns of hypoglycemia and the degree of variability and stability underlying the glucose levels. The objective of the present recommendation is to describe the steps for assessing an AGP in detail and to illustrate these steps using visual examples.

CONCLUSION

This paper describes the consensus recommendations from a group of German expert diabetologists on the necessary steps for assessing an AGP in a structured and detailed way and to explain these steps using practical clinical examples.

Effects of Continuous Glucose Monitoring on Metrics of Glycemic Control in Diabetes: A Systematic Review With Meta-analysis of Randomized Controlled Trials

BACKGROUND

Continuous glucose monitoring (CGM) provides important information to aid in achieving glycemic targets in people with diabetes.

PURPOSE

We performed a meta-analysis of randomized controlled trials (RCTs) comparing CGM with usual care for parameters of glycemic control in both type 1 and type 2 diabetes.

DATA SOURCES

Many electronic databases were searched for articles published from inception until 30 June 2019.

STUDY SELECTION

We selected RCTs that assessed both changes in HbA_1c and time in target range (TIR), together with time below range (TBR), time above range (TAR), and glucose variability expressed as coefficient of variation (CV).

DATA EXTRACTION

Data were extracted from each trial by two investigators.

DATA SYNTHESIS

All results were analyzed by a random effects model to calculate the weighted mean difference (WMD) with the 95% CI. We identified 15 RCTs, lasting 12-36 weeks and involving 2,461 patients. Compared with the usual care (overall data), CGM was associated with modest reduction in HbA_1c (WMD -0.17%, 95% CI -0.29 to -0.06, I ² = 96.2%), increase in TIR (WMD 70.74 min, 95% CI 46.73-94.76, I ² = 66.3%), and lower TAR, TBR, and CV, with heterogeneity between studies. The increase in TIR was significant and robust independently of diabetes type, method of insulin delivery, and reason for CGM use. In preplanned subgroup analyses, real-time CGM led to the higher improvement in mean HbA_1c (WMD -0.23%, 95% CI -0.36 to -0.10, P < 0.001), TIR (WMD 83.49 min, 95% CI 52.68-114.30, P < 0.001), and TAR, whereas both intermittently scanned CGM and sensor-augmented pump were associated with the greater decline in TBR.

LIMITATIONS

Heterogeneity was high for most of the study outcomes; all studies were sponsored by industry, had short duration, and used an open-label design.

CONCLUSIONS

CGM improves glycemic control by expanding TIR and decreasing TBR, TAR, and glucose variability in both type 1 and type 2 diabetes.