Hello, I'm Thomas Dunner from Hanover Medical School. And it's my pleasure. Thank you very much rich for starting this all to now talk about how we can maximize the patient engagement and satisfaction with the sensor based glucose monitoring and diabetes. First, let me show my disclosures and you see, we are doing quite a lot of research in Hanover and um to kind of get started. Um, let's take a look back into the DC CT trial and this data was analyzed again to show us what it means how early diabetes control matters in a long time. Here, you see two different people. Both of them have the same average glycaemic control over the time. But patient number or the person with diabetes number A actually has a good control in the beginning with uh A one C of seven and the average glucose of 1 53 while uh the person B achieves a 9% A one C and has an average glucose control of 210. Now, obviously, uh patient B is improving and patient A is not doing so well in the second uh decade. Now, what happens if we look although both have the same glycaemic exposure over 20 years. The person A actually has a 33% reduction in the risk of CV D compared to per uh person B and a 52% reduction in the EGFR in the kidney function. So, this early control is important and means for us people who are treating people with diabetes, we should do every effort to make them achieve best possible. Glycaemic control. From early on. Clearly, this results into greater reduction of the risk of kidney and cardiovascular complications. Relative to the later implementation of better glycemic control. How about type two diabetes? And again, if we look at what it means, 1% decrease in A one C for people with type two diabetes. The UK P DS study also showed the legacy effect for microvascular complication, an emergent risk, uh uh complication for death from any cause. You can see for example, a 43 reduction in amputation, you see a 37% reduction microvascular complications, 21% related uh diabetes related death, 14% for myocardial infarction and overall of 40% all cause mortality and this although everything was adjusted for age blood pressure, gender, ethnic background, smoking, uria and the lipids, all those things that we know also matter. So clearly early control, early good glycaemic control matters both for people with type one or type two diabetes. But now I have to put a little bit. Um well, another thought into this because take a look at these two curves of glucose, they have the same A one C. But the glycemic variability is hugely different. And also the risk of hypoglycemia is quite different because the person in red has a high glycaemic variability and lots of hypoglycemia and the green person does not so clearly, the A one C is just an average and may not reflect the time and range and the glucose variability. And I will show you in a moment that that matters a lot to people with diabetes who have to face this glycaemic variability every day in in and out. And of course, any type of therapy which reduces the glycaemic variability also improves the well-being of uh people with diabetes. So really to kind of um make my point clear from the start, what I was trying to tell you is that you kind of validate the A one C in showing what is really behind it. Uh because the time and range now really rep represents the blood glucose levels uh in terms of the variability, the highs and the lows that really characterize the life with diabetes. And so more and more people are going over this bridge and kind of add information to the A one C by using time and range. If we have glucose monitoring, continues glucose monitoring. For example, with the flash glucose monitor, both people with type one and type two diabetes. As we just can see from this um re recent meta analysis, whether we take studies that are short, 3 to 4 months or longer uh studies that are taken 4 to 7 months. You see there are many trials showing that uh both in adults with type one diabetes or with type two diabetes on the right, whether you take the short or the long trials have quite a considerable improvement in A one C when people are using CGM. Uh compared uh with uh those that are not using uh CGM. And this is uh really there's indication that this is sustained for 24 months in people with type one diabetes and for at least 12 months in those type two, with type two. Now, what does this all mean for the person with diabetes? Well, here we are asking three different groups on the left. You see people with type one diabetes in the middle, you see uh people with type two diabetes which are on insulin and on the right. You see people with type two diabetes, which are not on insulin. Interestingly, both for those with type one diabetes and with type two diabetes. What is really the most important for a positive mindset is whether your blood glucose numbers are on target all day in and out. And obviously, as I have shown you before having this information with the continuous glucose monitor is likely to help them with that for those not on insulin it really comes in in a close second. So even those people who are not necessarily having insulin and have some medication or uh lifestyle changes, it's really a biofeedback having these uh uh numbers uh available to you. Um and being able to react on those, uh for uh really achieving a positive mindset. Now, the diatribe foundation, obviously, this is a, a group of mainly us people who have diabetes who are really very engaged with their diabetes. But nevertheless, you see those numbers are in the tho thousands. And diatribe really proposes the, the possibility of uh using time and range to improve your outcome uh with uh diabetes, whether it's type one or type two with a time and range coalition. And you can see that these 3455 online service with a, with a big uh uh response rate. Um and had several questions show that in those well informed people, time and range really becomes something very, very important that they can easily relate to. And I'll show you in a moment how I would consider, uh we should move forward here. So, um now how, how does this whole issue of CGM actually relate to satisfaction uh of people with diabetes? And I hear very often in the old days that people said it will drive people crazy to have all these numbers. They don't know what to do. It's, it's too much overload of information. Uh CGM is not really doing it wrong. You see here, treatment satisfaction score in type one diabetes, top type two diabetes, bottom, the treatment satisfaction score is significantly better if you had access to continuous glucose monitoring. In this case with freestyle Libra. Now, uh if we take a deeper dive into, into this treatment satisfaction, what does it really mean? Or where, where is the satisfaction? It's first of all, the treat you more um satisfied with your treatment, you find your treatment more uh convenient and flexible because you really have the biofeedback with your CGM values. It leads to better understanding of your diabetes. It's easier to, to follow treatment recommendations. So, uh you, you see that in the subs coast or I want to continue with this type of treatment, both is there in type one and type two diabetes and if we take a little bit further, we, you know, very often we say, well, those elderly with type two diabetes, maybe they are overwhelmed. They, they're not so, um close to a um technology and, and, and they might have problems there. I don't believe so. Uh you know, my 92 year old father, he uses whatsapp. He can, you know, have simple technology is easy to understand also when you're uh not so young anymore. And again, you can see this also holds clue to for a freestyle Libra. You see that the total treatment satisfaction also in those elderly 267 elderly is significantly, uh, better. And again, if we look at the sub scores, again, it's, it's very similar to, to the previous, uh, survey, uh, both in type one and type two diabetes, which we have seen before. Um, we can see that uh, this, uh, really, uh, is basically the same and on top of that, the perceived frequency of hyperglycemia was significantly, uh less after using AC GM compared to BGM. And also uh that uh related particularly to the daily scan frequency. Uh you saw a decrease in A one C. So those who are using it frequently for their biofeedback were able to achieve a better glycaemic control. Um 0.036% a one C rejection, which was uh statistically significant. OK. So now what does it really mean uh uh for, for people uh when they uh they have, you know, better ways of managing their blood glucose? The most important point here is that sensor based CGM users report generally that they have a better understanding of their glucose fluctuations. Obviously, not every day is working out well. But again, you have this biofeedback tool, you see what is happening, you can relate it to what you have done previously and you can then discuss with your diabetes team what to do better. And so it doesn't, it's no surprise that 92% also found it easier to manage their mealtime glucose, particularly those, those, those highs and they might even uh not inju their therapy, but rather they uh the food that they eat, if they see that something is particularly difficult to deal with. And uh again, uh more than two thirds, uh 77% actually feel that the number of their hypoglycemia events was reduced. And also those who are engaging in physical activity, um you felt more secure uh in, in doing so if you have um the uh the access to continuous glucose monitoring. So if we look, for example, what that also means for ho hospitalization, which you know, both counts for um you know, disturbance in your life. But also, of course, there's a big cost issue. The flare study showed a decrease in both absenteeism of uh uh work and also um in, in patients with type one diabetes, uh reduction in hospital admissions, 66% less uh um admissions to the hospital, 58% less reduction in work absenteeism. I think this shows what it really is a big saving both in well uh uh reduced quality of life. And in the end of course, uh money both on the side of the the patient as well as uh the insurances. So um six months after getting AC GM type two diabetes patients, not on bolus insulin. In this study saw a 30% reduction in acute diabetes events that really counts a lot. Now, how about the long term outcomes? Obviously, with CGM, we don't have the type of long term outcomes like we have in the DC CD. But there are mathematical ways to kind of translate um the time and range into um HB one C and, and, and use those models that we have both for type one and type two diabetes to kind of calculate, you know, what type of risk production uh would be happening in. If, if you know, we have would have 10 years of uh an improved uh uh time and range. And you can see an improved time and range would uh really lead on a, on a uh kind of the more time and range you'll have uh the more uh improvement in your uh long term outcome you, you would have have and you, you can see already not having ideal time and range only 58% already. That would show you quite a uh quite an uh reduction in, in uh myocardial infection and so on. If, if you improve it from to 70% which is usually considered um as the target of both for people with type one and type two diabetes. And if you're even able to do better and have 80% then again, uh this will be uh um showing you um further reduction. So of course, we have to say, well, yeah, money makes the world go around. Let's let's take a look at uh the finances here because obviously continuous glucose monitoring might be an added cost. But how does that pay off in the long run? Depending on which type of um equation you can see you, you use uh nevertheless, um both uh equations kind of give you a big saving both in type one and even more in type two diabetes using this kind of uh translation of time and range into a one C uh between two to up to $7 billion that you can save by improving uh your time and range. Using um the, the, the CGM when you're able to reach the CGM target of 70% time and range or even 80% time and range. So, uh clearly, um I think uh this shows you depending, not only the, the, the, the um kind of the improvement with less complications, but obviously, the same also goes for the acute complications of hypoglycemia, which is also reduced uh with uh CGM. And here you see a kind of the numbers depending on how much you reduce the acute complication of hypoglycemia. If you reduce it by 10% it's already 1.2 billion. And this goes up to 2.8 billion if you reduce it to 40%. So basically, when we can uh already say right now that um there is a good reason for using uh CGM uh in uh people with type one and type two diabetes. And we find this now in uh the um uh standards of care. Um in the recommendations saying that the use of CGM devices should be considered from the outset of the disease because we have seen that it is important from very early on to achieve good glycaemic control and particularly those that are using uh uh insulin management. But if you take a little closer look, I mean, it says here uh in those not using uh noninsulin uh therapies, um the blood loose con control with, uh, fingersticks has not always showed, uh, uh, uh, to be very, very helpful. But particularly if you change something, if you change the nutrition plan, if you have a physical activities and change your medications you want, might wanna do blood glucose. And this in my mind translates as well. If you wanna do blood glucose, why don't you don't have the, the whole picture without fingersticks and have an intermittent use of a, of AC GM to, to do this clearly for those, uh, adults with, um, uh, diabetes who are, have multiple injections or continuous, sub continuous insulin fusion. Um, or, uh, even those, uh, which are using, uh, diabetes management, uh, with a basal insulin, you would recommend of course, using AC GM, particularly to, uh, reduce acute complications. And the same, of course holds true, uh, for, uh, the youth with type one diabetes and type two diabetes, once they have, uh, they are on insulin, of course, with type one diabetes, they are usually always on insulin you would uh and in, in our clinic, all people with type one diabetes and all youth with type two diabetes have AC GM uh if uh if this is possible with their, their insurance, which in, in, in Germany is possible. So, so how do do I do it? I mean, in, in, in the daily um clinic and, and why is this so successful? Well, it is because we have something where we can relate to eye to eye and, and you know, we can look at the data together, we have um a shared decision making. Um I can say, well, you know, I would recommend this and that change of, of the therapy, you can upload your data, you can actually look at it or you have it on your cell phone. If the green bar is increasing, we're doing well. And then I, I probably, you know, it worked what we decided on if the red bar is increasing uh on top of the green bar. Well, you know, you increase your hypoglycemia, maybe, then we have to adjust something if the green bar is not increasing. Ok, then time range is not increasing, then, you know, maybe we have to get together again and discuss what we uh need to do. And then as uh which has uh shown you already use the A GP to kind of look a little bit in more detail how um the therapy needs to adjust it where actually uh the, the the the issues are so we really are able to, to speed up actually the time of consultation because we have a, a common language using the CCGM data and easy to understand way of, of showing uh time and range with the red, green, yellow and orange bars. So, you know, what are you waiting for? I think we, we have shown that uh early glycaemic control is extremely important. We shouldn't wait later in the disease before you know, some time uh uh went through with poor control. We have the metabolic memory both in type one probably and in type two diabetes. And uh we need to avoid that, that uh that memory and and make it a good memory, the good as possible. We know that the CGM use leads to more patient satisfaction, improves cli uh quality of life, reduces hospital admissions, reduces absenteeism from work work. And also the long term prognosis less uh uh my in fact, infection or end stage renal disease, severe vision, vision loss, amputation, all these things in the end lead uh to, to a better life of people with type one and type two diabetes. And also if we look at the cost issues, there is good reason to believe it is cost effective. So I think we health care professionals are in a key position to educate and provide CGM to help, to improve the outcomes of people with diabetes in that are in our care. So, with this, I wish you well. And thank you very much for your attention and greetings from our team in Hanover, which is working while I'm speaking here. Thank you very much.