Video The Foundational Role of CGM for Outcome-Optimizing Behavioral and Lifestyle-Based Interventions Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides The Foundational Role of CGM for Outcome-Optimizing Behavioral and Lifestyle-Based Interventions Overview CONTINUE TO TEST Back to Symposium Hello everyone. My name is Ramsey Ajan. I'm a professor of metabolic medicine working in Leeds, United Kingdom. I'm very pleased and absolutely delighted to have you here in this meeting where we're going to discuss the use of CGM in diabetes. This symposium is supported by an education grant from other diabetes Care. And in addition to myself, we've got 2 speakers. Professor Monica Kellerer. Who's going to talk to you about, again, use of CGM. And also Michael Wallis, who is an associate professor in family medicine. Again, who's going to talk to you about behavioral changes with the use of CGM. Now, the title of my talk is in front of you. And I'm going to show you some cases here to emphasize how CGM can help in the management of people with diabetes. This is my disclosure slide. And moving on from there. So if you think of the two main types of diabetes, in type 2 diabetes, we initially manage with diet and exercise. And of course, eventually we add in medication and quite frequently we add in medication from the very start of the diagnosis. In type 2, in type 1 diabetes, we treat them with insulin, but unfortunately because you're giving insulin subcutaneously, people start to develop insulin resistance and they get a phenotype of a type 2 diabetes patient. So they get this mixed type of diabetes with a longer duration of type 1 diabetes. And the main problem with diabetes is that hyperglycemia can be asymptomatic. So usually there's no reaction to what you do not feel. And here is a prime example. I mean, these are people with diabetes who are started on an insulin sensor, and as you can see within 72 hours of wearing the sensor. The hypoglycemic exposure is reduced by 74%. Now this is not due to the effect of the healthcare professional telling the patient what to do, but the patient reacting to hypoglycemia. And it doesn't matter whether you're looking at hypoglycemia as a less than 70 mg per deciliter, 55 or 45 mg per deciliter, you do get an improvement. So you're reacting to those numbers. And this is a a nice little study showing that in 40 participants with insulin treated diabetes, majority were on a pump, survey showed that 88% noticed that actually the food choices affect glucose levels. 43% reported being more active after CGMUs, around 28% were already active, and 23% reported no difference. But importantly, the vast majority, 90% felt that CGM contributed to a healthier lifestyle, so it's affecting their lifestyle. And this is an example from one of my patients, so this is a patient who is getting a peak in glucose levels. Before going to bed, and then sometimes overcorrecting that peak and having a hypoglycemia. And this wasn't my intervention, as you can see, just a week later, things are much better. And I said, so what did you do? He said, Well, doctor, rather than eating a whole banana, I started to eat half a banana before bed to somebody who liked bananas. And indeed, if you look at motivating lifestyle modification uses the patient driven healthy driven healthier food choices, um, in this PDF study, you can see that if you give somebody. Um, glucose sensor plus structured education, they certainly get better control in their glucose levels. You can see the HbA1c shifting to the left, that's your red line. So at all levels, all levels um uh of HBA1C you do get an improvement. Now, um, patients who are not on insulin. Um, you can see again that if you have CGM alone or CGM plus food diaries. You do get an improvement, a reduction in time above range, an increase in time in range. And these changes occurred in the 1st 3 months, the majority of the change within the 1st 3 months where there were no medication changes. And of course you do get a reduction in A1C and in response, and you even get a change in weight. So the black line is the CGM alone and the CGM plus food diaries is the red line. There's no real difference if you add in the food diaries, so the CGM has done the job. Now, let's just discuss some cases here. So Alice, it's not her real name, but is a 25 year old lady. Type 1 diabetes for 16 years, she's got an A1C of 47 million more per more, which we all agree is pretty good. She's delighted by her HbA1C, says all is well and is keen to leave clinic. Are we satisfied? Well, the answer is no, because you need to know more than just HBA1C. Of course, when you look at her CGM data, the timing range is pretty impressive, 83%. But you start looking at the time below range is 10%. That's excessive. So looking at this, what is the most likely cause for her nocturnal hypoglycemia? And for those of you who haven't noticed, I would like to remind you that she was born on the 9th of May. That may have relevance or maybe be absolutely nothing. So what's the most likely cause for her nocturnal hypoglycem? Is it too much basal insulin? Possibly late injection of bless insulin. Well, unlikely there's no evidence for that. Alcohol maybe, exercise may be inappropriate correction ratio. Well, I would say that's unlikely because we're not seeing high glucose levels. And if you start looking at the days when she's having the hypos. You've got both Saturdays early hours, so maybe because she was out the night before on Friday. You've got then Monday, remember, birthday is on the 9th. So this, all these are pointers that this is likely to be an alcohol effect. And indeed when you discuss it with the patient, it was alcohol related, so you can give them the appropriate advice regarding alcohol. And for the eagle-eyed, you, you might have spotted that, that actually wasn't alcohol related, that was related to exercise the night before. So as you can see, you've got to be really um uh savvy when you're discussing things with a patient and explore all possibilities. So, this is John, who's 32 years old. Got tampon derbies for 23 years. A1C is very, very good. One MDI does not want an insulin pump and training for the London Marathon. So how do we manage him? And somebody like him definitely will need a CGM and you start looking at the CGM and you say, gosh, that is too much hypoglycemia. There's 23% of hypoglycemia. So that's pretty excessive training for the marathon. Is this exercise rated? Yes, almost certainly. So you give the right advice when it comes to exercise, and look, you can reduce it relatively easily from 23% to just 1%, and it's all level one, which we are not too worried about. What about this one? So, this is a case of somebody, would you say that this is related to exercise? Now, when you look at it, this is an increased period of hypoglycemia at night and also during the day. And actually, this wasn't exercise related. This was somebody who was vomiting, was unwell for a few days and. Should have adjusted insulin to some extent, maybe was still having too much insulin in and was having hypoglycemia, but everything corrected from the 15th. So this is not a pattern you usually see post exercise. And I would like to bring your attention to a study that will be presented at the ATTD. Assessing the impact of switching from real time CGM with predictive alarm to intermittently scan CGM with no alarm. Um, with alarms, they can be very helpful, but you've got to remember that some people get alarm fatigue. So this is, this study was done in 660 adults with type 1 diabetes, and they looked at the rate of severe hypoglycemic events before and after the switch. And as you can see here, there was a decrease with the switch. Now we can argue what the mechanisms for that, what, where, but this is something I encourage you to go and explore with with the people who wrote this really nice abstract. What about this case? This is Elizabeth who's 71 years old. She's got type 2 diabetes for 14 years. Her A1C is somewhat above target, but is not disastrous. BMI is 35, and she's on metformin, glilozide, and tezepatide. Now, what new therapy was introduced on the 13th of February? And is that insulin, is that GLP one receptor and the goodis, is that gliflozin, is that nothing? And actually, all that happened here in this particular lady that she started having the GLP one receptor agonist that she wasn't injecting before. And it it it is pretty typical that you see in, in people, you can see a very quick response to those high glucose peaks after having the GLP one receptor agonists. So this is something that prompted her to make sure that she's having her injections. What about Gareth, who's 64 years old, Tattoo abies for 11 years, got an E1C of 888, so very high. BMI of 30, on metformin, glycolozide, dappa and simaglitide. It's got that combination of treatment. So the question here, what is, excuse me, what, what are the reasons or reason for the rapid improvement in glucose control? So you can see that happened in a relatively short period of time, from the sort of end of September to the to end of November, there was a this big improvement. Was the introduction of insulin, so timing range went from 11 to 56%. Decrease or increased GLPY receptor agonist dose, buying a dog or starting a sensor. And actually all that happened here, there was absolutely no change in treatment of this gentleman and just having the sensor modified the lifestyle. So you can see that having a sensor helps people to modify their lifestyle or make sure that the treatment is given. What about this case, this is Beth, who's 68 years old. Um, current glycemic treatment is metformin, dapper, and Lantus. Has got major fear of hypoglycemia and she lives alone. So if you look at the CGM you can see that almost always before bed, it, the glucose levels go too high. And this is classical people who are worried about going hypoglycemic overnight. And just having a sensor, you can see that that that. The patient got reassured. Well, I can monitor it quite easily. I can see what's going on, and that peak before bed got smaller and smaller and smaller. And if you look at the, between the 29th to the 31st, there are no high peaks of glucose anymore. And the timing range improves gradually from 44 to 62. And if you look at the last 3 days, time in range is close to 90, if not above. OK, so there was no therapy modification here. There it's just the patient got reassured and modified the lifestyle. And uh again I encourage you here to have a look at this abstract that is presented at the ETTD. This was an RCT looking at people or on basal insulin or non-insulin therapy. Um, uh, to, uh, and they looked at CGM versus BGM blood glucose monitoring. And they studied the impact of glucose monitoring on self-management scale or IGMSS. So the IGMSS with the use of CGM gone up from 3.9 to 4.4, whereas in the BGM group there was no real difference. And this was associated with a decrease in HBA1C from 9.2% to 8.3% in the CGM group. Uh, the, the drop in the BGM group was smaller. You always get a slight drop when people get involved in studies, but you can clearly see that the drop with the CGM group was higher. So this also demonstrates improvement in type 2 diabetes management or engagement score and a reduction in E1C. And again, One of the challenges we all face when we manage type 2 diabetes is patient engagement. You know, patient engagement is very, very important because I always tell my patients, it's, you know, we work as partners, we help each other out, but it's an unfair partnership because the patient's doing 99.9% of the work and the healthcare professional will be doing 0.1% of that work. So engaging the patient in their condition is really important. So to conclude, CGM can certainly affect lifestyle. And as I said earlier, you don't react to what you don't feel or you don't see and the CGM allows you to see your glucose levels. It allows you to see how lifestyle changes affect glucose levels. One thing patients tell me all the time is that. We get irritated by not knowing what a particular activity does to our glucose levels. And sometimes some food would send the sugar levels very, very high, and they didn't know about that. That's what they tell me when they start the CGM set. It changed my life. Now I know what's happening with my glucose levels. So more specifically, CGM can help with glycaemic management through modifying diet. As I said, accounting for daily life activities, you've got the social interaction, alcohol, exercise, and increased confidence in managing glucose, as well as adherence to therapy. So overall, in my experience, CGM increases patient engagement with their diabetes management. I'm going to stop here. Thank you very much for your attention. Published Created by Related Presenters Ramzi Ajjan, MD, PhD Professor of Metabolic MedicineConsultant in Diabetes and EndocrinologyUniversity of Leeds and Leeds Teaching Hospitals TrustLeeds, United Kingdom
