Barriers and facilitators to continuous glucose monitor use in type 1 diabetes: A biopsychosocial model of the adolescent experience

Disclosure: K.M. St. Jean: None. P. Underwood: None. N. Patel: None. R. Franca: None. J.N. Keels: None. R. Rick Longo: None. J. Upadhyay: None.Introduction: Continuous glucose monitor (CGM) use improves diabetes (DM) clinical outcomes (lower hemoglobin A1c (A1c), reduced hypoglycemia) in Adults with DM prescribed insulin. The mechanisms underlying this relationship are unknown, but may relate to the influence of CGM use on diabetes self-management behavior (DMB). Methodology: A pilot-randomized control trial (RCT) was conducted on 30 patients (16 libre-professional CGM (user blind) and 14libre 2 CGM). Adults (18-80y) with an ICD-10 diagnosis of DM within the past 12 months, hemoglobin A1c (A1c >8%) measured within the past 6 months, stable weight within the past 3 months (BMI ± 2 units were included.. All participants were given information on CGM use and general diabetes self-management education (DSME). DMB was measured using the Diabetes Self Care Inventory-Revised scale at visit 1 (baseline), visit 2 (2 weeks). Additional outcome variables, including Diabetes Distress, sleep quality, exercise habits, and nutrition, were obtained. Provider satisfaction with patient CGM use was also evaluated using a newly developed provider satisfaction survey. Results: Personal-CGM use supports improved diabetes self-care and decrease rates of hypoglycemia. Individuals using the freestyle libre 2 CGM had significantly lower rates of hypoglycemia (% glucose time <80-60mg/dl mean± standard deviation (SD) User Blind CGM: 1.92±3.92 vs Libre 2 0.14±0.36 p<0.0001), % glucose <60mg/dl) User Blind CGM: 0.92±2.15 vs. Libre 2 0±0 p<0.0001). Libre 2 CGM users had significantly lower levels of anger and fear (User Blind CGM: 2.0±1.55 vs Libre 2 1.7±0.72 p=0.01) and lower levels of failing in their diabetes routine compared to User-blind CGM users as measured by the Diabetes Distress Scale (User Blind CGM: 2.81±1.74 vs Libre 2 2.42±1.94 p=0.04). Libre 2 CGM users also had significantly higher confidence in how exercise influences their glucose level compared to User-blind CGM users as measured by the DPP Diabetes Knowledge scale (User Blind CGM: 8.09±2.6 vs Libre 2 8.92±0.9 p=0.02). Further, 100% of the providers felt that CGM use by their patients was very effective and helped their clinical decision-making during the visit. Providers did not feel that reviewing CGM data prolonged their visit. Conclusion: This pilot RCT suggests that personal CGM use decreases rates of hypoglycemia, lowers diabetes distress, and improves some aspects of diabetes self-management behavior in adults with diabetes seen in an endocrine clinic. This data reaffirms that CGM use in patients with poorly controlled diabetes is associated with improved DM clinical outcomes and supports endocrine provider clinical decision making.Presentation: Monday, July 14, 2025

T2D disproportionately affects youth of minority and lower SES backgrounds with public insurance. Continuous glucose monitor (CGM) use in youth with T1D and adults with T2D benefits glycemia and quality of life. Use of CGM in youth with T2D has not been sufficiently evaluated. We aimed to determine feasibility of CGM use, measured by % wear time per 2-week period (&amp;gt;75% wear-time as goal) prior to clinic visit, clinical outcomes including time in range (TIR) and HbA1c. Youth were provided or prescribed Libre 2 CGM and followed using established clinic workflows with data collection at each visit. We present the first 6 months (m) of data. We enrolled 30 youth with T2D, mean age 15.1 y and mean HbA1c 10.2% (6.5%-15.5%) (Table 1). At baseline, 37% had history of prior intermittent CGM use and 53% did not have glucometer data. At 3 m 47% of youth who attended visits were using CGM, at 6 m 79% were using CGM, with no participant using CGM &amp;gt;75% of the time. Mean HbA1c was lower over 6 months (1.3% decrease in 8 youth with 6m CGM data and HbA1c) and TIR was lower between 3 and 6 m among those who attended clinic visits. CGM use for 6 m was not sustained in youth with T2D, but CGM was worn by a portion of youth and associated with lower HbA1c in those who used CGM. Strategies for CGM use in youth with T2D may differ from adults with T2D or youth with T1D. Additional studies are needed to evaluate facilitators and barriers of CGM use to optimize CGM use in youth with T2D. Disclosure S.Shah: Research Support; Boehringer-Ingelheim, Takeda Pharmaceutical Co., Ltd. N.Arrizon-ruiz: None. A.Loyola: None. P.Sagan: None. B.P.Conrad: Advisory Panel; Edgepark medical supplies, Consultant; Abbott Diabetes. J.Leverenz: None. F.K.Bishop: None. D.M.Maahs: Advisory Panel; Medtronic, LifeScan Diabetes Institute, MannKind Corporation, Consultant; Abbott, Research Support; Dexcom, Inc. Funding Stanford Diabetes Research Center (P30DK116074)

Background: Continuous glucose monitor (CGM) use has been linked with better glycemic outcomes (HbA1c), yet many adolescents with type 1 diabetes (T1D) struggle to maintain optimal CGM use. Methods: This study examined CGM use and its association with HbA1c and psychosocial factors among adolescents with T1D experiencing at least moderate diabetes distress (N = 198). We examined mean differences in HbA1c, diabetes distress, diabetes-related family conflict, and quality of life among CGM user groups (Current Users, Past Users, and Never Users). Results: Current Users demonstrated significantly lower HbA1c than Never Users and significantly lower diabetes distress than Past Users. CGM use was not associated with family conflict or quality of life. Conclusions: CGM use was associated with lower HbA1c and diabetes distress but not with other psychosocial outcomes. Longitudinal data may explain why many adolescents do not experience improvements in quality of life with CGM use.

Objective: To describe perceived burdens and benefits of continuous glucose monitor (CGM) use in CGM non-users vs. users with type 1 diabetes across the lifespan. Research Design and Methods: The Burdens of CGM (BurCGM) and Benefit of CGM (BenCGM) questionnaires were completed at clinic visits from Feb 2019 to Nov 2019. Mean scores were calculated (scale 1-5; higher score reflects greater perceived burdens and benefits). Data collected from medical records included demographic information, CGM and insulin pump use, and HbA1c within 3 months of the visit. Results: Participant characteristics (n=1143) and the 3 most common perceived CGM burdens (in non-CGM users) and benefits (in non-CGM users and CGM users) are shown in the Table. Individuals using real time (RT) and non-RT CGM described more benefits (mean scores 34.9 and 34.0) when compared to those who never used CGM (mean score 30.2) (p&amp;lt;.001). There were no differences in burdens or benefits by sex or race. Mean HbA1C was lower in CGM users (8.2%) vs. non-CGM users (mean A1c 9.3%; p&amp;lt;.001); 47.4% of non-CGM users vs. 29.3% of RT-CGM users and 30.6% of non-RT-CGM users had A1c&amp;gt;9.0%. Conclusions: Cost is a barrier to CGM use, particularly in adults. In non-CGM users (vs. users), CGM was perceived as having less benefit and to be associated with pain and concern that readings cannot be trusted. Advocacy (for lower cost) and education are needed to address these barriers. Disclosure V. Divan: None. M. Greenfield: None. C.P. Morley: None. R.S. Weinstock: Board Member; Self; JDRF. Consultant; Self; Insulogic LLC. Research Support; Self; Boehringer Ingelheim International GmbH, Diasome Pharmaceuticals, Inc., Eli Lilly and Company, Insulet Corporation, Jaeb Center for Health Research, Kowa Research Institute, Inc., Medtronic, Tolerion, Inc. Funding Type 1 Diabetes Exchange QI Learning Collaborative

Continuous glucose monitor use in type 2 diabetes mellitus in pregnancy and perinatal outcomes: a systematic review and meta-analysis

Background Socioeconomic (SES) and ethnic inequalities in type 1 diabetes (T1D) outcomes are widespread. There is concern that unequal access to technologies, such as continuous glucose monitoring (CGM), may increase disparities. This systematic review summarises the evidence for inequalities in access to CGM for children and young people (CYP) and outcomes for CGM users. Methods MEDLINE, Embase, and Web of Science were searched for observational studies published between January 2020 and July 2023 which report CGM use stratified by any PROGRESS-plus criteria for T1D patients under 26. Reports based in low- or middle-income countries or ≤ 500 participants were excluded. Primary outcomes were the proportion of patients using CGM and HbA1c of CGM users. Quality assessment was performed using the Newcastle-Ottawa Scale. Unadjusted odds ratios were calculated from extracted data, though heterogeneity precluded meta-analysis. The protocol was pre-registered with PROSPERO (CRD42023438139). Results Of the 3,369 unique studies identified, 27 met inclusion criteria. We found decreased CGM use and higher discontinuation for low SES, low education, publicly insured, and minority ethnic, especially black, CYP. These associations were generally robust to adjustment for other sociodemographic variables, suggesting an independent effect. Lower SES inequalities were seen in countries where CGM is reimbursed. Although low SES and minority ethnicity were generally associated with poorer outcomes, there was no significant association between domains of disadvantage and higher HbA1c for CGM users, excepting parental education. Conclusions There are significant SES, ethnic, and education inequalities in CGM use for CYP with T1D, particularly when reimbursement is limited. This is contributing to outcome inequalities. However, evidence suggests CYP benefit equally from CGM use, irrespective of ethnicity and SES. Increasing CGM funding and use is likely to reduce outcome inequalities. Key messages • There are significant SES, ethnic, and education inequalities in continuous glucose monitoring use for young people with T1D. Inequalities are more marked when technology is not reimbursed. • Increasing access to CGM may reduce outcome inequalities, as evidence suggests that young people benefit equally from CGM use, regardless of ethnicity or SES.

Clinical trials indicate continuous glucose monitor (CGM) use in type 2 diabetes (T2D) can be beneficial across medication regimens and outpatient settings. CGM use in care for T2D is increasing rapidly, but little is known about predictors of CGM use in T2D. Adults (age 18-75) with T2D receiving primary care at an academic medical center enrolled in a RCT evaluating a self-management support intervention. The intervention did not address CGM use. At enrollment, patients completed an A1c test, self-reported demographic, clinical characteristics and individual (diabetes distress, diabetes self-efficacy, health literacy) , social (family/friend involvement, shared illness perception) , and behavioral (self-care behaviors) factors. The 15-month assessment queried CGM use in prior 12 months (current use/used and quit vs. no use) . We explored potential correlates of CGM use with unadjusted non-parametric tests of difference. Patients (N=109) completed 15-month assessments from July 2021 to March 2022. Mean age was 58±10 years; 57% female; 54% non-Hispanic white, 31% non-Hispanic black, 7% Hispanic; mean baseline A1c was 8.8%±1.8%. One-third (n=36) used CGM during the prior 15 months (including n=3 who quit) . CGM users were younger (median [IQR]: age 55 [47, 62] vs. 60 [53, 68], p=.031) , had higher baseline A1c (9.1% [8.1, 10.4] vs. 8.3% [7.5, 9.5], p=.048) and more were using insulin (69% vs. 36%, p=.002) as compared to non-users. CGM users also had higher baseline diabetes distress (45 [25, 55] vs. 30 [15, 50], p=.09) . CGM use was not related to gender, diabetes duration, race, ethnicity, health literacy, diabetes self-efficacy, family/friend involvement, perceiving diabetes as a shared illness, nor self-care behaviors. In a prospective study of adults with T2D from primary care clinics, younger age, insulin use, higher A1c and higher diabetes distress were associated with starting CGM. Two-thirds of CGM users were taking insulin. We did not find gender, race, ethnicity nor health literacy disparities in CGM use in our diverse sample. Disclosure L. S. Mayberry: Consultant; Abbott Diabetes, Cecelia Health. M. K. Roddy: None. S. S. Jaser: None. T. A. Elasy: None. Funding National Institutes of Health (R01DK119282)

Frequency of Continuous Glucose Monitoring use and Change in Hemoglobin A1C for Adults With Type 1 Diabetes in a Clinical Practice Setting

Disclosure: K.M. St. Jean: None. P. Underwood: None. R. Longo: None. J. Keels: None. J. Upadhyay: None. Introduction: Continuous glucose monitor (CGM) use is increasing. While the relationship between CGM use and improved diabetes (DM) clinical outcomes is well known (lower hemoglobin A1c (A1c), reduced hypoglycemia events), the mechanisms underlying this association are unknown. Further, the factors that contribute to successful CGM use by patients and whether CGM use influences diabetes self-management behavior (DMB) change are still undetermined. Objective: To understand the extent to which personal CGM use influences DMB versus user-blind CGM. In addition, patient satisfaction and provider perspective were evaluated during the study. Methodology: A pilot-randomized control trial (RCT) was conducted on 30 patients (15 libre-professional CGM and 15 libre 2 CGM). Adults (18-80y) with an ICD-10 diagnosis of DM within the past 12 months, A1c &amp;gt;8% measured within the past 6 months, stable weight within the past 3 months (BMI ± 2 units), able to speak, read, and write English, and a negative pregnancy test for women of childbearing age seen in the Lahey Endocrine Clinic were included.Exclusion criteria included evidence of personal CGM device use prior to the trial, addition of new oral or injectable hypoglycemic agents within 3 months of trial start, current or anticipated acute use of steroids, pregnancy, medical conditions that, per investigator determination, make it unsafe to target A1c &amp;lt;8%, severe psychiatric illness, homeless, current substance abuse, vision or hearing impairment that may affect the use of CGM. All participants were given information on how to incorporate the CGM into daily DM management and general diabetes self-management education (DSME). DMB was measured using the Diabetes Self Care Inventory-Revised scale, which was provided at visit 1 (baseline), visit 2 (2 weeks), and visit 3 (3-6 months). Additional outcome variables, including Diabetes Distress, sleep quality, exercise habits, and nutrition, were obtained. A1c was measured at baseline and at the end of visit 3. Provider satisfaction with patient CGM use was also evaluated using a newly developed provider satisfaction survey. Results: This study remains active for enrollment. Thus far, 14 patients have been recruited (7 in Libre 2 arm and 7 in Libre Pro User blind arm). Based on initial results, personal-CGM use supports improved diabetes self-care. Further, improvements in A1c, glucose time in target range, and lower rates of hypoglycemia are evident in all CGM users. Further, 100% of the providers felt that CGM use by their patients was very effective and helped their clinical decision-making during the visit. Providers did not feel that reviewing CGM data prolonged their visit. Conclusion: This pilot suggests that personal CGM use improves diabetes self-management behavior and reaffirms that CGM use in patients with poorly controlled diabetes is associated with improved DM clinical outcomes. Presentation: 6/3/2024

Diabetic retinopathy (DR) is a complication of diabetes that can lead to vision loss. Outcomes of continuous glucose monitoring (CGM) and insulin pump use in DR are not well understood. To assess the use of CGM, insulin pump, or both, and DR and proliferative diabetic retinopathy (PDR) in adults with type 1 diabetes (T1D). A retrospective cohort study of adults with T1D in a tertiary diabetes center and ophthalmology center was conducted from 2013 to 2021, with data analysis performed from June 2022 to April 2023. Use of diabetes technologies, including insulin pump, CGM, and both CGM and insulin pump. The primary outcome was development of DR or PDR. A secondary outcome was the progression of DR for patients in the longitudinal cohort. Multivariable logistic regression models assessed for development of DR and PDR and association with CGM and insulin pump use. A total of 550 adults with T1D were included (median age, 40 [IQR, 28-54] years; 54.4% female; 24.5% Black or African American; and 68.4% White), with a median duration of diabetes of 20 (IQR, 10-30) years, and median hemoglobin A1c (HbA1c) of 7.8% (IQR, 7.0%-8.9%). Overall, 62.7% patients used CGM, 58.2% used an insulin pump, and 47.5% used both; 44% (244 of 550) of the participants had DR at any point during the study. On univariate analysis, CGM use was associated with lower odds of DR and PDR, and CGM with pump was associated with lower odds of PDR (all P < .05), compared with no CGM use. Multivariable logistic regression adjusting for age, sex, race and ethnicity, diabetes duration, microvascular and macrovascular complications, insurance type, and mean HbA1c, showed that CGM was associated with lower odds of DR (odds ratio [OR], 0.52; 95% CI, 0.32-0.84; P = .008) and PDR (OR, 0.42; 95% CI, 0.23-0.75; P = .004), compared with no CGM use. In the longitudinal analysis of participants without baseline PDR, 79 of 363 patients (21.8%) had progression of DR during the study. In this cohort study of adults with T1D, CGM use was associated with lower odds of developing DR and PDR, even after adjusting for HbA1c. These findings suggest that CGM may be useful for diabetes management to mitigate risk for DR and PDR.

Background: Adolescents with type 1 diabetes (T1D) are vulnerable to sleep difficulties that may negatively affect mental health and glycemic control. Fear of hypoglycemia (FOH) may contribute to these sleep problems. Although parental FOH has been associated with poor sleep quality in children with T1D, little is known about the relationship between adolescent FOH and sleep outcomes. Objective: To examine the association between adolescent FOH and sleep parameters and assess how continuous glucose monitor (CGM) use influences these relationships. Methods: Adolescents ages 14-18 years with T1D completed questionnaires evaluating FOH (Child Hypoglycemia Fear Survey) and sleep parameters (Pittsburgh Sleep Quality Index). Meaningful CGM use was defined as reporting using the device ≥ 50% of the time. Analyses included linear regression and T-tests. Results: One hundred adolescents (56 female) with a median (IQR) age of 16.3 (15.3,17.6) years and duration of T1D of 5.7 (2.5, 9.5) years completed surveys, and 45 used CGM. FOH was inversely associated with sleep duration (r=0.25, p=0.01) and quality (r=0.22 p=0.03), and positively associated with sleep disturbances (r=0.24, p=0.01). A stratified analysis showed that the inverse relationship between FOH and sleep duration (r=0.29, p=0.03), as well as the association with sleep disturbances (r=0.31, p=0.02) was only significant among those not using CGM. Furthermore, average sleep duration was longer in those using CGM [7.5 hours with CGM vs. 6.8 hours without, p=0.02] and the associations between FOH and sleep duration or disturbance were not significant among CGM users. Conclusions: Among adolescents with T1D, FOH is associated with reduced sleep duration, poor sleep quality and increased sleep disturbance. Our findings suggest that CGM use could mitigate the negative contribution of FOH on various sleep parameters in this population, a previously unrecognized benefit. Disclosure T.A. Hitt: None. J. Smith: None. E.L. Forth: None. P. Garren: None. D. Olivos-Stewart: None. M. De La Vega: None. F. Stuart: None. C.P. Hawkes: None. S.M. Willi: Advisory Panel; Self; Boehringer Ingelheim International GmbH. Research Support; Self; Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Tolerion, Inc. Other Relationship; Self; Caladrius Biosciences, Inc. J. Gettings: None.

Associations of insulin pump and continuous glucose monitoring use with pregnancy-related outcomes in women with type 1 diabetes

Continuous glucose monitor (CGM) use is associated with improved glucose control. We describe the effect of continued and interrupted CGM use on hemoglobin A1c (HbA1c) in youth with public insurance. We reviewed 956 visits from 264 youth with type 1 diabetes (T1D) and public insurance. Demographic data, HbA1c and two-week CGM data were collected. Youth were classified as never user, consistent user, insurance discontinuer, and self-discontinuer. Visits were categorized as never-user visit, visit before CGM start, visit after CGM start, visit with continued CGM use, visit with initial loss of CGM, visit with continued loss of CGM, and visit where CGM is regained after loss. Multivariate regression adjusting for age, sex, race, diabetes duration, initial HbA1c, and body mass index were used to calculate adjusted mean and delta HbA1c. Adjusted mean HbA1c was lowest for the consistent user group (HbA1c 8.6%;[95%CI 7.9,9.3]). Delta HbA1c (calculated from visit before CGM start) was lower for visit after CGM start (-0.39%;[95%CI -0.78,-0.02]) and visit with continued CGM use (-0.29%;[95%CI -0.61,0.02]), whereas it was higher for visit with initial loss of CGM (0.40%;[95%CI -0.06,0.86]), visit with continued loss of CGM (0.46%;[95%CI 0.06,0.85]), and visit where CGM is regained after loss (0.57%;[95%CI 0.06,1.10]). Youth with public insurance using CGM have improved HbA1c, but only when CGM use is uninterrupted. Interruptions in use, primarily due to gaps in insurance coverage of CGM, were associated with increased HbA1c. These data support both initial and ongoing coverage of CGM for youth with T1D and public insurance.

Continuous glucose monitoring use and glucose variability in pre-school children with type 1 diabetes

Two weeks of continuous glucose monitoring (CGM) sampling with >70% CGM use is recommended to accurately reflect 90 days of glycemic metrics. However, minimum sampling duration for CGM use <70% is not well studied. We investigated the minimum duration of CGM sampling required for each CGM metric to achieve representative glycemic outcomes for <70% CGM use over 90 days. Ninety days of CGM data were collected in 336 real-life CGM users with type 1 diabetes. CGM data were grouped in 5% increments of CGM use (45%-95%) over 90 days. For each CGM metric and each CGM use category, the correlation between the summary statistic calculated using each sampling period and all 90 days of data was determined using the squared value of the Spearmen correlation coefficient (R2). For CGM use 45% to 95% over 90 days, minimum sampling period is 14 days for mean glucose, time in range (70-180 mg/dL), time >180 mg/dL, and time >250 mg/dL; 28 days for coefficient of variation, and 35 days for time <54 mg/dL. For time <70 mg/dL, 28 days is sufficient between 45 and 80% CGM use, while 21 days is required >80% CGM use. We defined minimum sampling durations for all CGM metrics in suboptimal CGM use. CGM sampling of at least 14 days is required for >45% CGM use over 90 days to sufficiently reflect most of the CGM metrics. Assessment of hypoglycemia and coefficient of variation require a longer sampling period regardless of CGM use duration.