Continuous Glucose Monitoring Users Research Articles

The emotional burden of type 1 diabetes: A cross-sectional study to understand associations between diabetes distress and glucose metrics in adulthood.

Advancements in type 1 diabetes (T1D) management, such as continuous glucose monitoring (CGM), have helped people achieve narrower glucose ranges, but associations between CGM and diabetes distress are unclear. Although higher HbA1c is associated with higher distress, associations with other glucose metrics are unknown. To better understand this relationship, we characterized diabetes distress in a sample of CGM users and compared differences in glucose metrics (measured via CGM) between those with higher versus lower distress. CGM users with T1D from the T1D Exchange Registry completed an online survey including diabetes distress (DDS-2) and shared CGM data (N = 199). CGM metrics were computed from all available data within 3 months prior to survey completion. Participants were grouped by distress level: lower (DDS-2 < 3, n = 120) or higher (DDS-2 ≥ 3, n = 79). Welch's t-tests were used to compare mean differences in CGM metrics between groups and MANCOVA was used to further probe mean differences. Approximately 39.7% participants reported higher diabetes distress. Welch's t-tests revealed participants with higher distress spent significantly more time in higher glucose ranges (above 180 mg/dL and above 250 mg/dL), less time in target glucose ranges (between 70 and 180 mg/dL and between 70 and 140 mg/dL) and had higher glucose management index values compared to those with lower distress (p < 0.01). MANCOVA models showed similar results. CGM users continue to experience diabetes distress. Moreover, higher distress appears to be associated with hyperglycaemia. These findings provide support for broader screening efforts for diabetes distress.

Equity of continuous glucose monitoring in young people with type 1 diabetes: a systematic review

Abstract 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.

Consensus Considerations and Good Practice Points for Use of Continuous Glucose Monitoring Systems in Hospital Settings.

Continuous glucose monitoring (CGM) systems provide frequent glucose measurements in interstitial fluid and have been used widely in ambulatory settings for diabetes management. During the coronavirus disease 2019 (COVID-19) pandemic, regulators in the U.S. and Canada temporarily allowed for CGM systems to be used in hospitals with the aim of reducing health care professional COVID-19 exposure and limiting use of personal protective equipment. As such, studies on hospital CGM system use have been possible. With improved sensor accuracy, there is increased interest in CGM usage for diabetes management in hospitals. Laboratorians and health care professionals must determine how to integrate CGM usage into practice. The aim of this consensus guidance document is to provide an update on the application of CGM systems in hospital, with insights and opinions from laboratory medicine, endocrinology, and nursing.

Impact of Continuous Glucose Monitoring on Hemoglobin A1c and Height Trends in Latin American Children with Type 1 Diabetes Onset over 3 Years: A Multicenter Study

ObjectiveTo evaluate changes in HbA1c levels and z-height over three years based on Continuous glucose monitoring (CGM) usage among children with new-onset type 1 diabetes (T1DM) from various Latin American centers. MethodsData on z-height, CGM access, and HbA1c (%) were collected for Latin American children aged six months to 18 years with T1DM onset from 19 centers in a retrospective analysis of medical records, from 2020 to 2023. A two-way ANOVA method with repeated measures and multiple regression analyses were performed. Results433 children (46.0% F) aged 8.7 ± 3.7 years were included, and 199 (45.9%) used CGM. Mean HbA1c was significantly lower in years 1, 2, and 3 than in baseline in children with CGM but not those without CGM. The z-height decreased significantly with the years in both groups. However, the CGM users showed a significantly greater height in years 2 and 3 than the non-users. Multiple linear regression analysis showed that CGM users exhibited a significantly lower incremental area under the curve (AUC) for HbA1c during follow-up than non-users. Furthermore, a lower incremental AUC for HbA1c was associated with a smaller decremental AUC for z-height (R2 = 0.19). Multiple logistic regression analysis revealed that children with CGM were 80% more likely (OR=0.22; 95% CI 0.1-0.6) to achieve an HbA1c < 7% in the third year of follow-up. ConclusionsThis study reveals a significant association between CGM use and lower HbA1c from the onset of T1DM over a three-year follow-up in Latin American children. Further prospective studies should be performed to confirm this finding.

8118 Effect of Rurality on Diabetes Technology Use Among Medicaid-Insured Youth Enrolled in a Mid-Western Accountable Care Organization

Abstract Disclosure: E.E. Bell-Sambataro: None. J. Kilbarger: None. A. Lahoti: None. J.M. Ladd: None. Background: Diabetes technology (continuous glucose monitors (CGM) and insulin pumps), is associated with improved glycemic control and quality of life in children with type 1 diabetes (T1D), but technology use is not equitable. We explored whether rural/urban disparities exist in CGM and pump use among pediatric patients with T1D enrolled in an Accountable Care Organization (ACO) and thus on Medicaid. Methods: We conducted a retrospective cohort study using claims data from the central Ohio ACO database from January 1, 2018 to September 30, 2022. Individuals aged 1 to &amp;lt;21years were identified using T1D-specific billing codes. CGM or pump use was defined using established prescription codes. Rurality was based on zip codes of residence linked to RUCA codes. For descriptive analyses, we calculated proportions, means and standard deviations. T-tests were used to compare continuous variables; chi-square tests were used to compare categorical variables. Multivariable Poisson regression was used to model the association between rurality and CGM or pump use, adjusted for age, sex, race, and era (pre-/post-COVID pandemic). Results: We identified 1079 enrolled individuals with T1D during the study period; 878 (81.4%) were using CGM and 259 (24%) were using insulin pumps. In descriptive analysis, CGM users were younger than non-users (users 11.4±4.4years vs non-users 15.3±3.8years, p&amp;lt;0.01). The distribution of rurality between CGM users and non-users was similar (users 73.5% urban, 26.3% rural vs non-users 66.6% urban, 33.3% rural, p=0.05). There were no age or rurality differences between pump users and non-users (users 12.2±3.8years vs non-users 12.1±4.8years, p=0.86; users 72.6% urban vs non-users 72.1% urban, p=0.92). In regression modeling, rurality was not significantly associated with CGM use (adjusted risk ratio (aRR) 0.95, 95% confidence interval (CI) 0.89-1.02) whereas age, race, era, and pump use were significantly associated. Rurality was significantly associated with pump use (aRR 0.79, 95% CI 0.63-0.99) as were age, race and era. Conclusions: In this cohort limited to pediatric patients with T1D on Medicaid, rural residence did not have a significant effect on CGM use but did make pump use less likely. Those of older age or non-White race were significantly less likely to use CGM and pumps. Future efforts targeting these disparities should be undertaken to increase use of these standard of care technologies among all children. Presentation: 6/2/2024

6971 Effects of the Hybrid Closed-loop System in Pediatric-Onset Type 1 Diabetes

Abstract Disclosure: H. Woo: None. J. Yoo: None. S. Shin: None. Y. Lee: None. H. Kim: None. M. Gu: None. J. Kim: None. J. Kim: None. C. Shin: None. Y. Lee: None. Purpose: We evaluated the effectiveness and limitations of the MiniMedTM 770G, a hybrid closed-loop (HCL) system which adjusts basal insulin every five minutes using continuous glucose monitoring (CGM) data, for glycemic control in pediatric-onset type 1 diabetes (T1D) in South Korea. Methods: We enrolled 20 patients (10 boys and 10 girls) who had been using the 770G pump for over three months, initiating its use between February 2022 and May 2023. Prior to this, they were CGM users and were followed for over a year post T1D diagnosis. Clinical and biochemical data, along with CGM metrics such as time in range (TIR), time below range (TBR), time above range (TAR), and coefficient of variation (CV), were analyzed. Additionally, the percentage of SmartGuard Auto Mode system usage was collected. Results: The median age at the start of 770G was 13.97 years (IQR 11.24–17.86), with a median of 6.5 years of duration of type 1 diabetes. After utilizing the 770G pump (n=20), TIR, TAR, and CV improved over the year (P&amp;lt;0.05). Patients utilizing Auto Mode over 85% of the time exhibited significant improvements in HbA1c (P=0.02), TIR (P=0.04), CV (P&amp;lt;0.01), and TAR 250 (P=0.02), in contrast to those who used Auto Mode 85% or less. Hyperglycemia and lack of calibration contributed to over 50% of the exits from Auto Mode. Conclusions: The implementation of HCL in adolescents and young adults with T1D enhanced glycemic control over one year. Educating patients on sustained Auto Mode use without interruptions is crucial. Presentation: 6/2/2024

6521 Continuation of Continuous Glucose Monitors in Hospitalized Diabetic Patients Decreased the Incidence of Hypoglycemia

Abstract Disclosure: C.E. DeClue: None. S. Bao: None. Objective: Glycemic control improves patient outcomes in hospitalized patients, and this is generally achieved by monitoring point-of-care (POC) capillary glucose levels. In the outpatient setting, continuous glucose monitoring (CGM) devices have shown improved glycemic control in diabetic patients, but their evidence in hospitalized patients is lacking. Methods: To evaluate CGM accuracy and safety of use in the inpatient setting, 567 consults were analyzed in a single-center inpatient diabetes service between November 2022 and January 2023. Patients were included if managed with multiple daily injections or insulin pump therapy and separated into four groups based on CGM continuation and type of diabetes. POC glucose and incidence of hypoglycemia were recorded over 72 hours from the time of consultation. Results: Forty-six Type-1 (T1DM) and 72 Type-2 (T2DM) diabetic patients were included in this study, with average hemoglobin A1c of 8.6% and 9.0%, respectively. Both diabetic groups showed an average POC glucose that was not statistically different based on CGM continuation (185 mg/dL for T1DM and 187 mg/dL for T2DM continued on CGM versus 183 mg/dL for T1DM and 188 mg/dL for T2DM not using CGM). However, only 2 of the 18 T1DM patients continued on CGM experienced hypoglycemia, whereas 17 of the 28 T1DM patients not using CGM experienced at least 1 hypoglycemic event. Similarly, only 2 of the 20 T2DM patients continued on CGM experienced hypoglycemia, whereas 13 of the 52 patients not using CGM experienced at least 1 hypoglycemic event. Additionally, less glucose variability was observed in both T1DM and T2DM patients continued on CGM (average standard deviation of 64 mg/dL and 55 mg/dL, respectively) compared to those not using CGM (average standard deviation of 84 mg/dL and 62 mg/dL, respectively). Conclusion: CGM has great potential to improve patient care and nursing workload in the hospital, but the safety and accuracy are not yet well-established. In this study, there seemed to be a statistically insignificant trend to less glycemic variability for CGM users despite no glycemic difference on average POC testing. Importantly, significantly fewer hypoglycemic events were observed in patients continued on CGM devices regardless of type of diabetes or baseline glycemic control. This study adds further evidence to the growing body of work supporting improved safety of CGM utilization in hospitalized diabetic patients. Presentation: 6/1/2024

Continuous Glucose Monitoring With Geriatric Principles in Older Adults With Type 1 Diabetes and Hypoglycemia: A Randomized Controlled Trial.

Continuous glucose monitoring (CGM) use in older adults with type 1 diabetes (T1D) has shown benefits. However, the impact of CGM use, coupled with simplified treatment regimens and personalized glycemic goals that are better suited for older patients with multiple comorbidities and hypoglycemia, is not known. Older adults (≥65 years) with T1D with hypoglycemia (two or more episodes of hypoglycemia [blood glucose <70 mg/dL for ≥20 min over 2 weeks]) who were CGM naïve or CGM users were randomized to intervention and control groups. The intervention consisted of the combined use of CGM with geriatric principles (i.e., adjusting goals based on overall health, and simplification of regimens based on CGM patterns and clinical characteristics) over 6 months. The control group received usual care by their endocrinologist. The primary end point was change in time when blood glucose was <70 mg/dL from baseline to 6 months. Cost-effectiveness was calculated using a health care sector perspective. We randomized 131 participants (aged 71 ± 5 years; 21% ≥75 years old) to the intervention (n = 68; CGM users = 33) or the control (n = 63; CGM users = 40) group. The median change in hypoglycemia from baseline to 6 months was -2·6% in the intervention group and -0.3% in the control group (median difference, -2.3% [95% CI -3.7%, -1.3%]; P < 0.001). This improvement was seen in both CGM naïve (-2.8%; 95% CI -5.6%, -0.8%) and CGM users (-1.2%; 95% CI -2.7%, -0.1%). The HbA1c did not differ between the groups (7.5% vs 7.3%). The intervention was cost-effective (incremental cost-effectiveness ratio $71,623 per quality adjusted life-year). In older adults with T1D and high risk of hypoglycemia, CGM use enhanced by geriatric principles can lower hypoglycemia without worsening glycemic control in a cost-effective fashion.

Long-Term Glycemic Control Improvement After the Home and Self-Care Program for Patients With Type 1 Diabetes: Real-World-Based Cohort Study.

The prevalence of type 1 diabetes (T1D) is increasing worldwide, with a much higher proportion of adult patients. However, achieving stable glycemic control is difficult in these patients. After periodic implementation of structured education for patients with T1D through the Home and Self-Care Program, a pilot home health care project promoted by the Korean government, we evaluated the program's effects on glycemic control. This study was conducted from April 2020 to March 2023. We analyzed 119 participants with T1D aged >15 years. Nursing and nutrition education were provided separately up to 4 times per year, with physician consultation up to 6 times per year. A distinguishing feature of this study compared with previous ones was the provision of remote support using a general-purpose smartphone communication app offered up to 12 times annually on an as-needed basis to enhance the continuity of in-person education effects. Patients were followed up on at average intervals of 3 months for up to 24 months. The primary end point was the mean difference in glycated hemoglobin (HbA1c) at each follow-up visit from baseline. For continuous glucose monitoring (CGM) users, CGM metrics were also evaluated. The mean HbA1c level of study participants was 8.6% at baseline (mean duration of T1D 10.02, SD 16.10 y). The HbA1c level reduction in participants who received at least 1 structured educational session went from 1.63% (SD 2.03%; P<.001; adjustment model=1.69%, 95% CI 1.24%-2.13% at the first follow-up visit) to 1.23% (SD 1.31%; P=.01; adjustment model=1.28%, 95% CI 0.78%-1.79% at the eighth follow-up visit). In the adjustment model, the actual mean HbA1c values were maintained between a minimum of 7.33% (95% CI 7.20%-7.46% at the first follow-up visit) and a maximum of 7.62% (95% CI 7.41%-7.82% at the sixth follow-up visit). Among CGM users, after at least 1 session, the mean time in the target range was maintained between 61.59% (adjusted model, 95% CI 58.14%-65.03% at the second follow-up visit) and 54.7% (95% CI 50.92%-58.48% at the eighth follow-up visit), consistently staying above 54.7% (corresponding to an HbA1c level of <7.6%). The mean time below the target range (TBR) also gradually improved to the recommended range (≤4% for TBR of <70 mg/dL and ≤1% for TBR of <54 mg/dL). The Home and Self-Care Program protocol for glycemic control in patients with T1D is effective, producing significant improvement immediately and long-term maintenance effects, including on CGM indexes.

Long-term tracking of glycosylated hemoglobin levels across the lifespan in type 1 diabetes: from infants to young adults.

Glycosylated hemoglobin (HbA1c) is commonly used as a monitoring tool in diabetes. Due to the potential influence of insulin resistance (IR), HbA1c level may fluctuate over a person's lifetime. This study explores the long-term tracking of HbA1c level in individuals diagnosed with type 1 diabetes mellitus (T1DM) from infancy to early adulthood. The HbA1c levels in 275 individuals (121 males, 43.8%) diagnosed with T1DM were tracked for an average of 9.4 years. The distribution of HbA1c levels was evaluated according to age with subgroups divided by gender, use of continuous glucose monitoring (CGM), and the presence of complications. HbA1c levels were highest at the age of 1 year and then declined until age 4, followed by a significant increase, reaching a maximum at ages 15-16 years. The levels subsequently gradually decreased until early adulthood. This pattern was observed in both sexes, but it was more pronounced in females. Additionally, HbA1c levels were higher in CGM nonusers compared with CGM users; however, regardless of CGM usage, an age-dependent pattern was observed. Furthermore, diabetic complications occurred in 26.8% of individuals, and the age-dependent pattern was observed irrespective of diabetic complications, although HbA1c levels were higher in individuals with diabetic complications. HbA1c levels vary throughout the lifespan, with higher levels during adolescence. This trend is observed regardless of sex and CGM usage, potentially due to physiological IR observed during adolescence. Hence, physiological IR should be considered when interpretating HbA1c levels during adolescence.

The Association of Sociodemographic Factors and Utilization of Diabetes Technologies with Diabetes Management: An Investigation in Children and Adolescents with Type 1 Diabetes.

We aimed to investigate the relationship between sociodemographic and clinical characteristics, as well as the utilization of diabetes technologies, with diabetes management in individuals with type 1 diabetes (T1D). Our study included 134 cases diagnosed with T1D who were followed for at least 1 year with T1D. Of the cases, 67.2% were using insulin pens as their insulin regimen, while 37.8% were using insulin pumps. The rate of continuous glucose monitoring (CGM) usage was 29.9%. The rate of CGM usage was 5% in families with low income levels. Glycosylated hemoglobin A1c(HbA1c) level of children with working mothers was found to be higher compared to those with non-working mothers (median 9.2% vs. 8%; P = .009). Cases with 3 or more siblings had higher HbA1c levels compared to those with 2 or fewer siblings (median 8.7% vs. 8.1%; P = .044).The median HbA1c was 8.7% in cases using insulin pens and checking fingerstick blood glucose (SMBG); 8.3% in cases using insulin pumps and SMBG; 7.6% in cases using insulin pens with CGM, and 7.5% in cases using insulin pumps with CGM (P = .003). The utilization of insulin pumps with CGM in T1D cases exhibited lower HbA1clevels. Similarly, even the usage of insulin pens with CGM demonstrated improved diabetes management. Maternal employment and having a higher number of siblings may negatively affect diabetes management due to increased caregiver burden. We believe that personalized healthcare delivery tailored to the individual needs of T1D patients based on family and clinical characteristics could have positive effects on diabetes management.

'We're taught green is good': Perspectives on time in range and time in tight range from youth with type 1 diabetes, and parents of youth with type 1 diabetes.

Continuous glucose monitoring (CGM) systems are standard of care for youth with type 1 diabetes with the goal of spending >70% time in range (TIR; 70-180 mg/dL, 3.9-10 mmol/L). We aimed to understand paediatric CGM user experiences with TIR metrics considering recent discussion of shifting to time in tight range (TITR; >50% time between 70 and 140 mg/dL, 3.9 and 7.8 mmol/L). Semi-structured interviews and focus groups with adolescents with type 1 diabetes and parents of youth with type 1 diabetes focused on experiences with TIR goals and reactions to TITR. Groups and interviews were audio-recorded, transcribed and analysed using content analysis. Thirty participants (N = 19 parents: age 43.6 ± 5.3 years, 79% female, 47% non-Hispanic White, 20 ± 5 months since child's diagnosis; N = 11 adolescents: age 15.3 ± 2 years, 55% female, 55% non-Hispanic White, 16 ± 3 months since diagnosis) attended. Participants had varying levels of understanding of TIR. Some developed personally preferred glucose ranges. Parents often aimed to surpass 70% TIR. Many described feelings of stress and disappointment when they did not meet a TIR goal. Concerns about TITR included increased stress and burden; risk of hypoglycaemia; and family conflict. Some participants said TITR would not change their daily lives; others said it would improve their diabetes management. Families requested care team support and a clear scientific rationale for TITR. The wealth of CGM data creates frequent opportunities for assessing diabetes management and carries implications for management burden. Input from people with type 1 diabetes and their families will be critical in considering a shift in glycaemic goals and targets.

Impact of Continuous Glucose Monitoring on Glycemic Control and Lifestyle Changes among Diabetes Patients: Evidence from a Diverse Indian Cohort

Background: Continuous glucose monitoring (CGM) has emerged as a pivotal technology in diabetes management, offering real-time insights into glucose fluctuations. This study aims to assess the impact of CGM on glycemic control and lifestyle changes among diabetes patients in India. Methodology: A retrospective observational study was conducted on a cohort of 556 diabetes patients from 3 diabetes centers across India. Data were collected using a structured questionnaire focusing on demographics, CGM usage patterns, lifestyle changes, and glycemic outcomes, particularly hemoglobin A1c (HbA1c) levels. The analysis included descriptive statistics and inferential methods, such as paired t-tests and regression analysis, to evaluate the relationship between CGM usage and changes in glycemic control and lifestyle behaviors. Results: The study revealed a significant reduction in HbA1c levels, with an average decrease of 0.85% across the cohort. A higher frequency of CGM use was associated with greater improvements in glycemic control. Patients who made dietary improvements and managed stress levels effectively, as guided by real-time CGM feedback, exhibited more pronounced reductions in HbA1c. The study also identified that demographic factors such as age and gender had minimal influence on glycemic outcomes. A clustering analysis grouped patients based on their HbA1c improvement, identifying distinct patterns of lifestyle changes and CGM usage. Conclusion: CGM significantly improves glycemic control and promotes positive lifestyle changes among diabetes patients in India. The findings underscore the importance of frequent CGM usage and patient engagement in achieving optimal outcomes. Despite the challenges related to cost and accessibility in the Indian context, CGM presents a valuable tool for enhancing diabetes management. Future research should focus on optimizing CGM usage patterns and addressing barriers to its widespread adoption.

Skin Reactions in Children with Type 1 Diabetes Associated with the Use of New Diabetes Technologies—An Observational Study from a Regional Polish Pediatric Diabetes Center

The study aimed to estimate the prevalence of skin problems in children and adolescents with type 1 diabetes (T1D) using insulin pumps (IPs) and/or continuous glucose monitoring (CGM) in our center and analyze their association with various factors. As part of the international ISPAD JENIOUS-initiated SKIN-PEDIC project, we interviewed and examined patients who visited the regional pediatric diabetes center in Opole (Poland) for four weeks regarding the use of IP and/or CGM and the presence of skin problems. Body mass index (BMI) and glycemic parameters were obtained retrospectively from medical records. Among 115 individuals (45.2% girls, 83.5% IP users, 96.5% CGM users), old scars were the most common skin problem (IP users 53.1%; CGM users 66.4%), while ≥2 types of skin problems co-occurred (IP users 40.6%; CGM users 27.3%). Longer IP use was associated with a higher prevalence of skin problems (50% for IP &lt; 1 year, 98.1%-IP 1–3 years, 100% for IP &gt; 3 years; p &lt; 0.001), pointing out extra attention with IP use &gt; 1 year. No significant associations were found between skin problems and gender, age, BMI centile and glycemic parameters. Dermatological complications were common among children using IP and CGM in our center, highlighting the need for vigilant monitoring and early intervention to manage these skin-related issues effectively.

Association between recent exposure to continuous glucose monitoring-recorded hypoglycaemia and counterregulatory and symptom responses to subsequent controlled hypoglycaemia in people with type 1 diabetes.

Experimental hypoglycaemia blunts the counterregulatory hormone and symptom responses to a subsequent episode of hypoglycaemia. In this study, we aimed to assess the associations between antecedent exposure and continuous glucose monitoring (CGM)-recorded hypoglycaemia during a 1-week period and the counterregulatory responses to subsequent experimental hypoglycaemia in people with type 1 diabetes. Forty-two people with type 1 diabetes (20 females, mean ± SD glycated haemoglobin 7.8% ± 1.0%, diabetes duration median (interquartile range) 22.0 (10.5-34.9) years, 29 CGM users, and 19 with impaired awareness of hypoglycaemia) wore an open intermittently scanned CGM for 1 week to detect hypoglycaemic exposure before a standardized hyperinsulinaemic-hypoglycaemic [2.8 ± 0.1 mmol/L (50.2 ± 2.3 mg/dl)] glucose clamp. Symptom responses and counterregulatory hormones were measured during the clamp. The study is part of the HypoRESOLVE project. CGM-recorded hypoglycaemia in the week before the clamp was negatively associated with adrenaline response [β -0.09, 95% CI (-0.16, -0.02) nmol/L, p = .014], after adjusting for CGM use, awareness of hypoglycaemia, glycated haemoglobin and total daily insulin dose. This was driven by level 2 hypoglycaemia [<3.0 mmol/L (54 mg/dl)] [β -0.21, 95% CI (-0.41, -0.01) nmol/L, p = .034]. CGM-recorded hypoglycaemia was negatively associated with total, autonomic, and neuroglycopenic symptom responses, but these associations were lost after adjusting for potential confounders. Recent exposure to CGM-detected hypoglycaemia was independently associated with an attenuated adrenaline response to experimental hypoglycaemia in people with type 1 diabetes.

A Nutrition-Focused Approach During Continuous Glucose Monitoring Initiation in People With Type 2 Diabetes: Using a Theoretical Framework to Unite Continuous Glucose Monitoring and Food Choices.

Continuous glucose monitoring (CGM) has transformed diabetes care, yet opportunities for further innovations still exist. Some research suggests CGM could be an ideal tool to guide food choices and other healthy lifestyle behaviors, especially for people with type 2 diabetes (T2D). Behavior change theories can be used to understand and describe how CGM users make food-related decisions, which could ultimately lead to the design of more tailored and effective interventions. In this commentary, we describe what it looks like to use the behavior change wheel-a theory-based intervention development framework-to design an intervention for people with T2D who will use CGM data to guide food choices aligned with evidence-based nutrition recommendations. Such frameworks may be beneficial when designing or evaluating future technology-focused behavior change interventions.

Clinical Effectiveness of Continuous Glucose Monitoring in Pregnancies Affected by Type 1 Diabetes.

Background: Continuous glucose monitoring (CGM) improves neonatal outcomes in type 1 diabetes pregnancies; however, its effectiveness has not been assessed in a real-world setting in the United States. Objective: The Triple C Study aimed to examine the clinical effectiveness, assessed through maternal glucose control and gestational health outcomes, of CGM use compared with self-monitoring of blood glucose (SMBG) in pregnancies associated with type 1 diabetes in a real-world setting. Research Design and Methods: We retrospectively identified 160 type 1 diabetes pregnancies at the Barbara Davis Center for Diabetes managed with CGM therapy (n = 109) or SMBG (n = 51) over a 6.5-year period (2014-2020). Obstetric care was provided at multiple practices. CGM use was defined as ≥60% wear in the second and third trimesters of pregnancy. Data were obtained from the electronic medical record system, hospital records, and vital statistics departments (Colorado and Wyoming). We used Student's t-test for continuous variables and chi-square test for categorical variables to compare outcomes between groups. Results: The CGM group had more participants meeting trimester-specific hemoglobin A1C (HbA1c) goals throughout pregnancy and postpartum (P < 0.01 in each time period). The CGM group had fewer participants never meeting HbA1c goals in any trimester than the SMBG group (P < 0.001). There were no significant differences in neonatal outcomes between groups, other than for macrosomia (12.8% CGM vs. 29.4% SMBG, P = 0.01). Infants of CGM users required a neonatal intensive care unit admission less often (52.9% CGM vs. 68.3% SMBG, P = 0.0989). Conclusions: CGM use was associated with improved maternal glucose levels in a diverse real-world cohort.

Is It Time to Move Beyond TIR to TITR? Real-World Data from Over 20,000 Users of Continuous Glucose Monitoring in Patients with Type 1 and Type 2 Diabetes.

The growing use of continuous glucose monitoring (CGM) has been supported by expert consensus and clinical guidelines on glycemic management in diabetes with time in range (TIR 70-180 mg/dL) representing a key CGM-derived glucose metric. Time in tight range (TITR) has also been proposed for clinical use, spanning largely normal glucose levels of 70-140 mg/dL. However, keeping such narrow glucose ranges can be challenging, and understanding the factors modulating TITR can help achieve these tight glycemic targets. Our real-life study aimed to evaluate the relationship between average glucose (AG) and TIR/TITR in a large cohort (n = 22,006) of CGM users, divided into four groups: self-identified as having type 1 diabetes (T1D) treated with insulin using multiple daily injections (MDI) or pumps; type 2 diabetes (T2D) on MDI or insulin pumps; T2D on basal insulin only; and T2D not on insulin treatment. The T2D groups, regardless of treatment type, displayed the highest TIR and TITR values, associated with lowest glycemic variability measured as glucose coefficient of variation (CV; 23-30%). The T1D group showed the lowest TIR and TITR, associated with the highest CVs (36-38%). Overall, higher CV was associated with lower TIR and TITR for AG values below 180 and 140 mg/dL, respectively, with the reverse holding true for AG values above these thresholds. The discordance between AG and TIR/TITR was less pronounced in T2D compared with T1D, attributed to lower CV in the former group. It was also observed that TITR has advantages over TIR for assessing glycemia status and progress toward more stringent A1C, particularly when approaching normal glucose levels. The data detail how CV affects the AG relationship with TIR/TITR, which has implications for CGM interpretation. In many instances TITR, rather than TIR, may be preferable to employ once AG falls below 140 mg/dL and near-normal glucose levels are required clinically.

The Development and Potential Applications of an Automated Method for Detecting and Classifying Continuous Glucose Monitoring Patterns.

Continuous glucose monitoring (CGM) is emerging as a transformative tool for helping people with diabetes self-manage their glucose and supporting clinicians in effective treatment. Unfortunately, many CGM users, and clinicians, find interpreting the large volume of CGM data to be overwhelming and complex. To address this challenge, an efficient, intelligent method for detecting and classifying discernable patterns in CGM data was desired. We developed an automated artificial intelligence (AI)-driven method to detect and classify different discernable CGM patterns which called "CGM events." We trained different models using 60 days of CGM data from 27 individuals with diabetes from a publicly available data set and then evaluated model performance using separate test data from the same group. Each event is classified according to clinical significance based on three parameters: (1) glucose category at or near the beginning of the CGM event; (2) a calculated severity score that encompasses both signal shape and temporal characteristics (e.g., how high the CGM curve goes (measured in mg/dL) and how long it stays above target (as established by published consensus guidelines); and (3) the glucose category at or near the end of the event. The system accurately detected and classified events from actual CGM data. This was also validated with expert diabetes clinicians. Advanced pattern recognition methods can be used to detect and classify CGM events of interest and may be used to provide actionable insights and self-management support to CGM users and decision support to the clinicians caring for them.

Limitations of 14-Day Continuous Glucose Monitoring Sampling for Assessment of Hypoglycemia and Glycemic Variability in Type 1 Diabetes.

Continuous glucose monitoring (CGM) has become the standard of care in diabetes management with the recent advances in technology and accessibility in the last decade. An International Consensus was established to define CGM metrics and its goals in diabetes care. The 2019 International Consensus suggested 14 days of CGM sampling for the assessment of CGM metrics stating the limitations that may occur for hypoglycemia and glycemic variability metrics. Since then, several studies assessed the correlation between CGM metrics and duration of the sampling period. This review summarized the studies that investigated the relationship between 14-day CGM sampling to 90-day CGM data in >70% CGM users for all CGM metrics and highlighted possible solutions for more accurate CGM sampling durations in type 1 diabetes (T1D). Accumulating evidence showed that 14-day CGM sampling correlates well with 90-day CGM data for mean glucose, time in 70-180 mg/dL, and hyperglycemia metrics; however, it correlates weakly for hypoglycemia and glycemic variability metrics. In the studies included in this review, in adults with T1D, minimum sampling duration was 14 days for mean glucose, time in 70-180 mg/dL, and time in hyperglycemia (>180 and >250 mg/dL); however, minimum sampling duration varied between 21 to 30 days for time <70 mg/dL, 30 to 35 days for time <54 mg/dL, and 28 to 35 days for coefficient of variation. Longer than 14 days of CGM, sampling was required to properly assess hypoglycemia and glycemic variability in T1D.