Glucose Trends Research Articles

340-P: Nocturnal Hypoglycemia Prediction in Hospitalized Patients with Type 1 Diabetes Using Combined Supervised and Unsupervised Ensemble Learning

The Aim: To assess the efficacy of combined supervised and unsupervised ensemble machine learning based on continuous glucose monitoring (CGM) data for short-term prediction of nocturnal hypoglycemia (NH) in hospitalized patients with type 1 diabetes (T1D). Materials and Methods: We analyzed CGM records with a minimal duration of 72 hours obtained from 406 adult patients admitted to tertiary referral hospital. An episode of NH was defined as ≥3 consequent glucose values of <3.9 mmol/L recorded between 0 and 6 am. Depending on predictor sequence length (30 min - 1 h) and horizon (H) of forecasting (5-30 min), we obtained 209-256 and near 4∙104 records with and without NH respectively. Twenty nine metrics, including mean, minimal and maximum glucose, range, gradient, linear, quadratic and cubic trend coefficients, dynamic time wrapping similarity-based indices, and a number of glucose variability indices, were evaluated. The ensemble clustering was used for extraction of representative samples. Random Forest ensemble model was applied for NH prediction. The obtained quality metrics were averaged over 100 random partitions of the dataset on training and testing subsets. Results: The quality metrics did not depend significantly on predictor sequence length; we used 30 min as a baseline. Depending on H, values of sensitivity and specificity varied from 98% and 97% (H=5 min) to 85% and 87% (H=30 min). The false alarm ratio values were very high (>90%) due to the unbalanced nature of data. Minimal glucose, low blood glucose index, and increment in the penultimate value of sequence were the most important predictors assessed with Random Forest algorithm. Conclusions: The results demonstrate the usefulness of ensemble machine learning models based on CGM time series data for prediction of NH events in hospitalized patients with T1D. Additional studies are needed for improving false alarm ratio metrics of forecasting quality. Disclosure V. Berikov: None. J. F. Semenova: None. V. Klimontov: Advisory Panel; Self; Boehringer Ingelheim International GmbH, Sanofi, Research Support; Self; Boehringer Ingelheim International GmbH, Speaker’s Bureau; Self; AstraZeneca, Medtronic. Funding Russian Science Foundation (20-15-00057)

73-LB: Continuous Glucose Monitoring Utilization and Associated Metrics in People with Diabetes on Insulin Therapy in the U.S.

Background: Continuous glucose monitoring (CGM) systems generate real-time information on blood glucose trends in PwD, providing regular feedback that may help inform care decisions. This study aimed to describe real-world CGM use and CGM-derived glucometrics in insulin-using PwD. Methods: Data for adults (≥18 years) with T1D and T2D using insulin therapy and CGM were identified from Glooko’s cloud-based data storage and linked with Decision Resources Group™ Real-World Evidence repository (Jan 1, 2015-Jul 30, 2019). Summary statistics on 1-year aggregated CGM data and glucometrics are presented. Results: Over one year, CGM data were uploaded on average 215.7 days (59%) for people with T1D (n = 4896) and 191.5 days (52%) for people with T2D (n = 582). Among people with T1D and T2D, time in range (TIR) was 59.9% and 62.6%, coefficient of variation (CV) was 36.0% and 30.7%, time above range (TAR; level 2) was 13.3% and 12.2%, and time below range (TBR; level 2) was 0.8% and 0.3%, respectively (Table1). Conclusion: In this sample of PwD using insulin, level 2 TBR and CV were within the international consensus guideline recommendations, but TIR was below the recommended 70%, potentially driven by time spent in level 2 TAR. There is still an unmet clinical need for PwD to achieve guideline recommended targets; advancements in medications and technologies may help to achieve these goals. Disclosure M. Perez-nieves: Employee; Self; Eli Lilly and Company. R. Juneja: Employee; Self; Eli Lilly and Company. E. R. Hankosky: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company. L. Fan: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company, Stock/Shareholder; Spouse/Partner; Eli Lilly and Company. F. Gelsey: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company. E. L. Eby: Employee; Self; Eli Lilly and Company, Stock/Shareholder; Self; Eli Lilly and Company. T. J. Sims: Employee; Self; Eli Lilly and Company. E. Umeh: None. M. Betts: None. C. Lavallee: None. Funding Eli Lilly and Company

155-LB: Counterregulatory Response to Hypoglycemia after Short-Term Use of Low and Very Low Carbohydrate Diets in Children with Type 1 Diabetes (T1D)

Background: Low carbohydrate (CHO) diets are used to improve diabetes control, but the safety of these diets has not been studied in children. We assessed counterregulatory response to hypoglycemia after short-term low (LC) or very low (VLC) CHO diets in children with T1D. Methods: Epinephrine (epi), norepinephrine (NE), glucagon (gluc), and beta-hydroxybutyrate (BOHB) were measured before and immediately after becoming hypoglycemic at baseline and after 3 months on a LC or VLC diet (CHO made up 30-39% or 20-29% of total daily calories, respectively). 13 children were enrolled, mean (±SE) A1c 7.8±0.2%, diabetes duration 6.3±1.0 yrs. Participants were given sufficient insulin to decrease glucose to <60 mg/dL (<3.3 mmol/L). Continuous glucose monitoring (Dexcom® G5 or G6) was used to monitor glucose trends. Hypoglycemia was confirmed using a plasma glucose analyzer. Results: Mean age (±SE) for LC and VLC, 10.5±1.7 (n=7) and 15.0±0.6 yrs (n=6), respectively. Epi increased in response to hypoglycemia at baseline in both groups (mean±SE increase, pg/mL) (LC 130.9±60.1, p=0.072; VLC 412.6±84.0, p= 0.008). At 3 mos Epi increased in LC (181.6±66.7, p=0.053) but not significantly in VLC (100.2±67.9, p=0.214). The change in Epi in response to hypoglycemia was significantly less at 3 mos vs. baseline in VLC (100.2±67.9 vs. 412.6±84.0, p=0.019) but not in LC (181.6±66.7 vs. 191.4±61.7, p=0.935). Change in NE, gluc and BOHB during hypoglycemia was similar in both groups when comparing 3 months of diet with baseline. There was no effect of diet when comparing baseline and 3-month changes in Epi, NE, gluc and BOHB in response to hypoglycemia. Conclusion: Short-term use of a diet very low in CHO in children with T1D may adversely affect counterregulatory response to hypoglycemia, whereas LC diet did not affect response. Further studies are needed to confirm these findings and to assess whether these diets affect growth and development in young children. Disclosure L. Fox: None. J. W. Permuy: None. D. Perez santiago: None. M. Fox: None. M. Hossain: None. Funding Nemours Research Programs; Dexcom, Inc.

141-LB: MOVE! Enhanced: A Virtual Diabetes and Weight Management Pilot

Obese Veterans with diabetes and other comorbidities are at increased risk for complications and mortality. In this pilot, we examined the effectiveness of a multidisciplinary virtual intervention aimed to achieve weight loss and improve glycemic control in 10 high-risk obese Veterans with diabetes. Inclusion criteria were: age 18-75, BMI ≥ 30, A1c ≥ 8% or on high insulin doses (≥ 1 unit/kg or any dose of U-500 insulin), and at least one of the following: cardiovascular, kidney, nonalcoholic fatty liver, degenerative joint disease, or sleep apnea. All patients were recruited by the MOVE! Coordinator and enrolled in the Home Telehealth Program for diabetes and weight management. Participants worked with the dietitian to restrict carbohydrate intake (goal of 30-45 grams/meal) and with the occupational therapist to increase their physical activity through virtual sessions. A clinical pharmacist reviewed medications and made therapeutic recommendations in collaboration with the diabetes physician. Weekly huddles were held where information including glucose trends were discussed for each patient. With a mean duration of 5.5 months, participants have shown on average significant weight loss (-21.5 lbs or - 8.3%), improvement in glycemic control (-1.1% A1c), and decreased total daily insulin doses (-52.6%). At the end of the 12 months pilot duration, changes in other cardiometabolic markers, impact on quality of life, and cost will be assessed.View largeDownload slideView largeDownload slide DisclosureC. E. Mendez: None. J. M. Hansen: None. A. Feest: None. J. Taxman: None. K. Bertram: None. A. V. Hanley: None.

628-P: Accuracy of Continuous Glucose Monitoring (CGM) for Inpatient Diabetes Management

In the hospitalized patient with diabetes (DM), adequate glucose control requires frequent measurement of point-of-care (POC) blood glucose. Use of inpatient continuous glucose monitoring (CGM) could reduce workload on the staff, increase ease and frequency of glucose assessment, provide continuous glucose trends, and decrease nurse exposure to infectious patients, but data on accuracy of CGM in the hospital setting is limited. We conducted an observational study of 44 adult patients with DM who were admitted to our hospital non-intensive care units from July-October 2020. After placement of Abbott 14-day Freestyle Libre CGM sensors, patients continued to receive standard POC glucose measurement using the Accu-Chek device. Insulin dosing was based on POC data. 44% percent of participants were female, and 69% had type 2 DM. Median weight was 100.1 kg (IQR 89.0 - 109.5) and median age was 56.6 years (IQR 47.9 - 63.5). Relative to POC glucose measurement, the CGM mean absolute relative difference (MARD), %15/15, and %20/20, three standard measures of CGM accuracy, were 21.4%, 32.6%, and 47.9% respectively. CGM paralleled POC glucose, but CGM readings were consistently lower compared to POC by 20.9% (IQR 12.4 - 28.6). The variation did not change with POC glucose levels or sensor wear-time, though most data (82%) were from the first three days of sensor wear. On multiple regression analysis, participant age, sex, weight, DM type, baseline renal function, and admission HbA1c did not contribute to variation in individual’s MARDs. In conclusion, we report the accuracy of the Freestyle Libre CGM relative to POC measurements in hospitalized patients. CGM was lower than POC at all glucose levels, and accuracy did not change with other clinical variables measured. Future studies evaluating newer generations of CGMs relative to standardized plasma glucose measurements will further determine the safety and efficacy of using these new technologies for insulin dosing and glucose alerts in hospitalized patients. Disclosure J. J. Wright: None. A. Williams: None. R. Weaver: None. J. M. Williams: None. S. Bao: None.

The clinical utility of professional continuous glucose monitoring by pharmacists for patients with type 2 diabetes

BackgroundThere are limited data regarding the use of diabetes technologies, such as professional continuous glucose monitoring (CGM), as part of a pharmacist-managed diabetes service. ObjectiveTo assess how professional CGM affected treatment decisions and glucose control as part of a pharmacist-managed service for patients with type 2 diabetes.Practice description: Clinical Pharmacy Specialists (CPS's) within an outpatient diabetes management service provide comprehensive diabetes care under a scope of practice that includes prescriptive privileges. Practice innovationInsight into glucose patterns is paramount for pharmacists to use their medication expertise to its fullest capacity. CGM technology can provide detailed data on glucose trends, including percentage of time spent in a target range. Pharmacists involved in the provision of diabetes care have the opportunity to integrate professional CGM into their practice to acquire data for targeted therapeutic adjustments.Evaluation methods: A retrospective analysis was conducted of patients with type 2 diabetes who had professional CGM used as part of their routine diabetes care with the CPS from 2017-2019. The primary outcome was the percentage of patients meeting their individualized A1c goal at baseline versus 6 months post placement of the professional CGM. A McNemar’s test was used to compare the percentage of patients achieving A1c goal pre and postintervention. A P value of <0.05 denoted the presence of a statistically significant difference. ResultsPatients who implemented professional CGM had an average duration of diabetes of 15.6 years and an average A1c of 9.1%. The majority (76.7%) were not meeting their individualized A1c goal. Hypoglycemia was identified in 57% of the patients; almost half of patients evaluated had periods of nocturnal hypoglycemia. Hyperglycemia was present on the vast majority of reports (83%) with postprandial elevations being the most common trend identified overall. Mean A1c decreased from 9.11% ± 1.4 at baseline to 8.64% ± 1.3 at 3 months and 8.19% ± 0.8 at 6 months. Compared with baseline, more than 2 times the number of patients were within their A1c goal range at 3 and 6 months (23.3%, 53.6% and 69.6% respectively.) This represented a statistically significant difference at both time points (P = 0.008 at 3 months and P = 0.006 at 6 months.) ConclusionThe use of CGM technology may overcome treatment barriers, such as insufficient self-monitoring of blood glucose and lack of discernment of glucose trends with traditional A1c testing. Pharmacists employing professional CGM as part of a diabetes management service were able to achieve targets for significantly more patients with type 2 diabetes on a wide range of treatment regimens at 6 months compared with baseline. Widespread use of professional CGM in pharmacist-managed diabetes services may provide valuable care and improve outcomes more broadly. Larger randomized trials are warranted to examine ideal patient selection and optimal frequency of use.

Transient neonatal hyperinsulinism: early predictors of duration.

Hyperinsulinism is the most common cause of recurrent hypoglycemia in infants, with transient and permanent forms. Currently, there are no effective tools to predict severity and time to resolution in infants with transient hyperinsulinism (tHI). Therefore, our objective was to assess whether early glucose trends predict disease duration in tHI. A retrospective, pilot cohort of infants admitted with tHI was phenotyped for clinical and laboratory parameters. Blood glucose (BG) values were collected from the first documented hypoglycemia for 120h (fivedays). In 27 neonates with tHI, the presence of fetal distress (p=0.001) and higher mean daily BG (p=0.035) were associated with shorter time to resolution of hypoglycemia. In a further sensitivity analysis that grouped the cohort by the presence or absence of fetal distress, we found that in neonates without fetal distress, lower mean daily glucose was associated with longer disease duration (R2=0.53, p=0.01). Our pilot data suggests that predictors for disease duration of tHI may be elicited in the first week of life, and that tHI associated with fetal distress may represent a distinct clinical entity with a shorter time course.

A Multi-Biomarker Approach in European Sea Bass Exposed to Dynamic Temperature Changes under Dietary Supplementation with Origanum vulgare Essential Oil.

Simple SummaryTemperature fluctuations may induce metabolic and physiological imbalances over marine organisms, involving reproduction, growth, immune response, osmoregulatory capacity, and antioxidant defenses. It is of great importance to find tools, including nutritional interventions on farms, able to reduce such imbalances and the consequent stress for animals. In light of this perspective, we investigated the correlations between temperature and metabolic performance in sea bass fed on diet containing oregano essential oil. Under the condition of our study, thermal changes affected the levels of several biomarkers (e.g., triglycerides and cholesterol) highlighting an attempt to provide for additional energy, to counterbalance the oxidative damage, and to maintain cell homeostasis. On the other side, the activity of antioxidant enzymes, TBARS levels, and the energetic balance seemed to benefit from the intake of oregano essential oil under exposure to thermal changes.A feeding trial for 150 days was carried out to evaluate the cross-effects between oregano essential oil (EO) dietary supplementation and dynamic temperature change in sea bass. Under exposure to rising temperature (13–25 °C), fish were fed with a control diet (CD) and two experimental diets supplemented with 100 (D100) and 200 ppm (D200) of EO. Feed inclusion of EO promoted the activity of antioxidant enzymes in sea bass exposed to increasing temperature. Consistently with the temperature rise, TBARS concentrations increased in CD and D200 groups, whereas were almost stable in D100. Trend of blood glucose in fish fed on CD was likely affected by glycogenolysis and gluconeogenesis. Similarly, the depletion of triglycerides and cholesterol in fish fed on CD likely supported the energy cost of gluconeogenesis. On the other hand, the reduction of glucose, triglycerides, and cholesterol in D100 and D200 was mainly attributable to the hypoglycemic and hypolipidemic effects of EO. The higher levels of serum protein observed in D100 and D200 groups were also associated to a reduced thermal stress compared to CD. EO dietary supplementation may be a promising strategy to alleviate the negative effects of temperature shift on sea bass physiological and oxidative state.

Differences in intestinal microbiota profiling after upper and lower gastrointestinal surgery

We aimed to investigate the long-term effects of metabolic profiles and microbiota status in patients after upper gastrointestinal (GI) surgery and lower GI surgery and compared them to a control group. In this cross-sectional study, we analyzed the occurrence of metabolic syndrome (MS) in 10 patients who underwent curative total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) anastomosis, 11 patients who underwent curative partial colectomy with right hemicolectomy (RH), and 33 age and sex-matched controls. Fecal samples were also analyzed by a next-generation sequencing method. Compared with the control group, the occurrence of MS was significantly lower among patients who underwent total gastrectomy with RYEJ than the controls over the long-term follow-up (> 8 years; p< 0.05). Patients who received RH only had a trend of higher serum fasting glucose (p= 0.10). The diversity of the gut microbiota significantly decreased after RH in comparison with the control group and RYEJ group respectively (p < 0.05). Principal component analysis revealed significant differences between the control, RYEJ, and RH groups (p< 0.001). At the genus level, the ratio of Prevotella to Bacteroides (P/B) was significantly higher in the RYEJ group than the control group, whereas the P/B ratio was significantly lower in the RH group than the control group (p< 0.05). Early gastric cancer patients who received total gastrectomy with RYEJ had a lower occurrence of MS than the controls, while early CRC patients who received RH were associated with a higher serum fasting glucose than the controls during long-term follow-up. In parallel with the metabolic differences, the P/B ratio was also significantly altered in patients after upper and lower GI surgery.

SGLT2 inhibition alleviated hyperglycemia, glucose intolerance, and dumping syndrome-like symptoms in a patient with glycogen storage disease type Ia: a case report

BackgroundGlycogen storage disease (GSD) type Ia is a glycogenesis disorder with long-term complications such as hepatomegaly and renal dysfunction and is caused by congenital loss of glucose-6-phosphatase (G6Pase) expression. G6Pase is essential for the final step of gluconeogenesis and glycogenolysis, and its deficiency causes clinical hypoglycemia in the fasting state during infancy. Contrastingly, patients also show blood glucose trends and glucose intolerance similar to those in type II diabetes. Owing to the contrasting presentation of hypoglycemia with glucose intolerance, glucose control in patients remains a challenge, requiring management of both fasting hypoglycemia and post-prandial hyperglycemia.Case presentationThe patient was a 45-year old Asian (Japanese) woman who showed disease onset at 3 years of age, when hypoglycemia and hepatomegaly were observed, and GDS type Ia was diagnosed by the lack of G6Pase activity. Over the past 45 years, she presented hyperglycemia and dumping syndrome like symptoms (a feeling of fullness, even after eating just a small amount, abdominal cramping, nausea, sweating, flushing, or light-headedness and rapid heartbeat) at 2 hours after food intake. Her liver and kidney dysfunction also worsened over time. Treatment with exercise combined with a sodium-glucose co-transporter 2 inhibitor and an alpha glucosidase inhibitor alleviated her glucose intolerance and dumping syndrome-like symptoms, without increasing hypoglycemic events.ConclusionThis case suggests SGLT2 inhibitor as a promising candidate for treating glucose intolerance in GSD type Ia without worsening of hypoglycemia.

Impact of Initial eGlycemic Management System Dosing Strategy on Time to Target Blood Glucose Range.

Glucommander™ (GM), an electronic glycemic management system, was implemented across a multi-hospital health system as the standard of care for glycemic control. GM provides insulin dosing recommendations based on patient-specific blood glucose (BG) trends after providers select either a custom dose or weight-based multiplier as the initial dosing strategy for the first 24 hours. This study evaluated the impact of initial subcutaneous (SC) GM insulin dosing strategies on glycemic management. Non-intensive care unit patients treated with SC GM using either initial custom (based on provider discretion) or weight-based multiplier settings (0.3, 0.5, or 0.7 units/kg/day) were evaluated in this retrospective chart review. The primary endpoint was time to target BG range defined as time to first two consecutive in range point of care BG. Secondary endpoints included percentage of BG values in target range, percentage of orders following institutional recommendations, length of stay (LOS), average BG, and incidence of hypoglycemia and hyperglycemia. A review of 348 patients showed time to target BG was not significantly different between custom and multiplier groups (55 vs 64 hours, P = .07). Target BG was achieved in less than half of patients in both groups (47% vs 44%, respectively). There were no differences in hospital LOS, proportion of BG in target range, rates of hypo/hyperglycemia, and average BG. Custom initial SC GM insulin dosing settings showed a nonsignificant decrease in time to target BG range compared to pre-defined multiplier settings. Future studies evaluating the impact of compliance with institutional recommendations on BG control are warranted.

Glucose Control and Behavior Psychology of a T2D Patient using GH-Method: Mentality-Personality Modeling via Math-Physical Medicine (No. 306)

In this article, the author used 10-years’ worth of data of glucoses and prominent lifestyle details such as diet and exercise to address his glucose trend pattern analysis and progressive lifestyle behavior modifications. This progressive lifestyle behavior modification is closely related to behavior psychology. The research methodology used is the GH-Method: math-physical medicine (MPM) approach which has been developed by the author over the past decade. This “Progressive Behavior Modification concept is also a part of his Mentality-Personality Modeling (MPM). He addresses the quantitative linkage between diabetes physiological phenomena and behavior psychological influences of a type 2 diabetes (T2D) patient

EPS2.04 The role of Flash Glucose Monitoring System at annual review during the COVID-19 restrictions, within Cystic Fibrosis Diabetes Service at Blackpool Adult Cystic Fibrosis Centre, UK

Objectives: The gold standard of care for diagnosing Cystic Fibrosis-Related Diabetes (CFRD), as recommended by CF Trust and American Diabetes Association guidelines (Bridges et al., 2018), is to use the Oral Glucose Tolerance Test (OGTT). Flash Glucose Monitoring System (FGMS) was introduced for CF patients, shielding due to COVID-19, as part of their CF annual review (A/R) alongside chest status, weight and HbA1c. Methods: • A/R information sheet outlining reason for using FGMS and sharing data agreement via Libre View. • Video consultation with Dietitian/CF Diabetes Nurse to discuss and support insertion of Libre sensor and link to sharing data. • Patients completed 2 weeks of daily scanning and food diary. • 2 weekly CFRD MDT data analysis, using the Brompton CGM criteria for CFRD diagnosis (see table 1). [Table presented] Results: • Good uptake of CFRD screening process. • 13 patients screened with FGMS (see table 2). • Monitoring of glucose against timely food diary, using Libre View App. • FGMS has identified patients with impaired glucose handling that may have been missed on OGTT. • Patients able to observe effect of food on blood glucose levels. [Table presented] Conclusion: Using the FGMS has enhanced patient's compliance with A/R screening for CFRD. The FGMS has identified early diagnosis of patients with CFRD and patients with delayed insulin response leading to effective insulin treatment and appropriate dietary changes. Feedback to the patient following A/R has been quicker and more efficient due to video consultations and the sharing of glucose results and food diary via the App and Libre View sharing agreement. The role of FGMS at annual review allows closer analysis of glucose trends which otherwise would have been missed on the OGTT screening.

Using progressive lifestyle modifications via alternative medicine to control both body weight and glucose (GH-Method: math-physical medicine No. 309)

In this article, the author used 10-years’ worth of data of glucoses and prominent lifestyle details such as diet and exercise to address his glucose trend pattern analysis and progressive lifestyle behavior modifications. This progressive lifestyle behavior modification is closely related to behavior psychology. The research methodology used is the GH-Method: math-physical medicine (MPM) approach which has been developed by the author over the past decade. This “Progressive Behavior Modification” concept is also a part of his Mentality-Personality Modeling (MPM). He addresses the quantitative linkage between the physiological phenomena for diabetes and obesity along with the behavior psychological influences of a patient with chronic diseases. Food and exercise are important elements of alternative medicine that serve as the major influential factors in controlling glucose and weight, not medications.

Time in Range from Continuous Glucose Monitoring: A Novel Metric for Glycemic Control.

Glycosylated hemoglobin (HbA1c) has been the sole surrogate marker for assessing diabetic complications. However, consistently reported limitations of HbA1c are that it lacks detailed information on short-term glycemic control and can be easily interfered with by various clinical conditions such as anemia, pregnancy, or liver disease. Thus, HbA1c alone may not represent the real glycemic status of a patient. The advancement of continuous glucose monitoring (CGM) has enabled both patients and healthcare providers to monitor glucose trends for a whole single day, which is not possible with HbA1c. This has allowed for the development of core metrics such as time spent in time in range (TIR), hyperglycemia, or hypoglycemia, and glycemic variability. Among the 10 core metrics, TIR is reported to represent overall glycemic control better than HbA1c alone. Moreover, various evidence supports TIR as a predictive marker of diabetes complications as well as HbA1c, as the inverse relationship between HbA1c and TIR reveals. However, there are more complex relationships between HbA1c, TIR, and other CGM metrics. This article provides information about 10 core metrics with particular focus on TIR and the relationships between the CGM metrics for comprehensive understanding of glycemic status using CGM.

Continuous Glucose Monitoring With Low-Carbohydrate Diet Coaching in Adults With Prediabetes: Mixed Methods Pilot Study.

BackgroundType 2 diabetes mellitus (T2DM) is preventable; however, few patients with prediabetes participate in prevention programs. The use of user-friendly continuous glucose monitors (CGMs) with low-carbohydrate diet coaching is a novel strategy to prevent T2DM.ObjectiveThis study aims to determine the patient satisfaction and feasibility of an intervention combining CGM use and low-carbohydrate diet coaching in patients with prediabetes to drive dietary behavior change.MethodsWe conducted a mixed methods, single-arm pilot and feasibility study at a suburban family medicine clinic. A total of 15 adults with prediabetes with hemoglobin A1c (HbA1c) levels between 5.7% and 6.4% and a BMI >30 kg/m2 were recruited to participate. The intervention and assessments took place during 3 in-person study visits and 2 qualitative phone interviews (3 weeks and 6 months after the intervention). During visit 1, participants were asked to wear a CGM and complete a food intake and craving log for 10 days. During visit 2, the food intake and craving log along with the CGM results of the participants were reviewed and the participants received low-carbohydrate diet coaching, including learning about carbohydrates and personalized feedback. A second CGM sensor, with the ability to scan and record glucose trends, was placed, and the participants logged their food intake and cravings as they attempted to reduce their total carbohydrate intake (<100 g/day). During visit 3, the participants reviewed their CGM and log data. The primary outcome was satisfaction with the use of CGM and low-carbohydrate diet. The secondary outcomes included feasibility, weight, and HbA1c change, and percentage of time spent in hyperglycemia. Changes in attitudes and risk perception of developing diabetes were also assessed.ResultsThe overall satisfaction rate of our intervention was 93%. The intervention induced a weight reduction of 1.4 lb (P=.02) and a reduction of HbA1c levels by 0.71% (P<.001) since enrollment. Although not significantly, the percentage of time above glucose goal and average daily glucose levels decreased slightly during the study period. Qualitative interview themes indicated no major barriers to CGM use; the acceptance of a low-carbohydrate diet; and that CGMs helped to visualize the impact of carbohydrates on the body, driving dietary changes.ConclusionsThe use of CGMs and low-carbohydrate diet coaching to drive dietary changes in patients with prediabetes is feasible and acceptable to patients. This novel method merits further exploration, as the preliminary data indicate that combining CGM use with low-carbohydrate diet coaching drives dietary changes, which may ultimately prevent T2DM.

Longitudinal Fasting Blood Glucose Trends and Mortality Risk in Mice Differs From That of Non-Human Primates and Humans

Longitudinal studies in humans have led to the development of strong predictors of outcomes of health, disease and mortality. Translation from model organisms to human has been faced with species-specific regulation of metabolic function and challenged by the lack of longitudinal studies addressing trajectories of change that can be used, as in humans to predict outcomes. Here we compare longitudinal predictors of health and mortality of three major metabolic indices among mice, non-human primates and humans. Longitudinal fasting blood glucose, body weight and body composition over the lifespan were compared across species, mice, Rhesus monkeys and humans. Survival analysis was conducted to calculate the risk of death for subjects with highest and lowest quartiles of fasting blood glucose. We will present data highlighting species-specific mechanisms of glucose homeostasis over the lifespan and its association with mortality.

Disordered eating in women with type 1 diabetes: Continuous glucose monitoring reveals the complex interactions of glycaemia, self-care behaviour and emotion.

Glycaemia in people with type 1 diabetes and disordered eating is not well characterised. We explored the glycaemia, self-care behaviour and emotional state of women with type 1 diabetes and disordered eating. In all, 13 women with and 10 without disordered eating and type 1 diabetes participated in this case-control study. We used a mixed-methods approach with a 7-day blinded continuous glucose monitoring and real-time record of non-prompted capillary glucose (CG), emotion, activity and physical symptoms on a diabetes diary using a smartphone application (mySugr®). We compared groups using Mann-Whitney U test or Fisher's exact test. We conducted thematic analyses of free-text diary entries (NVivo®) and quantitative analysis of emotion/symptom tags. People with type 1 diabetes and disordered eating spent longer time above range in level 2 hyperglycaemia (>13.9mmol/L, Median [interquartile range]: 21% [16,60] vs 5% [2,17], p=0.015). They had lower time in range and similar time below range compared to those without disordered eating. The standard deviation of CG was significantly higher in the disordered eating group (4.7mmol/L [4.5, 6.1] vs 3 [2.8, 3.2], p=0.018). The median of the percentage of rising sensor glucose trends was three times higher in the disordered eating group. They also had higher negative emotional and physical symptoms associated with high blood glucose (>15mmol/L). Disordered eating has a significant impact on the glycaemia and emotion of a person with type 1 diabetes.

Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions.

This review highlights challenges associated with weight management in children and adolescents with type 1 diabetes (T1D). Our purpose is to propose potential solutions to improve weight outcomes in youth with T1D. A common barrier to weight management in T1D is reluctance to engage in exercise for fear of hypoglycemia. Healthcare practitioners generally provide limited guidance for insulin dosing and carbohydrate modifications to maintain stable glycemia during exercise. Adherence to dietary guidelines is associated with improved glycemia; however, youth struggle to meet recommendations. When psychosocial factors are addressed in combination with glucose trends, this often leads to successful T1D management. Newer medications also hold promise to potentially aid in glycemia and weight management, but further research is necessary. Properly addressing physical activity, nutrition, pharmacotherapy, and psychosocial factors while emphasizing weight management may reduce the likelihood of obesity development and its perpetuation in this population.

Dynamic changes in nocturnal blood glucose levels are associated with sleep-related features in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has a bidirectional relationship with insulin resistance conditions; however, the mechanism remains unclear. This study aimed to compare dynamic nocturnal glucose changes among patients with OSA of varying levels of severity and evaluate temporal changes associated with the cardinal features of OSA (sympathetic hyperactivation, intermittent hypoxemia, and sleep fragmentation) in nondiabetic subjects. Nocturnal glucose was measured with a continuous glucose monitoring device every 5 min during polysomnography (PSG). The OSA features were evaluated using heart rate variability (HRV), minimum saturation, and electroencephalography. Eleven subjects with moderate to severe OSA and 12 subjects with no or mild OSA were evaluated. Those with moderate to severe OSA showed an increasing trend in blood glucose levels after sleep onset, whereas those without or with mild OSA showed a decreasing trend (F = 8.933, p < 0.001). Delta band power also showed different trends during sleep between the two groups (F = 2.991, p = 0.009), and minimum saturation remained lower in the moderate to severe OSA group than in the no or mild OSA group. High degrees of coupling between nocturnal glucose levels and each OSA feature were observed. Altered trends in nocturnal glucose in moderate to severe OSA may reflect glucose intolerance and result in metabolic consequences. Managing the features of sleep-related OSA may have implications for metabolic management in the future.