Well, thank you so much for joining me. I get to dive into an interactive case based uh review. Uh Talking about some of my clinical patients that I've utilized CGM with, we're gonna go through some of the data, the intervention patient care optimization. And I'm gonna take what we have learned previously and kind of really put it boots on the ground because this is more of a real world experience. I also dive a little bit deeper into teasing out some of the nuances of identifying individuals early on and early diabetes as well as those in oral anti diabetic therapies. And we're just gonna have a great uh time interacting. I want you to think a bit as I'm going through this particular slide set, I'll pause to let you think about what you would do in that clinical scenario and then we'll discuss it and and see how we can go into different directions for um for improved uh management using CGM as a tool. So I'm Doctor Eden Miller. I'm a family practitioner by training, I am the director of diabetes and obesity C in Bend Oregon. I also have my diplomat status in the American College of Diabetes as well as uh uh obesity medicine. And you can contact me uh through www Doctor Sweet life.com. So we really have heard about how important it is to go beyond A one C. A lot of times, I like to say that I'm gonna validate my A ONE C by time and range. And oftentimes when I get asked to educate my colleagues, I say if I know the time and range, I'm gonna know the A one C. But if I know the A one C, I don't know the time and range and so really time range goes beyond that average A one C. It really illuminates all the past journeys of glucose in the present and it predicts the future. It really is all of that historical data compiled into one and, and we can't go wrong in utilizing it. It, it, it's often been said, you cannot man which you don't monitor and, and to be blind to the glycemia and to try to make effective interventions as the person living with diabetes, trying to do lifestyle intervention as well as a prescriber. And as we get a further broader understanding of how CGM and its implication on pharmacokinetic and dynamics. We're really starting to see that there are definite signatures of medications. And so this really is um this 21st century kind of pivotal moment uh that we are now finding ourselves of where we see all the data. And not only that is very individualized, it's not generalized, this is an amazing uh utilization to be able to discover the different journeys that a person with diabetes has. And so, you know, seguing into that, this is dual beneficial. Now, what do I mean by that? You know, there aren't a lot of things in medicine that benefit the prescriber and the patient in equality as well as differences. And that is, you know, imagine if there was just a test that benefited the health care provider, kind of like an EKG, right? We do an EKG, we can determine if there's any abnormalities, but you show it to the patient and they're like, I have no idea what this is. Now when we look at a metric that just uh benefits the patient, but maybe not the prescriber. We go uh you know, is it worth the time of me looking at this, the continuous glucose monitoring is the Rosetta Stone of diabetes. It's totally bringing diabetes out of the past into the present and we're predicting the future. And so we can see that there are vast benefits to both the person and the provider. We can see trend arrows, directional arrows, rate of change, which just even in and of itself is so good at informing individuals of the effects of things on their glycemia and in and of itself preventing hypoglycemia. One of the things that we kind of heard a little bit earlier is how can you use CGM as a risk identification, risk reduction tool? What do I mean by that? Well, this is where the individualization of diabetes comes in. And oftentimes I will talk to people about the fabulous five, the five foods that don't bother their blood sugar. In other words, don't create this real glycaemic variability. In addition, I talk about the forbidden five, you know, those five foods that for that individual really just don't appear to be worth it, right? They don't want to spend all their carbohydrate poker chips on that. And so this is this opportunity through journaling to see how activity and illness and food choices as well as medication adherence. We're gonna go through a case a little bit later about an individual who saw the effects of not adhering to her medication uh on the CGM. It also allows those individuals, those loved ones, those family members to share the data points. I can't tell you how many times I've been in the office where family members and loved ones say I just worry about him. I lose sleep. Talk about parents and kids. Imagine yourself with a new kid that had died is that y'all are not going to get a lot of sleep, but utilizing CGM gives you that peace of mind. Uh I've had patients call it their little guard dog and it gives them those alarms. Uh the predictive alarms, the trend arrows the the highs and lows, you can customize those as as to give the patient that ultimate value. And really one of the parts that I think we often don't really fully realize the impact is applying AC GM to a person will increase that personal engagement and thereby lessening diabetes distress. You know, one of my colleagues will say, oh, I don't, I know my patient is not gonna benefit from it, but you can see this list here uh of all the many benefits and these are the struggles we have in diabetes. And so CGM really fills in that gap between adherence and and um just that information of how diabetes affects you. Now, if we look at the provider side again, that dual benefit both to the person wearing it and both of us as a prescriber, we see that increased engagement, which actually gives us more time, we allow them or empower them to become experts on their own disease, which is like one of my uh you know, mission statements and that is in giving them a tool so they can be more responsible, not in a judgmental way, but more in an equipped way. And as a result of that, the individual can bear the burden in monitoring for hypoglycemia. We, we're not living with them. We get those panic phone calls. Uh In addition, those family members can share with that as well. One of the things that I think is starting to see more and more, um, out in with my colleagues is the opportunity to see their therapeutic impact. Uh, you need to learn how to read these things. They, they give you the information in an actionable compatible manner. And as a result, as a clinician, you're gonna start to see patterns, the more you look at them the better you're going to get. Sometimes I just talk out loud. I just look at it and I go, what do I see? What are the things? Sometimes I write out the different medications and you'll start to see how different medicines are both, you know, f fasting and postprandial or, or one or the other. And so this is this opportunity to not just use the A one C as your therapeutic driver, but use that CGM to be more specific and deliberate and pointed about where you impact the glycemia and all of that actionable data. There's all these nomenclatures you've heard about, many of you are starting to get this vocabulary, time and target or time and range variability. That's the roller coasters as well as those trends over time. And then just an awesome way to have that discussion, a shared discussion with the patient regarding that effects of lifestyle intervention. And so, you know, this is enough to really demonstrate and it kind of really shows the passion that I have because too often CGM has been put in this, well, it's only used for insulin and only used for people for hypoglycemia. It's like, really you're neglecting all the very many benefits that can be out there uh for continuous glucose monitoring. And, and my opinion is you have diabetes, you can benefit in some away from CGM in your own care as well as you as a clinician in the care of persons with diabetes. Now, if we look at a clinical case, so now we're gonna take this and we're gonna dive into the clinical cases. These are real cases in our practice. Um My husband, Doctor Kevin Miller, who he and I have uh done our clinic and we've worked together for years now. Uh We do a lot of consultation regarding prediabetes and I put early diabetes in here because I'm going to also introduce you to a presentation he gave last year on the reclassification. I often tease, I don't like to use the word prediabetes because it's like being prep pregnant. Uh but rather it's early diabetes. And what we had is we had this 59 year old male that came into the office for prediabetes consultation. You know, as we went through his medical history that you can see here his uh previous history, you know, as well as his, his current A one C is 61, his fasting glucose is 112. He struggles with excess apoe and is in the overweight category and we can see his medications. Then when we talked about his lifestyle, he says, you know what I do walk about three times per week, about 30 minutes and I don't need any sugar. And so this is where I want you to pause for a moment and say, what are you gonna do to try and help this individual? And what's the next step given his current presentation? Would it be number one to continue his current diet and exercise? Because, you know, he doesn't have diabetes and what he's doing right now is doing just fine because his A one C is at 61. Would you advise him to work on a weight reduction of 30% of his body weight? Uh What about a trial of CGM to look at diet and physical activity journey? And you know, with this individual, he's already on target. In other words, he doesn't have diabetes, let's just repeat it in about six months. So I'm gonna pause a moment for you to think about what you would do, you know, and be honest with yourself, what are you gonna do? Don't just put in here because we're talking about CGM. Be honest with yourself, what would you typically do in this person? Because what I wanna do is kind of open your eyes to new opportunities. Well, I'll tell you what we do. We use in our clinic, a continuous glucose monitoring as a risk identification, risk reduction tool. And what we do is we say to an individual, hey, we wanna put this monitor on you that's gonna sample your blood sugar every so many minutes. And I want you to learn about yourself. This is not a judgment, this is not a distress. In fact, if it makes you distress, then I'm missing my objective. Rather, I want you to journal, I want you to learn that there is an opportunity for lifestyle management. In addition, we also have data indicating that the utilization of CGM with individuals can help with secondary weight loss. And so what an opportunity to take this person's a GP to have them have the journal and to go at the very bottom and see that daily model. And to say, what did you learn? In fact, you can look at this particular one and see the first week we had a higher glucose vary than the second week. We see a glucose management indicator of six, which is similar to that 6.1. We see that this individual as we talk to them, yes, their, their time and target range is 100% but we're using it or 95% we're using it to create behavioral issues. And so when you bring them in, you're gonna say, what did you learn about this? What was something that you got from it? Because this is the natural history of type two diabetes. You know, let's just pause for a moment and remember, look at the arrow, the red arrow that talks about the onset of diabetes. And let's go back to Ralph to Franz's data. What percentage of the beta cell is gone when a person develops type two diabetes? At that red arrow, it's not really the zero hour, I guess we call it the zero hour of the diagnosis of diabetes, but the studies have shown between 50 to 70% of the beta cell is gone. That means you're ever halfway there. And that's why many of us thought leaders are talking about the early identification and and uh and intervention of diabetes. We know that that prediabetes or early diabetes state shows impaired fasting glucose, impaired glucose tolerance and and metabolic syndrome. We know that we can see these changes related to insulin resistance and the rising of the glucose. What if we could define this? Identify it, intervene, do a combination of lifestyle intervention early through weight reduction and choices and, and encouragement and direction for these people maybe in the stages that are closer to diabetes, actually use medication to halt the progression. So you see that it's a continuum that we're expanding this identification and we don't wanna be late to the diagnosis. We actually wanna be early in risk identification and we wanna reduce that. So what if we do nothing? What if we do nothing with these individuals? Because you know, we really wouldn't want to hurt their feelings telling that 98 million people in the United States, 435 million people in the world that they have just a touch of sugar. And we would dare tell them that they had early diabetes because, you know, they would feel bad. Now, I had the opportunity to work with Doctor Michael, uh Vialli out of uh Canada. And he did study that talked about individuals that were told that they had prediabetes or individuals that were told they had early diabetes that was at risk for developing diabetes. And which do did they feel more strongly about and which led them to have better interventions? And the reality is, is that 80% of the people out there, that big number I told you about 98 million, right? You add that to the amount of people who have diabetes. We're talking over a third of the population almost getting close to 40%. They didn't even know they have early diabetes for those a one CS of 6 to 65, 25 to 50% will progress in five years. Some of the data indicates in eight years, we will have about an 80% progression. That means we're going to have 60 plus million people with type two diabetes in the next 8 to 10 years. And we also understand that those individuals that are 45 and above with these early diabetes, 74% of them are gonna progress. And we are now seeing emerging data that those early diabetes that prediabetic state has risk of stroke and retinopathy and neuropathy and kidney failure. And then I hate to mention it as well. Type two diabetes is the leading pediatric chronic disease right now. In addition, we're not dealing with an average age of 62 for developing type two diabetes. We're dealing with an average age of the late thirties, early forties. And we're dealing with a cohort of individuals who are going to live the majority of their life with diabetes. And so I think it's time to take diabetes out of the reactive category and take it into the preventative category. So this new classification of prediabetes, as I mentioned earlier was a first um put out there by Doctor Kevin Miller, my sweet husband who I work with, he presented this at the ad a last year in 2023 and through lots of work which I helped him as well. We came up with kind of a starting point, a starting point of where do we classify? How do we look at individuals with that are at risk? And can we create a staging like a stage one prediabetes? A stage two early diabetes. Can we have language that makes it sound more actionable for individuals, not just that little touch of sugar. And so you can see here that through this uh presentation that we gave last year, we also uh published it in um diabetes Technology and Therapeutics uh back in 2023. And then in 2024 in clinical diabetes. And so these numbers were just were thought upon and, and use quite a bit of data for us to come up with. I do believe that they may change in the future, be refined, but it is a way for us to tear out those individuals based on staging for those that are at much higher risk on the right hand side to call them early type two diabetes. But also look about how we put at the bottom coefficient of variability through CGM around the mean, not just the variability saying, well, it's this particular number but rather we know when we have those high and lows that though that individual is losing their first phase insulin, they have gone from that, you know, prandial type of inner uh uh problem to elevated fasting blood glucose. And so we are looking at CGM as a risk assessment and risk reduction metric. In other words, a way to use CGM to narrow or improve the glycemic variability to identify it and take action to stave off the disease. Now, I have heard of some trials going forward about possibly using CGM as a diagnostic criteria for prediabetes. I don't think we're there yet, but I think by looking at these standards will give us a better idea of how to identify those at risk and those very much at risk because we really want to try and intervene because in intervening, we need lifestyle intervention for that or stage one prediabetes. We can use CGM as at risk assessment. Help them with lifestyle, help them with diet just like we did with this other individual. We're looking for that 7% weight reduction because that's what the diabetes prevention program encourages us. It allows us to address other chronic diseases such as adiposity of cardiovascular disease to help with that. Maybe utilize therapies to improve upon that. Then if shift from stage one to stage two, early diabetes, we're going to do all that foundational CGM and lifestyle. But we really need to get that 10 to 15% weight reduction. And many of us experts including Doctor Kevin Miller and myself are calling for the AD A to create a classification of early diabetes. So it would open up the AD A S algorithm that we would use that to treat that glycemic state. In that stage two, we wouldn't wait until they burst into flames. We would put them out when they had smoke, uh going on in their life when they were having that dysfunctional glycemia because we would treat the cell. We would treat the person who had excess adiposity. We would treat the cardiovascular disease and renal disease and have glycemic effects which would ultimately delay or prevent the onset of diabetes. And we have to do that as my great friend, Gene Wright would say we're not interested and saving people who were drowning upstream in the diagnosis, pulling them out. We're gonna try to prevent them from falling into the river. So let's go through a second case. The clinical case number two, it's really an unexpected A one C elevation. There's a great gal that came in 63 year old female. She had type two diabetes for 3.5 years. She was testing her glucose in the morning and she said they didn't look too bad and she goes, I don't understand. And so why is my A one C so high? She had a typical, you know, uh trifecta of type two diabetes. She struggled with class two, obesity, hyperlipidemia and hypertension. She currently was on Metformin 1000 mg twice a day. But she really did admit to poor adherence in the evening dose. When I talked with her about that engagement, I would say to her, how many times in a given week do you not take your nighttime Metformin? And so our baseline A one C was at 8.4. And what I did is I said, you know, I really would like to have a little accountability partner for you. And would you be interested in utilizing CGM to see how medication adherence and, and lifestyle? Because she actually shared with me, she wanted to improve her overall lifestyle intervention. And so she and I decided to go ahead and put AC GM on and I said, hey, I want you to be journaling the effects of food and all the different glucoses you visit. And then I had her come in at about a 2 to 3 week interval. That's something I really want you guys to do. You know, I know some of you are booked so far out. But I like to have this, I apply the CGM in my office and then I have them walk to the front desk and I said, please schedule AC GM follow up because it's just to go over the data. I said try to give me as much detail about so we can have a meaning uh de detail about your lifestyle so we can have a meaningful discussion. And then I put in the chart, what kind of CGM they are on it really prompts my, my uh staff to when it says CGM appointment to make sure it's all downloaded and really just I complete the circle. So what do you see here at this baseline? A GP? So remember had the lady come in? She was on Metformin. I put AC GM on and I told her journal and I want you to come back in three weeks to discuss it. So what do you see? OK, of course, I know you see the time and range and the target range and that kind of thing. But I'd like to highlight that glucose management indicator. I called that a sensor derived A one C. It wasn't my thing. It was this great guy that did a, a journal article that I reviewed for clinical diabetes and this individual called it a sensor derived A one C I thought that's really pretty cool. That means that, that A one C is derived over the last two weeks. It doesn't mean that's the A one C. But what can you get out of that? Right. What can you get out of that particular type of intervention? First of all, you saw her three weeks later, do you remember what her A one C was? When you did the point of care? She has made meaningful impact with her glycemia in three weeks. I call that the CGM effect. That means that that is happening even before you as a clinician is downloading it. And so this is where I asked the patient, what do you, what did you learn? What did you find out? Share this with me? That's amazing to be able to share with people. I've heard everything from Oatmeal hates me. So I didn't know this had this effect. I didn't know my sugars were so high. I didn't know medication adherence and physical activity helped me with engaging in my overall disease process. And so it is imperative that we use this daily profile to be able to say, hey, what happened here? So what do you see again here? Just pause for a minute. Now, I know you're all saying, I see a bunch of yellow and I see some highs. Well, how is week one compared to week two? I think you can see it. You can see that there is overall improvement in the glycemia. I don't mean that they're not having that, but I had this opportunity to say what happened from week one to week two. And what happened is she said to me, I started taking my Metformin more regularly and I said, ok, what was Friday night And Saturday, Sunday night, the second week? Oh, I went out to dinner. I, are you learning? Are you learning that effect? I'm not saying you go out to d don't go out to dinner. But what are you learning as a result? So this CGM is really a lifestyle barometer, an exercise and medication adherence, barometer. It also can give you as a clinician the ability to say, hey, wait a minute, do I need to do anything different? Right? Because we did notice something different from the first week and the changes in the second week. But the question is, do we need to do anything else with this individual? Yes. This is where she is putting in of the skin in the game, she's putting in that. She noticed the changes, she's showing up with medication adherence. She says it's still hard to adhere to that Metformin and, and looking at that diet. And so the question then comes, what would you do? So her sensor derived a one C was what about 74 A one C when she came in was 86. Would you a discontinue the CGM and maintain current medication? Because she's learned her lesson? Would you number two, continue CGM and recheck the A one C in two months to get a full wash out? Right? Because remember that was sensor derived, it wasn't a full wash out. It was two weeks. Would you just augment the medication to achieve your targeted A one C maybe add something and then just not do CGM and never come back in two months or would you continue the CGM and intensify the medication intervention because you don't want clinical inertia to abound. What would you do? Be honest with yourself? What would you do in this scenario? What would be your first inclination as you're thinking about yourself in clinical practice? I can tell you what I did. I said you mentioned that you're really not adhering to the Metformin. She goes, yes, it's really hard to take twice a day. Now, you and I could have done the extended release, Metformin do it two in the morning. But do you think we're gonna gain all that target by just doing that? She reported that significant awareness of effects of food and activities doesn't mean she was perfect. But she says, I now know and I now have information to make very impactful decisions. The two of us decided that her glycemic needs, especially with removing Metformin would be to add a G LP one receptor agonist because she had trouble with adherence. She needs a good 1.5% a one C reduction. She wasn't going to be adherent to the Metformin and we needed to remove it. And so she says, but I wanna continue the CGM. She because says it's her diabetes accountability partner. It wasn't distressful, it was empowering for her. So this is six months of a follow up. So now does that mean I didn't see her in between? No, this is six months because I had to titrate the G LP one. So the patient reports, she has significant improved adherence to medication and that she's taking it weekly. She is titrated on it and she notices the direct effects of her glucose control. She indicates she's having a great deal of understanding of how diet choices and exercise affect her. Look at her target range, it's 90% and her glucose management indicator or sensor drived A one C is 6.6. Look at her variability, her variability is 22. Now that doesn't mean she's perfect. We still see that she pops up above 180 at that high range, but she doesn't have any more of that very high range anymore. So here's a great example of medication adherence, changing therapy plus having the patient by into that therapeutic change as well as that lifestyle intervention. So let's go through clinical case number three. This is a 70 year old female of type two diabetes for nine years. Her health goals when she comes in and says, you know what? I wanna lose weight. There's hypertension hyperlipidemia. She's class three obesity and she has hypothyroidism. She's on an SDLT 2 25 mg of Icy Flos Pyle glitazone at 15 and D glutose at 1.5 mg weekly. Her point of care because I do point of care. A One C's at the office is seven. So she says I wanna lose weight, I wanna do different things. And I said, you know what, we might be able to put AC GM on you and have you look and see the effects of food, how it has on your glucose control. And do you know that if you have foods that have less glycemic variability? There's a lot of studies that Weight Watchers is doing with type two diet CD and CGM use that helps with secondary weight loss. They even have an app that has the CGM built into it so it can give you meaningful feedback regarding that. I think we've just begun to look at how metabolism is affected by CGM. So what we did is we did the application, we closed the loop, we had her come back and have some journaling of finding out the Forbidden five and the Fabulous Five. And this is what we saw, we saw a very similar type of A one C but what she reports is that she says, you know, I'm really determining those foods and seeing how they affect my glucose. I'm still trying to work on the foods that are good. So I did this opportunity and I looked at particular days and said, what do you notice about this? What do you notice about this and how are some of those things that you can do to change it? So we went through those, we went through uh line by line or, or day by day and then we came up and identified those foods that she should avoid and those foods that she should should um increase. And then when she had successful days, what seemed to happen during those days? And so which of the following benefits were seen following, incorporating CGM and analysis of an A GP. When we look at adding CGM to individuals, what do we see? We see a number one, an A one C drop of 1% with time and range improvement. Number two titration of the G LP one requested at follow up. That is what this individual suggested as well as a total weight loss of 12% observed by the patient or all of the above. This is what we saw all of the above. So when we saw that patient's baseline A one C and we talked to them about doing dietary intervention, doing that journaling, figuring out when her glucoses was best. What occurred was it exercise. Was it food? She wanted to increase her G LP one. She says, you know what it looks like I need additional G LP one doses. I said that's great. And then what we saw and this was about four months later, this was her follow up A GP. You see, we saw an A one C drop of 1%. We have time and range at 98%. She ended up having a weight loss of 12%. And so all of the above occurred because you gave the patient a tool to see them where they were at, which also benefited you because you as a clinician could titrate the med, but the patient actually brought it up. We love that, right? Because we always feel like we're pulling teeth to get people to agree to that. So all of the above now this is a study that I had the opportunity to present at att D both in poster form and in publication. And that is uh with my partner Gene Wright. Uh He also did another compendium article and that was looking at CGMU with the OP one receptor agonist. So you can see the study design on the left. We use Optum D I five mark clarity data and we link that E hr claims space. We did adults with type two diabetes uh with I CD 10 diagnosis. And we looked at those who had an A one C greater than eight at the time of using freestyle Libra, they had to be active users of G LP one therapy divi defined by having it greater uh greater than one equal to or greater than one refill prescription filled within the last six months of first using CGF. So these individuals were adult with type two diabetes with a one C above eight. And we had a G LP one. And then what we did is we looked at what occurred when they filled a sensor and then we looked at that change in a one C from the time of first using AC GM to six months later. So as you can see the patients who are already using G LP one saw a significant P value positive improvement in A one C after adding the freestyle libre, they dropped by 1.5%. And so we saw that average of 8.3. That's amazing because that is that lifestyle component because many of us are like, oh, we just put a GOP one on, we're fine. No. And that the reality is is that if you augment a GOP one with a sensor, you get additional A one C reduction because you're really empowering the patient to know the effects of glycemia. So we're also gonna talk uh just in the next few moments about economics of CJ M utilization. This was another article that I helped publish several years ago, also with my friend Gene Wright and that it was the look at the flare study for those with type one and type two diabetes. Whereas the reduction in hospital admission and absenteeism from work, that's bank right there. That's a lot of money because we're actually preventing some of the complications. And you're gonna be diving into the health econo economics of this in just a few moments. There is another fun study that I really enjoyed presenting as well um, back in 2020. And that was really the look at CGM for those individuals who were on O A DS and one shot of insulin or O A DS and non insulin. And on the left it was the combined cohort. So it was everybody on O A DS and one shot of insulin or not. And on the left hand side, we saw the improvement or the reduction in A one C in the first six months and then sustained at 12 months in that cohort. But what was exceedingly fascinating is we took those individuals who were not taking baseline sin and look at their A one C reduction. Those are people traditionally, we say uh they don't need to look at their CGM, but how is it gonna improve them? And then I say to colleagues who are a bit skeptical, do all of your patients know the effects of food and lifestyle and medication adherence on their glucose? And do you know the effects of your prescribing on their glucose? No. And so you can see that this is additional data that I actually believe helped get C MS to cover CGM in those patients on basal insulin. And I just think we're gonna see broader and broader coverage and utility of this as it is a tool to get people to target. So remember, it's about clinical inertia, it's that inactivity in action by a prescriber when guidelines or optimal care would recommend a more aggressive course. So we're telling you be familiar with the ad A S recommendations and coverage for CGM. But it's also like I said, you can't manage what you don't monitor and don't ever let clinical and nurse should be traced back to you if you're like, well, I don't really want to do a sensor. Don't be the barrier to that person getting a sensor because it's their disease and you're trying to turn them into experts. And again, my motto is I only succeed as a provider if I turn my patient into experts on their own disease. Thank you so much.
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