Video The Power of CGM as a Lifestyle Intervention PlatformInteractive Case Study: Deploying the AGP Report to Engage and Motivate Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides The Power of CGM as a Lifestyle Intervention PlatformInteractive Case Study: Deploying the AGP Report to Engage and Motivate Overview CONTINUE TO TEST Back to Symposium Hello, I'm Rich Bergenthal from the International Diabetes Center in Minneapolis, Minnesota. And it's really a pleasure to be able to present on a topic today that I think gets much less attention that it deserves. And that is the power of CGM as a lifestyle intervention tool or platform. We're really lucky at the International Diabetes Center to have a great diabetes education and care specialists and primary care, eager to learn about how to use CGM most effectively. So let's dive in to this topic today. These are my disclosures. Let's start off with uh just asking the question who can benefit from optimizing lifestyle choices. Well, I think if we're honest, the answer is probably almost every one of us could eat better, uh more healthy foods on a consistent basis. But let's dive a little deeper. Is it really worth it? Do we really need to make good food choices and selections? Well, this was an interesting study that says the risk of death after age 40 if you stick to certain lifestyle factors is pretty amazing and we know about physical activity and not smoking, but right up there is healthy eating, which really includes usually a lot of plant based foods. So I think it's well worth our effort. But what we wanna really discuss today is this combination of looking at the mortality reduction from eating healthy and there is a healthy eating index that's pretty well established as a guide for that. But also the value of optimizing glycemic control. Do we have to make a choice, eat healthy or get good glucose control? Or can we really work to try to optimize both? Which I think in the long run is obviously our goal. Let me give you the data just quickly. Um Does diet quality matter? Look at this study? Um If you eat a quality diet in this big UK study where they track people over time, you could increase your, your lifespan 10 years by having a healthy diet, the average was 3 to 4, but those who really stuck to it as much as 10 years and this other study, 36 years of follow up linking healthy eating patterns to reduce mortality. Um So that's pretty powerful data to say we should give it a try. How about in people with diabetes? This Dutch um cohort uh of over 40,000 people where they tracked if you had type two diabetes and you had a poor diet quality by that healthy food eating index, you had 87% higher mortality risk than if you had a good quality diet. And then finally, how about a one c how does that stack up? And, and it's hard to find these exact numbers. But I thought this study from 2017 was probably the best over several decades. If you maintained an A one C of over eight, your mortality rate was 60% higher, over 9 80%. So, look at that. A one c over 9 80% higher risk of mortality. Uh, a poor diabetes, uh, a poor quality diet, 87% a higher risk of mortality. So both of those factors, we've got to improve the quality uh and the glycemia. So you look at a uh at a picture like this and someone is looking at their glucose on their phone and, and they're, they're eating, look at, we know that uh CGM can give us better overall picture of the glucose, but it's really good also at showing up these spikes. Uh and if you do something about those spikes, they, they can actually go away and you can have a smoother curve. So that's the theory. Um how do we put that into practice? What groups of people tend to have those spikes that we should use CGM to evaluate their overall uh glycemic profiles? Well, here's the five that I thought of that, I think managing postprandial glucose excursions uh with CGM and looking at lifestyle changes, pregnancy type one, type two prediabetes and even those people who are overweight and uh and don't have diabetes. Uh I think can benefit. So I'll talk about these five really focusing on the first four for just a couple of minutes. What is the data that it's worth looking at these post brandal spikes? Well, pregnancy is kind of a no brainer brainer, but we have to really emphasize that over the years post brandal glucoses have been our main target. Um And if we can reduce those, the health of the baby, the health of the mother uh really improves, you all know, there's targets 1 41 hour after 1 22 hours after, when you really look at the data, they're about 20 points lower than that actually. But our guidelines give a little wiggle room, maybe they shouldn't. Um And then we also have time and range in pregnancy uh greater than 70% in this middle bar, 63 to 140. And in GDM, we're still wrestling with a consensus, but it's somewhere around 90%. Um time and range is necessary to really have a healthy uh baby and best outcomes for the mother. So this article was interesting saying it may be time for more precision uh medicine in pregnancy and particularly GDM. And I'll show you just one slide that I think we're starting to arrive at that precision that this paper asked for just a couple of years ago. And this is a paper just published um this last month in diabetes care by from a team that uh the I DC worked with in the University of Pennsylvania. And this was normal women, uh who were pregnant and we always watch for GDM and we did CGM on them throughout pregnancy. And I'll just show you this one picture on the left hand side of this, that week, 13 to 14 when they had AC GM on, some of the women had time over 100 and 40 on their CGM of over 10% other women had it under 5%. Those who had spikes in their glucose by their first ob visit at week 13 to 14 were those who went on to develop gestational diabetes and those who didn't did not get GDM. So I think this is really a breakthrough study that says CGM lifestyle choices, monitoring your glucose early could make a huge difference. We now need to do the intervention study and show that intervening on this data at 13 to 14 weeks really makes a difference. How about we move to type one diabetes? You just heard a wonderful discussion uh of the incredible value of CGM linked with pumps and, and an algorithm. And you saw how the fasting glucose is just get incredibly uh tight control. But there are, there is still room even with a ID for postprandials and daytime glucoses to improve. And why make the algorithm do all the work, why not use CGM to make better lifestyle choices as well and try to optimize the daytime. Uh along with the incredible technology of A ID, then I'll move to type two diabetes uh data. And I think the best way is to just look at the ad a standards of care and this was a little stair step. I put together of the evidence with a one C and time and range or GM I at the top and you, and you see down here at the bottom, the the pumps and, and MD I and A ID A level evidence type one and now even type two and basal and pregnancy. Um Up here a little further is our discussion today. CGM and non insulin users needs more data. So it's promising though. And so that's what we're gonna focus on. Where is the data that we need? Well, we're kind of lucky that there was just published uh earlier this year, a meta analysis of just this cohort that we're really interested in today, noninsulin using people with type two. And you see on the left there aren't many studies, a couple of mine uh uh in there, but uh there are but all the studies that we do have in this specific population, you see the A one C over to the left favoring CGM. You see the time and range over to the right favoring CGM. Um So it looks encouraging that we should stick with this and figure out the tools we need to use in this population. Let me just pick out one of these, the immediate study because it was the largest 51 people. Uh um And, and you see here from the immediate study that the A one C went down 0.9 the time and range went up 20%. Uh So that's a pretty remarkable uh result in these noninsulin using patients. Is there any other new data to add to this? Well, I'll show you one that's just out, uh headed up by our team, Doctor Martins and Doctor Holly Willis. Uh and they presented it, uh just in June at the ad A again, type two, not using insulin and highlighted here without making medication changes over the next three months, they either use CGM alone with some tools to help guide them or they use CGM with an app that log their food. And since the two of these did about the same, I'm gonna lump them together for their outcomes. 72 people, how did they do using CGM without making any medication changes? And it's really right in line with even it's not even a little better than the immediate study, 1.1% drop in a one C 25% increase in time and range without medication changes. So it is possible. Uh I'm not saying we shouldn't use the medications. I'm just saying add CGM as an important, valuable component to make lifestyle choices. In addition, those are randomized trials. I pull out one that I was involved in as well as a, a real world study just using a database. This one was from the Dexcom Clarity Database and they said we've got s over almost 4000 people who are not using insulin by their des description and definition of uh that they put in. And at baseline, they had 41% 42% time and range. And over six and 12 months that time and range once they started CGM went up 17% and the GM I down 0.5 it's a pretty remarkable uh improvement. We don't know exactly what therapy, but we know that CGM was the one ingredient that got added uh at the baseline and down be. And so I'm sorry, and down below, you see that if their time and range uh settings on their device were activated to get an alert or alarm, that increase the time and range even more. If they turned off their alerts, they didn't get quite as much increase. Ok, let's move to prediabetes. You know how it's defined these days. Although I think it's, it's kind of a uh a hodgepodge because we have three different definitions. A one c fasting glucose, oral glucose tolerance test and they're all have their own criteria, but they overlap and really identify often very different populations. So my wonder and uh question is what if we did CGM on these people? Might that tie these three disparate ways of looking at uh the definition of prediabetes together and give you a clearer picture and not only give you a clearer picture but give you a tool that then you could continue to use to try to improve the glycemia. If you did have prediabetes, I'm not sure of that. We need uh, several thousands of people with uh prediabetes to really get CGM profiles. But, um, Doctor Herman, re respected endocrinologist, uh in the field, an epidemiologist said, you know, that prediabetes term is pretty imprecise and we need to get away from it. And maybe CGM, he doesn't say it, but I'm putting those words in his mouth. Maybe CGM is one of those tools that could really help us move this field forward. And there happens to be uh a little bit of data that shows these spikes that occur, not that often above 140. But I think you see enough variability that there's some room for improvement. And maybe we even tighten up the, the, the picture to look at 70 to 120 to see the spikes, uh even more clearly. And then I show you this article just out. Um, oh, in this last week that showed that a big group of people with prediabetes look at that almost 15,000. If they lost weight, their progression from prediabetes to type two diabetes went way down. And also if they lost weight, their chance of reverting regressing back to normal glycemia went way up. So what could help them lose weight? Of course, there's medications to do it. But I contend that the CGM making lifestyle choices could be a key tool. And I really like this data in prediabetes to say there's reasons to move ahead. So that's the data in four of those categories with a little mention of obesity. Now, what do we do? How do we act on the CGM to facilitate going from something like this with spikes and variability to something a little flatter, a little narrower, a little closer to our goal of getting under 7% if possible. Well, I think this may be the most important slide today. I just want to emphasize, we need two components. If we're gonna tackle this and use CGM as a foundational tool for lifestyle choices, we need to educate the patient, how to look at their data on their phone and we need to educate the clinician for a retrospective look at the data. Both of these are critically important and sometimes we pick one or we pick the other but doing both really makes a difference. So on the patient side, you know, people just have to be curious, but you have to peak their curiosity and tell them to look at their, look at their meals and look at their uh their glucose profiles. Here's the person at 47% time in range. We emphasized looking at their meals and changing them up, they went to 94% time in range just by making food choices. It really is possible. And I think again, my uh nutrition team who have given me these actual slides that they snipped uh of the profiles. Um How about on the side of the clinician, that's the patient on the clinician side. We need to just really get him comfortable with the A GP determine if action is needed because the time and range is high or the time below time and range is too low or the time below range is too high. We need to have them look at the profile and if they're not flat, narrow and in range, how do I squeeze those in and tackle that hypo first and then most important, do something, do something. You can really appreciate it by looking at the A GP. But the goal is, what do I, what am I going to do? Uh Next, how can I make a change? And I'll just close this little section with saying, remember I said both were important and there finally is a randomized trial to bring home. Uh My point. If you, if you do finger sticks and you teach a patient, they can get better if you give them CGM and they do that real time looking, they do even better. And if you do both teach the patient and you as a clinician, look at their data together and make a shared decision. You do even the best. So nutrition quality, how um we showed you, I showed you how important I thought it was at the beginning. The ad a standards of care says there's over 600 papers that say lots of ways to eat. The important thing is to pick out an eating pattern that fits your lifestyle, individualize it, but stick with the principles. And here's the four principles, nonstarchy vegetables, get rid of those refined sugars, more whole foods and get rid of those sweetened beverages wherever possible, those four elements, then you can eat many different ways. Uh Mediterranean diet, uh dash diet, um moderately low carbohydrate diet, but stick to those principles. And let's look at what can, what can happen when you put those principles in place. This was another person in the clinic on Metformin and semaglutide already still struggling with glu glycemic control. And we just said, let's talk about lifestyle on top of these good medications you're on. And here's what happened. Two months later, 47% increased time and range non starchy vegetables, minimize the sugars that were being added, um and more whole foods. So 60% time and range is not perfect, but look at the increase just with nutrition um guided by CGM. So are there tools that we can really use? And this will be the closing section here just on resources. These are a bunch from the International Diabetes Center and, and our our, our team, the ad A uh like these tools too. And we partner with the AD A to um update them and put them in the AD A S template. So whether you reach out to I DC, to the AD A to other places, get some tools and I'll walk you through just a couple of them. Um A as we, as we uh move along here, this is the CGM tool for patients. I really like this one. It's called No Learn Act. Uh, and it's just two pages and it guides the patient. Uh, on the first page, it really says, do you know your glucose targets? You'll be amazed how many patients really don't know their glucose targets. What should it be before a meal? What should it be after a meal? I've got CGM. Now, I can see the data, I really need to know what those targets should be and my overall time and range is really valuable, but also knowing the specific numbers with CGM. So that's on the first page just really getting comfortable with that. And on the second page it says, well, now you know your targets, you gotta learn how foods are affecting you and then you've gotta do something about it. You've gotta make a change. And so we, we can learn about foods, activity, medications, sleep, and actually a little place to log what I tried. Uh, and people have really liked this tool just to get them going. But on the clinician side, clinicians say, uh, I don't really have much time to talk about this in clinic. Uh, I wish I had a tool that helped me walk through the CGM from a nutrition point of view. So here is one, we call a conversation starter. Uh, and it says, oh, just pick, for instance, this evening here and says, I notice a peak between six and nine pm. Can you tell me what you were eating? What, what foods you usually were taking? Uh, little tips, try a side salad. Uh, have you ever tried the plate method? And it gives you a picture. So you have something to relate to the patient and, and, and, uh, and talk about the CGM and nutrition terms, which many of us are, are not. Well, we've, we've learned it but we haven't practiced it as much as our medication changes. Um, and here's one also just with more and more discussion about less processed foods, more whole foods, how to have that discussion and try to get this curve that's so broad with variability, more flat and narrow and in range and encourage patients. It really is possible. And the type of food you eat is one component of getting that curve as well as medications, um, activity, et cetera. So there's lots of other good resources. Um, uh, in, in addition that are out there that I refer you to and we'll close with two actual CGM in clinic, uh nutrition points beyond just the big A GP, looking at the daily views can really spark a conversation. So like this one where every day you see these spikes in, in, in orange there and, and, and you just have to ask the question. Can you tell me what's going on in these, in these points and, and what you're eating or drinking? And in this case, it was really a lot of sugar, sweetened beverages or even orange juice, which sounds good, but can be loaded with uh carbohydrates and, and people track this and just said, I'll try a diet soda or I'll try water and went from 47% to yes, 93% just by re replacing those and look at the profile. So again, a real case from our team of just making that one intervention and finally, um be positive, help guide people in these four concepts of healthy eating even if they're doing well. So here's a person you might say, Hurrah, we've made it, you're 89% time in range without hypo. I think we all would congratulate this person. But remember what I said about healthy eating on top of good control, helping your longevity, uh your life expectancy if this is what they were eating to get to that. 89%. Congratulations on the A one C. But do you think you could maybe substitute a few things and see if you can still stay in good range um by substituting some healthier foods. And here is the last case where we actually did that end of one test and said, I see there's sweetened beverage at breakfast. I see there's um, sweets in the afternoon. What if you just replace a couple of those things? How could you do? And here's what happens, 76% time and range. And it's always nice to have AAA little quote from the patient to say this is what we hear a lot. It really did open up my eyes. Um Once I could see these spikes make a change um in one thing or the other and see a difference. So I hope that was helpful to say, show how this can be an in incredible tool to help make lifestyle interventions using CGM. I do think we need more data, more trials so we can get this into the standards of care instead of be promising to give it a level A B. Um And each of these five areas I think need attention, need some more data. But really, it's showing promising data in most all of these areas and finally pick up some tools for the patient, for the clinicians so that we can help facilitate uh these changes. Uh Thank you very much. Uh look forward to any questions you might have. Published Created by Related Presenters Richard Bergenstal, MD Executive DirectorPark Nicollet International Diabetes CenterAdjunct Professor, Department of MedicineUniversity of MinnesotaSt. Louis Park, MN
