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Colmegna P, McFadden R, Fabris C, Lobo B, Nass R, Oliveri MC, Brown SA, Kovatchev B. Adaptive Biobehavioral Control: A Pilot Analysis of Human-Machine Coadaptation in Type 1 Diabetes. Diabetes Technol Ther 2024. [PMID: 38662425 DOI: 10.1089/dia.2023.0399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background: While it is well recognized that an automated insulin delivery (AID) algorithm should adapt to changes in physiology, it is less understood that the individual would also have to adapt to the AID system. The adaptive biobehavioral control (ABC) method presented here attempts to compensate for this deficiency by including AID into an information cloud-based ecosystem. Methods: The Web Information Tool (WIT) implements the ABC concept via the following: (1) a Physiological Adaptation Module (PAM) that tracks metabolic changes and adapts AID parameters accordingly and (2) a Behavioral Adaptation Module (BAM) that provides information feedback. The safety of WIT (primary outcome) was assessed in an 8-week randomized, two-arm parallel pilot study. All participants used the Control-IQ® AID system enhanced with PAM, but only those in the Experimental group had access to BAM. Secondary glycemic outcomes were computed using the 2-week baseline period and the last 2 weeks of treatment. Results: Thirty participants with type 1 diabetes (T1D) completed all study procedures (17 female/13 male; age: 40 ± 14 years; HbA1c: 6.6% ± 0.5%). No severe hypoglycemia, DKA, or other serious adverse events were reported. Comparing the Experimental and Control groups, no significant difference was observed in time in range (70-180 mg/dL): 74.6% vs 73.8%, adjusted mean difference: 2.65%, 95% CI (-1.12%,6.41%), P = 0.161. Time in 70-140 mg/dL was significantly higher in the Experimental group: 50.7% vs 49.2%, 5.71% (0.44%,10.97%), P = 0.035, without increased time below range: 0.54% (-0.09%,1.17%), P = 0.089. Conclusion: The results demonstrate that it is safe to integrate an AID system into the WIT ecosystem. Validation in a full-scale study is ongoing.
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Affiliation(s)
- Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Dexcom Inc, San Diego, California, USA
| | - Ryan McFadden
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Dexcom Inc, San Diego, California, USA
| | - Chiara Fabris
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Benjamin Lobo
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
| | - Ralf Nass
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Sue A Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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2
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Tozzo V, Genco M, Omololu SO, Mow C, Patel HR, Patel CH, Ho SN, Lam E, Abdulsater B, Patel N, Cohen RM, Nathan DM, Powe CE, Wexler DJ, Higgins JM. Estimating Glycemia From HbA1c and CGM: Analysis of Accuracy and Sources of Discrepancy. Diabetes Care 2024; 47:460-466. [PMID: 38394636 PMCID: PMC10909686 DOI: 10.2337/dc23-1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/12/2023] [Indexed: 02/25/2024]
Abstract
OBJECTIVE To examine the accuracy of different periods of continuous glucose monitoring (CGM), hemoglobin A1c (HbA1c), and their combination for estimating mean glycemia over 90 days (AG90). RESEARCH DESIGN AND METHODS We retrospectively studied 985 CGM periods of 90 days with <10% missing data from 315 adults (86% of whom had type 1 diabetes) with paired HbA1c measurements. The impact of mean red blood cell age as a proxy for nonglycemic effects on HbA1c was estimated using published theoretical models and in comparison with empirical data. Given the lack of a gold standard measurement for AG90, we applied correction methods to generate a reference (eAG90) that we used to assess accuracy for HbA1c and CGM. RESULTS Using 14 days of CGM at the end of the 90-day period resulted in a mean absolute error (95th percentile) of 14 (34) mg/dL when compared with eAG90. Nonglycemic effects on HbA1c led to a mean absolute error for average glucose calculated from HbA1c of 12 (29) mg/dL. Combining 14 days of CGM with HbA1c reduced the error to 10 (26) mg/dL. Mismatches between CGM and HbA1c >40 mg/dL occurred more than 5% of the time. CONCLUSIONS The accuracy of estimates of eAG90 from limited periods of CGM can be improved by averaging with an HbA1c-based estimate or extending the monitoring period beyond ∼26 days. Large mismatches between eAG90 estimated from CGM and HbA1c are not unusual and may persist due to stable nonglycemic factors.
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Affiliation(s)
- Veronica Tozzo
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
- Department of Systems Biology, Harvard Medical School, Boston, MA
| | - Matthew Genco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- Medical Service, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH
| | | | - Christopher Mow
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
- Mass General Brigham Enterprise Research IS, Boston, MA
| | - Hasmukh R. Patel
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Chhaya H. Patel
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Samantha N. Ho
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Evie Lam
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Batoul Abdulsater
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Nikita Patel
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | - Robert M. Cohen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- Medical Service, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH
| | - David M. Nathan
- Diabetes Research Center, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Camille E. Powe
- Diabetes Research Center, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
- Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA
| | - Deborah J. Wexler
- Diabetes Research Center, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John M. Higgins
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, Boston, MA
- Department of Systems Biology, Harvard Medical School, Boston, MA
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3
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Nimri R, Phillip M, Clements MA, Kovatchev B. Closed-Loop Control, Artificial Intelligence-Based Decision-Support Systems, and Data Science. Diabetes Technol Ther 2024; 26:S68-S89. [PMID: 38441444 DOI: 10.1089/dia.2024.2505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Revital Nimri
- Diabetes Technology Center, Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Phillip
- Diabetes Technology Center, Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark A Clements
- Division of Pediatric Endocrinology, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Boris Kovatchev
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA, USA
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4
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Stanton RC, Gabbay RA. 6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S111-S125. [PMID: 38078586 PMCID: PMC10725808 DOI: 10.2337/dc24-s006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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5
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Bezerra MF, Neves C, Neves JS, Carvalho D. Time in range and complications of diabetes: a cross-sectional analysis of patients with Type 1 diabetes. Diabetol Metab Syndr 2023; 15:244. [PMID: 38008747 PMCID: PMC10680248 DOI: 10.1186/s13098-023-01219-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/14/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND/ OBJECTIVE To evaluate the association of CGM parameters and HbA1c with diabetes complications in patients with Type 1 Diabetes (T1D). METHODS Patients with T1D using the CGM system Freestyle Libre were included in this analysis. The association of CGM-metrics and HbA1c with diabetes complications (any complication, microvascular complications, or macrovascular complications) was assessed using logistic regression unadjusted and adjusted for age, sex, and diabetes duration (model 1), and further adjusted for hypertension and dyslipidemia (model 2). RESULTS One hundred and sixty-one patients with T1D were included. The mean (± SD) age was 37.4 ± 13.4 years old and the median T1D duration was 17.7 ± 10.6 years. Time in range (TIR) was associated with any complication and microvascular complications in the unadjusted model and in the adjusted models. TIR was associated with retinopathy in the unadjusted model as well as in model 1, and was associated with macrovascular complications only in the unadjusted model. HbA1c was associated with any complications, microvascular complications, and retinopathy in the unadjusted model but not in the adjusted models. HbA1c was associated with macrovascular complications in the unadjusted model and in the adjusted model 1. CONCLUSIONS In this cross-sectional analysis of patients with T1D using intermittent scanned CGM, TIR, and HbA1c were associated with complications of diabetes. TIR may be a better predictor than HbA1c of any complication and microvascular complications, while HbA1c may be a better predictor of macrovascular complications.
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Affiliation(s)
- Marta Fernandes Bezerra
- Faculty of Medicine of the University of Porto, Alameda Hernâni Monteiro, Porto, 4200-319, Portugal.
| | - Celestino Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - João Sérgio Neves
- Faculty of Medicine of the University of Porto, Alameda Hernâni Monteiro, Porto, 4200-319, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Davide Carvalho
- Faculty of Medicine of the University of Porto, Alameda Hernâni Monteiro, Porto, 4200-319, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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6
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Affiliation(s)
- Roy W Beck
- Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, Florida, United States, 33647;
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7
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA. 6. Glycemic Targets: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S97-S110. [PMID: 36507646 PMCID: PMC9810469 DOI: 10.2337/dc23-s006] [Citation(s) in RCA: 205] [Impact Index Per Article: 205.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Uemura F, Okada Y, Torimoto K, Tanaka Y. Association Between Time in Range and Postprandial Glucose Contribution Rate in Non-Insulin-Treated Type 2 Diabetes Patients: Inverse Correlation of Time in Range with Postprandial Glucose Contribution Rate. Diabetes Technol Ther 2022; 24:805-813. [PMID: 35849000 DOI: 10.1089/dia.2022.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Whether time in range (TIR), a parameter derived from continuous glucose monitoring (CGM), is a marker of postprandial hyperglycemia remains to be determined. In this study, we examined the association between TIR and postprandial glucose in non-insulin-treated type 2 diabetic patients. Methods: Our cross-sectional study included 729 non-insulin-treated patients with type 2 diabetes who underwent CGM without any changes in drug therapy on admission. The 24-h CGM record was analyzed for average glucose, standard deviation, percentage coefficient of variation, time above range, TIR, time below range, area under the curve (AUC) of basal glucose, AUC of postprandial glucose, and postprandial glucose contribution rate (%). The primary endpoint was the association between TIR and the postprandial glucose contribution rate. Results: We made TIR groups divided into 10% increments for a 7-group and compared with <40% to >90%. The basal and postprandial glucose AUCs correlated negatively with TIR. The postprandial glucose contribution rate correlated with TIR. The cutoff value for TIR, where postprandial glucose contribution rate was lower than the basal glucose contribution rate, was 66.3%. Conclusions: In non-insulin-treated type 2 diabetic patients, postprandial glucose AUC was higher in the high TIR group, whereas the basal glucose AUC was higher in the low TIR group. Good glycemic control can be achieved with therapeutic interventions that target postprandial glucose and basal glucose in patients with TIR ≥66.3% and <66.3%, respectively. University Medical Information Network [UMIN] ID: UMIN0000254333.
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Affiliation(s)
- Fumi Uemura
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keiichi Torimoto
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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9
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Monzon AD, Patton SR, Clements M. An Examination of the Glucose Management Indicator in Young Children with Type 1 Diabetes. J Diabetes Sci Technol 2022; 16:1505-1512. [PMID: 34098763 PMCID: PMC9631514 DOI: 10.1177/19322968211023171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous studies utilizing glucose data from continuous glucose monitors (CGM) to estimate the Glucose Management Indicator (GMI) have not included young children or determined appropriate GMI formulas for young children with type 1 diabetes (T1D). METHODS We extracted CGM data for 215 children with T1D (0-6 years) from a repository. We defined sampling periods ranging from the 3-27 days prior to an HbA1c measurement and compared a previously established GMI formula to a young child-specific GMI equation based on the sample's CGM data. We examined associations between HbA1c, GMI values, and other CGM metrics for each sampling period. RESULTS The young child-specific GMI formula and the published GMI formula did not evidence significant differences when using 21-27 days of CGM data. The young child-specific GMI formula demonstrated higher correlations to laboratory HbA1c when using 18 or fewer days of CGM data. Overall, the GMI estimate and HbA1c values demonstrate a strong relationship in young children with T1D. CONCLUSIONS Future research studies may consider utilizing the young child-specific GMI formula if the data collection period for CGM values is under 18 days. Further, researchers and clinicians may consider changing the default number of days of data used to calculate glycemic metrics in order to maximize validity of CGM-derived metrics.
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Affiliation(s)
| | - Susana R. Patton
- Center for Healthcare Delivery Science,
Nemours Children’s Health System, Jacksonville, FL, USA
| | - Mark Clements
- Children’s Mercy Hospital,
Endocrine/Diabetes Clinical Research, Kansas City, MO, USA
- Mark Clements, MD, PhD, Children’s Mercy
Hospital, Endocrine/Diabetes Clinical Research, 2401 Gillham Road, Kansas City,
MO 64108, USA.
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10
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Zaharieva DP, Addala A, Prahalad P, Leverenz B, Arrizon-Ruiz N, Ding VY, Desai M, Karger AB, Maahs DM. An Evaluation of Point-of-Care HbA1c, HbA1c Home Kits, and Glucose Management Indicator: Potential Solutions for Telehealth Glycemic Assessments. DIABETOLOGY 2022; 3:494-501. [PMID: 37163187 PMCID: PMC10166120 DOI: 10.3390/diabetology3030037] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
During the COVID-19 pandemic, fewer in-person clinic visits resulted in fewer point-of-care (POC) HbA1c measurements. In this sub-study, we assessed the performance of alternative glycemic measures that can be obtained remotely, such as HbA1c home kits and Glucose Management Indicator (GMI) values from Dexcom Clarity. Home kit HbA1c (n = 99), GMI, (n = 88), and POC HbA1c (n = 32) were collected from youth with T1D (age 9.7 ± 4.6 years). Bland-Altman analyses and Lin's concordance correlation coefficient (ρc) were used to characterize the agreement between paired HbA1c measures. Both the HbA1c home kit and GMI showed a slight positive bias (mean difference 0.18% and 0.34%, respectively) and strong concordance with POC HbA1c (ρc = 0.982 [0.965, 0.991] and 0.823 [0.686, 0.904], respectively). GMI showed a slight positive bias (mean difference 0.28%) and fair concordance (ρc = 0.750 [0.658, 0.820]) to the HbA1c home kit. In conclusion, the strong concordance of GMI and home kits to POC A1c measures suggest their utility in telehealth visits assessments. Although these are not candidates for replacement, these measures can facilitate telehealth visits, particularly in the context of other POC HbA1c measurements from an individual.
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Affiliation(s)
- Dessi P. Zaharieva
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
- Correspondence: ; Tel.: +1-(628)-238-9420; Fax: +1-(650)-475-8375
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
| | - Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
- Stanford Diabetes Research Center, Stanford, CA 94304, USA
| | - Brianna Leverenz
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
| | - Nora Arrizon-Ruiz
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
| | - Victoria Y. Ding
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Stanford University, Stanford, CA 94305, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Stanford University, Stanford, CA 94305, USA
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA 94304, USA
- Stanford Diabetes Research Center, Stanford, CA 94304, USA
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11
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Benedict Á, Hankosky ER, Marczell K, Chen J, Klein DJ, Caro JJ, Bae JP, Benneyworth BD. A Framework for Integrating Continuous Glucose Monitor-Derived Metrics into Economic Evaluations in Type 1 Diabetes. PHARMACOECONOMICS 2022; 40:743-750. [PMID: 35668248 DOI: 10.1007/s40273-022-01148-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Economic models in type 1 diabetes have relied on a change in haemoglobin A1c as the link between the blood glucose trajectory and long-term clinical outcomes, including microvascular and macrovascular disease. The landscape has changed in the past decade with the availability of regulatory approved, accurate and convenient continuous glucose monitoring devices and their ability to track patients' glucose levels over time. The data emerging from continuous glucose monitoring have enriched the clinical understanding of the disease and indirectly of patients' behaviour. This has triggered the development of new measures proposed to better define the quality of glycaemic control, beyond haemoglobin A1c. The objective of this paper is to review recent developments in clinical knowledge brought into focus with the application of continuous glucose monitoring devices, and to discuss potential approaches to incorporate the concepts into economic models in type 1 diabetes. Based on a targeted review and a series of multidisciplinary workshops, an influence diagram was developed that captures newer concepts (e.g. continuous glucose monitoring metrics) that can be integrated into economic models and illustrates their association with more established concepts. How the additional continuous glucose monitoring-based indicators of glycaemic control may contribute to economic modelling beyond haemoglobin A1c, and more accurately reflect the economic value of novel type 1 diabetes treatments, is discussed.
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Affiliation(s)
- Ágnes Benedict
- Evidera, Bocskai út 134-146. E/2, 1113, Budapest, Hungary.
| | | | - Kinga Marczell
- Evidera, Bocskai út 134-146. E/2, 1113, Budapest, Hungary
| | | | | | | | - Jay P Bae
- Eli Lilly and Company, Indianapolis, IN, USA
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12
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Alharthi S, Alrajeh A, Alyusuf E, Alguwaihes AM, Jammah A, Al-Sofiani ME. "Pre-Ramadan" telemedicine: Effect on fasting experience and glycemic control during ramadan in people with type 1 diabetes. Diabetes Metab Syndr 2022; 16:102567. [PMID: 35939941 DOI: 10.1016/j.dsx.2022.102567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/23/2022] [Accepted: 07/03/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE People with type 1 diabetes (T1D) are advised to have a "pre-Ramadan" visit to receive the assessment and education needed to safely fast during the holy month of Ramadan. The COVID-19 lockdown has interrupted this standard of care in Muslim-majority countries where telemedicine is not well-established. Here, we examined the impact of virtual"pre-Ramadan" visits, as an alternative option to the traditional (in-person) visits, on fasting experience and glycemic control during Ramadan in people with T1D. METHOD 151 individuals with T1D were categorized into 3 groups according to the type of"pre-Ramadan" visit that they attended in 2020: virtual (n = 50), in-person (n = 56), and no visit (n = 45). Number of days fast was broken and CGM metrics were retrospectively compared across the groups. RESULT Patients who had a virtual"pre-Ramadan" visit were more likely to use continuous glucose monitors (CGM) than those who had no visit (61.7% and 38.6%, respectively, p < 0.05). Attending a virtual"pre-Ramadan" visit was associated with the least number of days fast was broken compared to those who had no visit (p < 0.01) or in-person visit (p = 0.02). CGM time in range (TIR) during Ramadan was the highest in those who had virtual "Pre-Ramadan" visits compared to those who had no visit or in-person visits (59%, 44%, and 47%,respectively). After adjusting for age, gender, pre-Ramadan A1c, and CGM use, the odds of fasting most days of Ramadan were highest in the virtual group [OR (CI): 9.13 (1.43, 58.22)] followed by the in-person group [3.02 (0.54,16.68)] compared to the no visit group. CONCLUSION Virtual"pre-Ramadan" visits are effective alternative to in-person visits when managing people with T1D who plan to fast during Ramadan.
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Affiliation(s)
- Sahar Alharthi
- Department of Internal Medicine, College of Medicine, King Saud University, Saudi Arabia
| | - Areej Alrajeh
- Department of Internal Medicine, College of Medicine, King Saud University, Saudi Arabia
| | - Ebtihal Alyusuf
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah M Alguwaihes
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Anwar Jammah
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed E Al-Sofiani
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University, Baltimore, MD, USA; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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13
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Xu NY, Nguyen KT, DuBord AY, Pickup J, Sherr JL, Teymourian H, Cengiz E, Ginsberg BH, Cobelli C, Ahn D, Bellazzi R, Bequette BW, Gandrud Pickett L, Parks L, Spanakis EK, Masharani U, Akturk HK, Melish JS, Kim S, Kang GE, Klonoff DC. Diabetes Technology Meeting 2021. J Diabetes Sci Technol 2022; 16:1016-1056. [PMID: 35499170 PMCID: PMC9264449 DOI: 10.1177/19322968221090279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 4 to November 6, 2021. This meeting brought together speakers to discuss various developments within the field of diabetes technology. Meeting topics included blood glucose monitoring, continuous glucose monitoring, novel sensors, direct-to-consumer telehealth, metrics for glycemia, software for diabetes, regulation of diabetes technology, diabetes data science, artificial pancreas, novel insulins, insulin delivery, skin trauma, metabesity, precision diabetes, diversity in diabetes technology, use of diabetes technology in pregnancy, and green diabetes. A live demonstration on a mobile app to monitor diabetic foot wounds was presented.
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Affiliation(s)
- Nicole Y. Xu
- Diabetes Technology Society,
Burlingame, CA, USA
| | | | | | | | | | | | - Eda Cengiz
- University of California, San
Francisco, San Francisco, CA, USA
| | | | | | - David Ahn
- Mary & Dick Allen Diabetes Center
at Hoag, Newport Beach, CA, USA
| | | | | | | | - Linda Parks
- University of California, San
Francisco, San Francisco, CA, USA
| | - Elias K. Spanakis
- Baltimore VA Medical Center,
Baltimore, MD, USA
- University of Maryland, Baltimore,
MD, USA
| | - Umesh Masharani
- University of California, San
Francisco, San Francisco, CA, USA
| | - Halis K. Akturk
- Barbara Davis Center for Diabetes,
University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Sarah Kim
- University of California, San
Francisco, San Francisco, CA, USA
| | - Gu Eon Kang
- The University of Texas at Dallas,
Richardson, TX, USA
| | - David C. Klonoff
- Diabetes Research Institute,
Mills-Peninsula Medical Center, San Mateo, CA, USA
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14
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Inverso H, LeStourgeon LM, Parmar A, Bhangui I, Hughes B, Straton E, Alford M, Streisand R, Jaser SS. Demographic and Glycemic Factors Linked With Diabetes Distress in Teens With Type 1 Diabetes. J Pediatr Psychol 2022; 47:1081-1089. [PMID: 35656859 PMCID: PMC9801711 DOI: 10.1093/jpepsy/jsac049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Diabetes distress (DD) is a negative emotional response related to the burdens of living with type 1 diabetes (T1D) and is linked with diabetes outcomes, such as hemoglobin A1c (A1c). Yet, less is known about how other glycemic indicators, average blood glucose and time in range, relate to DD, and which demographic characteristics are associated with higher DD. METHODS In total, 369 teens (Mage 15.6 ± 1.4, 51% female, MT1D duration 6.7 ± 3.8 years) screened for DD using The Problem Areas in Diabetes-Teen Version to determine eligibility for an ongoing multi-site behavioral trial. The associations of DD, demographic factors, and glycemic indicators (A1c, average blood glucose, and time in range) were analyzed. RESULTS Twenty-nine percent of teens (n = 95) scored above the clinical cutoff (≥44) for DD. Females scored significantly higher on average than males. Black/African American, non-Hispanic youth screened significantly higher compared to youth from other racial/ethnic groups. Higher DD scores were related to higher A1c and average blood glucose, and lower time in range. Logistic regression models revealed that females were significantly more likely to report clinically elevated DD than males, and teens with higher A1c were 1.3 times more likely to report DD. Age and diabetes duration were not significantly associated with clinically elevated DD scores. CONCLUSIONS Results demonstrated that DD is most prevalent in Black, non-Hispanic and female teens, and DD is associated with higher average blood glucose and lower time in range. Further investigation into these disparities is warranted to promote optimal health outcomes for teens with T1D.
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Affiliation(s)
- Hailey Inverso
- Children’s National Hospital, Center for Translational Research, USA
| | | | - Angie Parmar
- Department of Pediatrics, Vanderbilt University Medical Center, USA
| | - Isha Bhangui
- Children’s National Hospital, Center for Translational Research, USA
| | - Bailey Hughes
- Department of Pediatrics, Vanderbilt University Medical Center, USA
| | - Emma Straton
- Children’s National Hospital, Center for Translational Research, USA
| | - Madeleine Alford
- Children’s National Hospital, Center for Translational Research, USA
| | - Randi Streisand
- Children’s National Hospital, Center for Translational Research, USA,The George Washington University School of Medicine, USA
| | - Sarah S Jaser
- All correspondence concerning this article should be addressed to Sarah S. Jaser, PhD, Department of Pediatrics, Vanderbilt University Medical Center, 2146 Belcourt Ave., Nashville, TN 37232, USA. E-mail:
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15
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Prahalad P, Ding VY, Zaharieva DP, Addala A, Johari R, Scheinker D, Desai M, Hood K, Maahs DM. Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Type 1 Diabetes: the Pilot 4T Study. J Clin Endocrinol Metab 2022; 107:998-1008. [PMID: 34850024 PMCID: PMC8947228 DOI: 10.1210/clinem/dgab859] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Youth with type 1 diabetes (T1D) do not meet glycated hemoglobin A1c (HbA1c) targets. OBJECTIVE This work aimed to assess HbA1c outcomes in children with new-onset T1D enrolled in the Teamwork, Targets, Technology and Tight Control (4T) Study. METHODS HbA1c levels were compared between the 4T and historical cohorts. HbA1c differences between cohorts were estimated using locally estimated scatter plot smoothing (LOESS). The change from nadir HbA1c (month 4) to 12 months post diagnosis was estimated by cohort using a piecewise mixed-effects regression model accounting for age at diagnosis, sex, ethnicity, and insurance type. We recruited 135 youth with newly diagnosed T1D at Stanford Children's Health. Starting July 2018, all youth within the first month of T1D diagnosis were offered continuous glucose monitoring (CGM) initiation and remote CGM data review was added in March 2019. The main outcomes measure was HbA1c. RESULTS HbA1c at 6, 9, and 12 months post diagnosis was lower in the 4T cohort than in the historic cohort (-0.54% to -0.52%, and -0.58%, respectively). Within the 4T cohort, HbA1c at 6, 9, and 12 months post diagnosis was lower in those patients with remote monitoring than those without (-0.14%, -0.18% to -0.14%, respectively). Multivariable regression analysis showed that the 4T cohort experienced a significantly lower increase in HbA1c between months 4 and 12 (P < .001). CONCLUSION A technology-enabled, team-based approach to intensified new-onset education involving target setting, CGM initiation, and remote data review statistically significantly decreased HbA1c in youth with T1D 12 months post diagnosis.
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Affiliation(s)
- Priya Prahalad
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Correspondence: Priya Prahalad, MD, PhD, Department of Pediatrics, Division of Pediatric Endocrinology, Center for Academic Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA.
| | - Victoria Y Ding
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Dessi P Zaharieva
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
| | - Ramesh Johari
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
| | - David Scheinker
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California 94304, USA
- Clinical Excellence Research Center, Stanford University, Stanford, California 94304, USA
| | - Manisha Desai
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, California 94304, USA
| | - Korey Hood
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California 94304, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, California 94304, USA
- Department of Health Research and Policy (Epidemiology) Stanford University, Stanford, California 94304, USA
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16
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Kaushal T, Tinsley L, Volkening LK, Ambler-Osborn L, Laffel L. Improvement in Mean CGM Glucose in Young People with Type 1 Diabetes During 1 Year of the COVID-19 Pandemic. Diabetes Technol Ther 2022; 24:136-139. [PMID: 34524008 PMCID: PMC8817688 DOI: 10.1089/dia.2021.0258] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic likely affected youth with type 1 diabetes (T1D). We used electronic health record-extracted data to compare continuous glucose monitoring (CGM) metrics during 1 year of the pandemic with those of the previous year. The sample comprised CGM users, aged 1 to <18 years, with T1D duration ≥6 months (age <6 years) or ≥1 year (age ≥6 years). The prepandemic sample comprised 641 youth (52% female, aged 12.3 ± 3.5, T1D duration 6.0 ± 3.5 years). The pandemic sample comprised 648 youth (52% female, age 13.3 ± 3.5, duration 6.7 ± 3.8 years), with care delivered primarily through telemedicine. Mean CGM glucose was 6.3 mg/dL lower during the pandemic (187.3 ± 35.6) versus prepandemic (193.6 ± 33.0) (P < 0.001). A higher percentage of youth achieved glucose management indicator <7% during the pandemic than the prior year (P < 0.001). Lower CGM glucose values were observed during the COVID-19 pandemic. Future studies are needed to assess how changes in health care delivery, including telemedicine, and lifestyle during this time may have supported this improvement.
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Affiliation(s)
- Tara Kaushal
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts, USA
- Address correspondence to: Tara Kaushal, MD, MSHP, Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215, USA
| | - Liane Tinsley
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Lisa K. Volkening
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Louise Ambler-Osborn
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Lori Laffel
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts, USA
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17
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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18
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Sekiguchi S, Yamada E, Nakajima Y, Matsumoto S, Yoshino S, Horiguchi K, Ishida E, Uehara R, Okada S, Yamada M. The Optimal "Time in Range" and "Time below Range" are Difficult to Coordinate in Patients with Type 1 Diabetes. TOHOKU J EXP MED 2021; 255:221-227. [PMID: 34759118 DOI: 10.1620/tjem.255.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Achieving the optimal glucose level time in range (TIR), as recently proposed by the "International Consensus on Time in Range," is challenging. We retrospectively analyzed data from 192 patients, including 58 with type 1 diabetes, using the FreeStyle Libre Pro system. This device was used by physicians for continuous glucose monitoring (CGM) and for making therapeutic decisions based on unbiased data, as the patients were blinded to their blood glucose levels during monitoring. The desired 70% TIR among patients with type 2 diabetes corresponded to an HbA1c of 7.7%. Importantly, however, a 70% TIR for patients with type 1 diabetes corresponded to an HbA1c of 6.9%, which diverged markedly from the HbA1c of 7.9% that corresponded to the desired 4% time below range (TBR). Moreover, these dissociations were observed more in patients with type 1 diabetes with a higher % coefficient of variation (> 36%). Hence, while the TIR is strongly correlated with HbA1c, it is difficult to coordinate with the TBR in Japanese patients with type 1 diabetes. As these metrics (which are critical indicators in clinical practice) are rapidly gaining popularity globally, including in Japan, our data strongly support the cautious use of new CGM metrics such as TIR and TBR/time above range, and emphasize the importance of individualized treatment in achieving the optimal TIR and TBR, especially in patients with type 1 diabetes.
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Affiliation(s)
- Sho Sekiguchi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Eijiro Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Yasuyo Nakajima
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Shunichi Matsumoto
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Satoshi Yoshino
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Kazuhiko Horiguchi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Emi Ishida
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Ryota Uehara
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Shuichi Okada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine
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19
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Mohebbi A, Bohm AK, Tarp JM, Lind Jensen M, Bengtsson H, Morup M. Early Glycemic Control Assessment Based on Consensus CGM Metrics . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:1269-1275. [PMID: 34891517 DOI: 10.1109/embc46164.2021.9631015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Continuous glucose monitoring (CGM) has revolutionized the world of diabetes and transformed the approach to diabetes care. In this context, an expert panel has reached consensus on clinical targets for CGM data interpretation based on eight CGM metrics. At least 70% of 14 consecutive CGM days (referred to as a period) are recommended to assess glycemic control based on the metrics. In clinical practice less CGM data may be available. Therefore, the primary aim of this study is to explore the ability to recover the consensus metrics utilizing less than 14 days of CGM data (intra-period). As a secondary aim, we investigate the recovery considering two consecutive periods (inter-period). The analyses are based on real-world CGM data from 484 diabetes users (4726 periods) acquired from the Cornerstones4Care® Powered by Glooko app. Using up to 14 accumulated days, the consensus metrics are calculated for each user and period, and compared to the fully 14 accumulated intra- and inter-period days. Relatively low deviations were observed for time in range (TIR) and average based metrics when using less than 14 days, however, we observed large deviations in metrics characterizing infrequent events such as time below range (TBR). Furthermore, the consensus metrics obtained in two consecutive 14 day periods have clear discrepancies (inter-period). Recovering consensus metrics using less than 14 days might still be valuable in terms of interpreting CGM data in certain clinical contexts. However, caution should be taken if treatment decisions would be made with less than 14 days of data on critical metrics such as TBR, since the metrics characterizing infrequent events deviate substantially when less data are available. Substantial deviation is also seen when comparing across two consecutive periods, which means that care should be taken not to over-generalize consensus metric based glycemic control conclusions from one period to subsequent periods.
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20
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Rodbard D. Quality of Glycemic Control: Assessment Using Relationships Between Metrics for Safety and Efficacy. Diabetes Technol Ther 2021; 23:692-704. [PMID: 34086495 DOI: 10.1089/dia.2021.0115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Numerous methods have been proposed as measures of quality of glycemic control resulting in confusion regarding the best choice of metric to use by clinicians and researchers. Some methods use a single metric such as HbA1c, Mean Glucose, %Time In Range (%TIR), or Coefficient of Variation (%CV). Others use a combination of up to seven metrics, for example, Q-Score, Comprehensive Glucose Pentagon (CGP), and Personal Glycemic State (PGS). A recently proposed Composite continuous Glucose monitoring index utilizes three metrics: %TIR, Time Below Range (%TBR), and standard deviation (SD) of glucose. This review proposes that only two metrics can be sufficient when monitoring an individual patient or when comparing two or more forms of management interventions. These two metrics comprise (1) a measure of efficacy such as Mean Glucose, HbA1c, %TIR, or %Time Above Range (%TAR) and (2) a measure of safety based on risk of hypoglycemia such as %TBR, Low Blood Glucose Index (LBGI), or frequency of specified types of hypoglycemic events per patient year. By analysis of the two-dimensional graphical and statistical relationships between metrics for safety and efficacy and by testing identity versus nonidentity of these relationships, one can improve sensitivity for detection of the effects of medications and of other therapeutic interventions, avoid the need for arbitrary scoring systems for glucose values falling within versus outside the target range, and offer the advantage of conceptual and practical simplicity.
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Affiliation(s)
- David Rodbard
- Biomedical Informatics Consultants LLC, Clinical Biostatistics Department, Potomac, Maryland, USA
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21
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Xu Y, Bergenstal RM, Dunn TC, Ajjan RA. Addressing shortfalls of laboratory HbA 1c using a model that incorporates red cell lifespan. eLife 2021; 10:69456. [PMID: 34515636 PMCID: PMC8437432 DOI: 10.7554/elife.69456] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/24/2021] [Indexed: 12/19/2022] Open
Abstract
Laboratory HbA1c does not always predict diabetes complications and our aim was to establish a glycaemic measure that better reflects intracellular glucose exposure in organs susceptible to complications. Six months of continuous glucose monitoring data and concurrent laboratory HbA1c were evaluated from 51 type 1 diabetes (T1D) and 80 type 2 diabetes (T2D) patients. Red blood cell (RBC) lifespan was estimated using a kinetic model of glucose and HbA1c, allowing the calculation of person-specific adjusted HbA1c (aHbA1c). Median (IQR) RBC lifespan was 100 (86–102) and 100 (83–101) days in T1D and T2D, respectively. The median (IQR) absolute difference between aHbA1c and laboratory HbA1c was 3.9 (3.0–14.3) mmol/mol [0.4 (0.3–1.3%)] in T1D and 5.3 (4.1–22.5) mmol/mol [0.5 (0.4–2.0%)] in T2D. aHbA1c and laboratory HbA1c showed clinically relevant differences. This suggests that the widely used measurement of HbA1c can underestimate or overestimate diabetes complication risks, which may have future clinical implications.
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Affiliation(s)
- Yongjin Xu
- Abbott Diabetes Care, Alameda, United States
| | - Richard M Bergenstal
- International Diabetes Center, Park Nicollet, HealthPartners, Minneapolis, United States
| | | | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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22
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Grossman J, Ward A, Crandell JL, Prahalad P, Maahs DM, Scheinker D. Improved individual and population-level HbA1c estimation using CGM data and patient characteristics. J Diabetes Complications 2021; 35:107950. [PMID: 34127370 PMCID: PMC8316291 DOI: 10.1016/j.jdiacomp.2021.107950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022]
Abstract
Machine learning and linear regression models using CGM and participant data reduced HbA1c estimation error by up to 26% compared to the GMI formula, and exhibit superior performance in estimating the median of HbA1c at the cohort level, potentially of value for remote clinical trials interrupted by COVID-19.
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Affiliation(s)
- Joshua Grossman
- Department of Management Science and Engineering, Stanford School of Engineering, Stanford, CA, USA
| | - Andrew Ward
- Department of Management Science and Engineering, Stanford School of Engineering, Stanford, CA, USA
| | - Jamie L Crandell
- School of Nursing, Department of Biostatistics, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Priya Prahalad
- Division of Pediatric Endocrinology, Stanford School of Medicine, Stanford, CA, USA; Lucile Packard Children's Hospital, Stanford, CA, USA
| | - David M Maahs
- Division of Pediatric Endocrinology, Stanford School of Medicine, Stanford, CA, USA; Lucile Packard Children's Hospital, Stanford, CA, USA; Stanford Diabetes Research Center, Stanford School of Medicine, Stanford, CA, USA; Department of Health Research and Policy, Stanford School of Medicine, Stanford, CA, USA
| | - David Scheinker
- Department of Management Science and Engineering, Stanford School of Engineering, Stanford, CA, USA; Division of Pediatric Endocrinology, Stanford School of Medicine, Stanford, CA, USA; Lucile Packard Children's Hospital, Stanford, CA, USA; Stanford Diabetes Research Center, Stanford School of Medicine, Stanford, CA, USA; Clinical Excellence Research Center, Stanford School of Medicine, Stanford, CA, USA.
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23
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Relación entre hemoglobina glucosilada, tiempo en rango y variabilidad glucémica en una cohorte de pacientes pediátricos y adultos con diabetes tipo 1 con monitorización flash de glucosa. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2020.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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24
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Díaz-Soto G, Bahíllo-Curieses MP, Jimenez R, Nieto MDLO, Gomez E, Torres B, López Gomez JJ, de Luis D. The relationship between glycosylated hemoglobin, time-in-range and glycemic variability in type 1 diabetes patients under flash glucose monitoring. ENDOCRINOL DIAB NUTR 2021; 68:465-471. [PMID: 34863411 DOI: 10.1016/j.endien.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/23/2020] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Flash glucose monitoring in patients with type 1 diabetes provides new glucometric data that allow for the assessment of glycemic control beyond HbA1c. The objective of the study was to evaluate the relationship between HbA1c, time-in-range (TIR) and glycemic variability in a cohort of paediatric and adult patients with type 1 diabetes and treatment with flash glucose monitoring. MATERIAL AND METHODS This was a cross-sectional study in 195 patients with type 1 diabetes (42.6% females, 70 paediatric, 26.2% continuous subcutaneous insulin infusion, 28.7% coefficient of variation [CV]≤36%) in intensive treatment and flash glucose monitoring. Clinical, analytical and glucometric data were evaluated. RESULTS The relationship between the TIR and HbA1c showed a strong negative linear correlation (R=-0.746; R2=0.557; P<.001), modified in those patients with CV≤36% (R=-0.852; R2=0.836) compared to CV>36% (R=-0.703; R2=0.551). A similar correlation was found when evaluating the TIR and the Glucose Management Indicator (R=-0.846; R2=0.715; P<.001); in patients with CV≤36% (R=-0.980; R2=0.960) versus CV>36% (R=-0.837; R2=0.701); P<.001. Both correlations remained stable in the paediatric population (R=-0.724; R2=0.525; P<.001) and adults (R=-0.706; R2=0.498; P<.001) and by type of treatment: multiple doses of insulin (R=-0.747; R2=0.558; P<.001) and continuous subcutaneous insulin infusion (R=-0.711; R2=0.506; P<.001). In a multiple regression analysis evaluating HbA1c as dependent variable, the only parameters that maintained statistical significance were the TIR (β=-0,031; P<.001), CV (β=0.843; P<.05) and TIR-CV interaction (β=-0.017; P<.01). CONCLUSIONS The glycemic variability defined by the CV modifies the relationship between the TIR and HbA1c/Glucose Management Indicator and should be taken into account when individualising TIR targets, regardless of age or the type of treatment used.
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Affiliation(s)
- Gonzalo Díaz-Soto
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain.
| | | | - Rebeca Jimenez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
| | - Maria de la O Nieto
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
| | - Emilia Gomez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
| | - Beatriz Torres
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
| | - Juan Jose López Gomez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
| | - Daniel de Luis
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, Spain
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Dehghani Zahedani A, Shariat Torbaghan S, Rahili S, Karlin K, Scilley D, Thakkar R, Saberi M, Hashemi N, Perelman D, Aghaeepour N, McLaughlin T, Snyder MP. Improvement in Glucose Regulation Using a Digital Tracker and Continuous Glucose Monitoring in Healthy Adults and Those with Type 2 Diabetes. Diabetes Ther 2021; 12:1871-1886. [PMID: 34047962 PMCID: PMC8266934 DOI: 10.1007/s13300-021-01081-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION While continuous glucose monitoring (CGM) has been shown to decrease both hyper- and hypoglycemia in insulin-treated diabetes, its value in non-insulin-treated type 2 diabetes (T2D) and prediabetes is unclear. Studies examining the reduction in hyperglycemia with the use of CGM in non-insulin-treated T2D are limited. METHODS We investigated the potential benefit of CGM combined with a mobile app that links each individual's glucose tracing to meal composition, heart rate, and physical activity in a cohort of 1022 individuals, ranging from nondiabetic to non-insulin-treated T2D, spanning a wide range of demographic, geographic, and socioeconomic characteristics. The primary endpoint was the change in time in range (TIR), defined as 54-140 mg/dL for healthy and prediabetes, and 54-180 mg/dL for T2D, from the beginning to end of a 10-day period of use of the Freestyle Libre CGM. Logged food intake, physical activity, continuous glucose, and heart rate data were captured by a smartphone-based app that continuously provided feedback to participants, overlaying daily glucose patterns with activity and food intake, including macronutrient breakdown, glycemic load (GL), and glycemic index (GI). RESULTS A total of 665 participants meeting eligibility and data requirements were included in the final analysis. Among self-reported nondiabetic participants, CGM identified glucose excursions in the diabetic range among 15% of healthy and 36% of those with prediabetes. In the group as a whole, TIR improved significantly (p < 0.001). Among the 51.4% of participants who improved, TIR increased by an average of 6.4% (p < 0.001). Of those with poor baseline TIR, defined as TIR below comparable A1c thresholds for T2D and prediabetes, 58.3% of T2D and 91.7% of healthy/prediabetes participants improved their TIR by an average of 22.7% and 23.2%, respectively. Predictors of improved response included no prior diagnosis of T2D and lower BMI. CONCLUSIONS These results indicate that 10-day use of CGM as a part of multimodal data collection, with synthesis and feedback to participants provided by a mobile health app, can significantly reduce hyperglycemia in non-insulin-treated individuals, including those with early stages of glucose dysregulation.
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Affiliation(s)
| | | | - Salar Rahili
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Kirill Karlin
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Darrin Scilley
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Riya Thakkar
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Maziyar Saberi
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Noosheen Hashemi
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Dalia Perelman
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | - Nima Aghaeepour
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA
| | | | - Michael P Snyder
- January AI, 1259 El Camino Real #231, Menlo Park, CA, 94025, USA.
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Shang T, Zhang JY, Bequette BW, Raymond JK, Coté G, Sherr JL, Castle J, Pickup J, Pavlovic Y, Espinoza J, Messer LH, Heise T, Mendez CE, Kim S, Ginsberg BH, Masharani U, Galindo RJ, Klonoff DC. Diabetes Technology Meeting 2020. J Diabetes Sci Technol 2021; 15:916-960. [PMID: 34196228 PMCID: PMC8258529 DOI: 10.1177/19322968211016480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 12 to November 14, 2020. This meeting brought together speakers to cover various perspectives about the field of diabetes technology. The meeting topics included artificial intelligence, digital health, telemedicine, glucose monitoring, regulatory trends, metrics for expressing glycemia, pharmaceuticals, automated insulin delivery systems, novel insulins, metrics for diabetes monitoring, and discriminatory aspects of diabetes technology. A live demonstration was presented.
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Affiliation(s)
- Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | - Jennifer K. Raymond
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Gerard Coté
- Texas A & M University, College Station, Texas, USA
| | | | | | | | | | - Juan Espinoza
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Sarah Kim
- University of California San Francisco, San Francisco, CA, USA
| | | | - Umesh Masharani
- University of California San Francisco, San Francisco, CA, USA
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Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract 2021; 27:505-537. [PMID: 34116789 DOI: 10.1016/j.eprac.2021.04.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders. METHODS The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development. MAIN OUTCOME MEASURES Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range. RESULTS This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base. RECOMMENDATIONS Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology. CONCLUSIONS Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.
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Affiliation(s)
| | - Jennifer Sherr
- Yale University School of Medicine, New Haven, Connecticut
| | - Myriam Allende
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, Georgia
| | | | - Richard Hellman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - David Rodbard
- Biomedical Informatics Consultants, LLC, Potomac, Maryland
| | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | - Jeff Unger
- Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California
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28
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Xu Y, Grimsmann JM, Karges B, Hofer S, Danne T, Holl RW, Ajjan RA, Dunn TC. Personal Glycation Factors and Calculated Hemoglobin A1c for Diabetes Management: Real-World Data from the Diabetes Prospective Follow-up (DPV) Registry. Diabetes Technol Ther 2021; 23:452-459. [PMID: 33395370 DOI: 10.1089/dia.2020.0553] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background: Glycated hemoglobin A1c (HbA1c) is a key biomarker in the glycemic management of individuals with diabetes, but the relationship with glucose levels can be variable. A recent kinetic model has described a calculated HbA1c (cHbA1c) that is individual specific. Our aim was to validate the routine clinical use of this glucose metric in younger individuals with diabetes under real-life settings. Materials and Methods: We retrieved HbA1c and glucose data from the German-Austrian-Swiss-Luxembourgian diabetes follow-up (DPV) registry, which covers pediatric individuals with type 1 diabetes (T1D). The new glycemic measure, cHbA1c, uses two individual parameters identified by data sections that contain continuous glucose data between two laboratory HbA1c measurements. The cHbA1c was prospectively validated using longitudinal HbA1c data. Results: Continuous glucose monitoring data from 352 T1D individuals in 13 clinics were analyzed together with HbA1c that ranged between 4.9% and 10.6%. In the prospective analysis, absolute deviations of estimated HbA1c (eHbA1c), glucose management indicator (GMI), and cHbA1c compared with laboratory HbA1c were (median [interquartile range]): 1.01 (0.50, 1.75), 0.46 (0.21, 084) and 0.26 (0.12, 0.46), giving an average bias of 0.6, 0.4 and 0.0, respectively, in National Glycohemoglobin Standardization Program (NGSP) % unit. For eHbA1c and GMI only 25% and 54% of subjects were within ±0.5% of laboratory HbA1c values, whereas 82% of cHbA1c were within ±0.5% of laboratory HbA1c results. Conclusions: Our data show the superior performance of cHbA1c compared with eHbA1c and GMI at reflecting laboratory HbA1c. These data indicate that cHbA1c can be potentially used instead in laboratory HbA1c, at least in younger individuals with T1D.
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Affiliation(s)
- Yongjin Xu
- Clinical and Computational Research, Abbott Diabetes Care, Alameda, California, USA
| | - Julia M Grimsmann
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sabine Hofer
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Children's and Youth Hospital "Auf der Bult," Hannover, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Timothy C Dunn
- Clinical and Computational Research, Abbott Diabetes Care, Alameda, California, USA
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Beck RW, Bergenstal RM. Beyond A1C-Standardization of Continuous Glucose Monitoring Reporting: Why It Is Needed and How It Continues to Evolve. Diabetes Spectr 2021; 34:102-108. [PMID: 34149250 PMCID: PMC8178725 DOI: 10.2337/ds20-0090] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Continuous glucose monitoring (CGM) systems are becoming part of standard care for type 1 diabetes, and their use is increasing for type 2 diabetes. Consensus has been reached on standardized metrics for reporting CGM data, with time in range of 70-180 mg/dL and time below 54 mg/dL recognized as the key metrics of focus for diabetes management. The ambulatory glucose profile report has emerged as the standard for visualization of CGM data and will continue to evolve to incorporate other elements such as insulin, food, and exercise data to support glycemic management.
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Chrzanowski J, Michalak A, Łosiewicz A, Kuśmierczyk H, Mianowska B, Szadkowska A, Fendler W. Improved Estimation of Glycated Hemoglobin from Continuous Glucose Monitoring and Past Glycated Hemoglobin Data. Diabetes Technol Ther 2021; 23:293-305. [PMID: 33112161 DOI: 10.1089/dia.2020.0433] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Accurate estimation of glycated hemoglobin (HbA1c) from continuous glucose monitoring (CGM) remains challenging in clinic. We propose two statistical models and validate them in real-life conditions against the current standard, glucose management indicator (GMI). Materials and Methods: Modeling utilized routinely collected data from patients with type 1 diabetes from central Poland (eligibility criteria: age >1 year, diabetes duration >3 months, and CGM use between 01/01/2015 and 12/31/2019). CGM records were extracted from dedicated Medtronic/Abbott databases and cross-referenced with HbA1c values; 28-day periods preceding HbA1c measurement with >75% of the sensor-active time were analyzed. We developed a mixed linear regression, including glycemic variability indices and patient's ID (glucose variability-based patient specific model, GV-PS) intended for closed-group use and linear regression using patient-specific error of GMI (proportional error-based patient agnostic model, PE-PA) for general use. Models were validated with either new HbA1cs from closed-group patients or separate patient-HbA1c pool. External validation was performed with data from clinical trials. Performance metrics included bias, its 95% confidence interval (95% CI), coefficient of determination (R2), and root mean square error (RMSE). Results: We included 723 HbA1c-CGM pairs from 174 patients (mean age 9.9 ± 4.4 years and diabetes duration 3.7 ± 3.6 years). GMI yielded R2 = 0.58, with different bias between Medtronic and Abbott devices [0.120% vs. -0.152%, P < 0.0001], and overall 95% CI = -0.9% to +1%, RMSE = 0.47%. GV-PS successfully captured patient-specific variance (closed-group validation: R2 = 0.83, bias = 0.026%, 95% CI = -0.562% to 0.591%, RMSE = 0.31%). PE-PA performed similarly on new patients (R2 = 0.76, bias = -0.069%, 95% CI = -0.790% to 0.653%, RMSE = 0.37%). In external validation GMI, GV-PS, and PE-PA produced 73.8%, 87.5%, and 91.0% predictions within 0.5% (5.5 mmol/mol) from the true value. Conclusion: Constructed models performed better than GMI. PE-PA provided an accurate estimate of HbA1c with fast and straightforward implementation.
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Affiliation(s)
- Jędrzej Chrzanowski
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Arkadiusz Michalak
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Łosiewicz
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Hanna Kuśmierczyk
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Beata Mianowska
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Szadkowska
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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31
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Rodbard D, Garg SK. Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring. Diabetes Technol Ther 2021; 23:221-226. [PMID: 33480828 DOI: 10.1089/dia.2021.0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Recent development and availability of several connected insulin pens with digital memory are likely to expand the availability of glucose and insulin metrics that previously had been available only for the much smaller number of people using insulin pumps. It would be highly desirable to standardize data presentations to avoid the chaotic emergence of multiple formats that might reduce the clinical utility of connected pens. Methods: We reviewed the literature and analyzed data displays from multiple blood glucose monitoring, continuous glucose monitoring (CGM), insulin pump, and automated insulin delivery systems, and methods for combination of glucose and insulin data. We examined multiple forms of presentation and now propose a prototype for a standardized method for data analysis and display, focusing on the content and format of a one-page dashboard summary for patients on multiple daily injection (MDI) insulin regimens. Results: We propose the following metrics to be included in the one-page report: (A) glucose metrics: simplified glucose distribution in the form of a stacked bar chart showing percentages of time below-, above-, or within-target ranges overall and (optionally) by date, by time of day, or day of the week; (B) insulin metrics: types and doses, and timing of basal and bolus insulin; (C) an enhanced ambulatory glucose profile or "AGP+" showing glucose data points and/or distributions (10th to 90th percentiles), dosages and timing of basal and bolus insulins and (optionally) graphical display of risk of hypoglycemia and hyperglycemia; and (D) user experience regarding technology usage, frequency of alerts for hypo- and hyperglycemia, and information regarding lifestyle, meals, exercise, and sleep, if available; and (E) clinical insights and interpretation. Conclusion: We propose a prototype for a dashboard summary report of glucose, insulin, meals, and activity data intended for providers and patients on MDI using connected pens and CGM. Our goal is to stimulate development of a standardized approach.
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Affiliation(s)
- David Rodbard
- Biomedical Informatics Consultants LLC, Clinical Biostatistics Department, Potomac, Maryland, USA
| | - Satish K Garg
- Barbara Davis Center for Diabetes, Departments of Medicine and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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32
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Methoden der Stoffwechselkontrolle – HbA1c versus „time in range“. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00730-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Relationship of continuous glucose monitoring-related metrics with HbA1c and residual β-cell function in Japanese patients with type 1 diabetes. Sci Rep 2021; 11:4006. [PMID: 33597626 PMCID: PMC7889608 DOI: 10.1038/s41598-021-83599-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/04/2021] [Indexed: 12/26/2022] Open
Abstract
The targets for continuous glucose monitoring (CGM)-derived metrics were recently set; however, studies on CGM data over a long period with stable glycemic control are limited. We analyzed 194,279 CGM values obtained from 19 adult Japanese patients with type 1 diabetes. CGM data obtained during stable glycemic control over four months were analyzed. CGM-related metrics of different durations “within 120, 90, 60, 30, and 7 days” were calculated from baseline. Time in range (TIR; glucose 70–180 mg/dL), time above range (TAR; glucose ≥ 181 mg/dL), and average glucose levels, but not time below range (TBR; glucose ≤ 69 mg/dL), strongly correlated with glycated hemoglobin (HbA1c) values (P < 0.0001). TBR correlated with glucose coefficient of variation (CV) (P < 0.01). Fasting serum C-peptide levels negatively correlated with glucose CV (P < 0.01). HbA1c of approximately 7% corresponded to TIR of 74% and TAR of 20%. The shorter the CGM period, the weaker was the relationship between HbA1c and CGM-related metrics. TIR, TAR, and average glucose levels accurately reflected HbA1c values in Japanese patients with type 1 diabetes with stable glycemic control. Glucose CV and TBR complemented the limitation of HbA1c to detect glucose variability and hypoglycemia. Stable glycemic control with minimal hypoglycemia depended on residual β-cell function.
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Yoo JH, Kim JH. Time in Range from Continuous Glucose Monitoring: A Novel Metric for Glycemic Control. Diabetes Metab J 2020; 44:828-839. [PMID: 33389957 PMCID: PMC7801761 DOI: 10.4093/dmj.2020.0257] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jee Hee Yoo
- Division of Endocrinology and Metabolism, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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