Using Freestyle Libre to Tame Your Diabetes & What is Better HbA1c or Time In Range?

Diabetes is a beast. It is your job to tame it, but it will do what it wants when it wants without rhyme, reason or warning.

Paul Coker hosts Prof Partha Kar, Prof Pratik Choudhary and Dr Emma Wilmot  where we talk about taming the beast that is diabetes using continuous glucose monitoring or Flash Freestyle Libre and clinically what is better HbA1c or Time In Range?

Listen to The Podcast (audio) by clicking here

Introducing Dr Emma Wilmot is a consultant diabetologist in Derby

“ I mainly do type one diabetes clinics and I'm the founder of the Diabetes Technology Network, UK, which sort of promotes access to technology for people living with diabetes, Pratik chairs.”

Introducing Prof Pratik Choudhary a consultant diabetologist and academic

“ I'm Pratik Choudhary. I'm a consultant in diabetes. I worked almost exclusively in type one diabetes for the last 20 years. I used to be in London at King's College Hospital and I've recently moved to Leicester about a year ago. And I'm an academic, which means it's been half my time doing research, running studies, many around new technology or in particular hypoglycemia. My pastime is taking people’s blood glucose level down to 2.5 mmols/L and putting them in an MRI scanner to see what happens to their brains. And in my spare time, I try and run the DTN with them.

Introducing Professor Prof Partha Kar

“I'm, Partha, I'm a consultant in diabetes in Portsmouth, that's my main job and I also NHS England lead for Diabetes technology”

what have been the main benefits of Libre and what's going on in the national data in England?

Dr Wilmot tells us that “from a clinician point of view, we want to understand what are the hard core outcomes. When we look at clinical data. So we've done a large audit across the UK of about 15,000 users of the freestyle Libre's.

Last year we published on the first follow-up data from over 3000 of those people. And you won't be surprised by this, but it showed

• Reductions in HbA1c
• Reductions in episodes of severe hypoglycaemia, where individual’s needed help from somebody else to treat their hypos.
• They reduced the number of hospitalisations reduced
• The number of diabetic ketoacidosis reduced,
• Most importantly diabetes related distress was also reduced.

We wanted to capture that in an academic way  to help policymakers and doctors across the country to really understand what the benefits are, but Partha has been the driving force in making sure it's got into the hands of people with diabetes. So I'll hand over to him to talk about the national data.

Prof Partha Kar tells us, I've always stuck to a principle that if you improve three things, if you want to make things better for people with type 1 diabetes:

• better self-management
• better peer support
• better access to trained professionals

I think in a one way, Libre does all three. When we started this journey people talked about, well, where's the evidence, where's the randomized controlled trial, where is the improvement in HbA1c which in fairness they didn't have at that stage. But if you take a step back using continuous glucose monitoring is fundamentally an improvement of the quality of your life.

There is not many people around the world who will turn around and said, you know what? I really, really fancy pricking my fingers if there was a choice.

I mean, that is a crazy thought, right? So if you take it to that level, then it works because, you know, none of us as consultants would want, if we had it or in Emma's case herself, or, you know, our children had it, we would want them to be pricking their fingers. That that's where it basically boils down to. So I think what we see and the national data, we see it reflected all across the board. I probably haven't seen the improvement of HbA1c that I've seen over the last two, three years as a collective in clinics that I have seen across the board. People are happier. It doesn't work for everybody. And I think that's an important thing to say is that, you know the praise one part of the puzzle, but I think what I do see, and I think it's going to reflect and lots of the national dataset, if you, if you improve somebody's quality of life. And I think the recent data that's come on from ABC shows that people's diabetes, distress has improved. Yet it live with type one diabetes. It's toughen up a little bit type two diabetes is toughen up. You improve your quality of life, your diabetes care improves. I mean, it's not rocket science really isn't. So that's when Libra does. So, and I think that's a, the more, the more we can bring that sort of technology to people's lives the better. So that will be my reflection.

Paul Coker:

What Benefits Do You See in Your Clinic?

Professor Kar:

 “The majority of people’s feelings towards it are that you have transformed my life. Suddenly I can see what's happening. Why didn't we have something like this before? Why did it have to go through hoops to get this in general? The feedback has been very, very good. And I can only say that people whose diabetes control has been very difficult to turn around due to many, many reasons. They have done really well. They found it to be a godsend from that point of view. That's what I do see.

Dr Emma Wilmot:

“The whole point of diabetes care is to help support people to improve HbA1c and avoid complications. But why are we actually doing that? We do that because if you get complications of diabetes that has a negative impact on your quality of life, but actually if the care that we as clinicians and the demands that we put on you as individuals to manage your diabetes makes you feel like rubbish, we've completely lost the plot. We have to ask what's the point in what we're doing? For me, we need to get a balance between getting the best quality of life, so you can manage your diabetes from day to day and life is good and also offset and reduce the risk of complications in the longer term. And I think that's where the role of diabetes technologies increasingly have.”

Prof Pratik Choudhary:

I think people in different places on their journey with diabetes might find different benefits. Some people are  working on really tight control and they want to know what's happening all the time, so they can be aggressive with what their insulin dosing.

But, we have got a large group of people with Type 1 Diabetes in the UK with an average of A1C floating around 8.5%, or in the mid what is that in the mid, late fifties, early sixties and in new numbers.

We know that from that sort of place to get into the lower numbers the most important value is knowing where you are in the number of times per day people look at their blood glucose data. The average number of fingerpricks that the average person with Diabetes was doing per day  was two to three, but the average number of scans per day is about 14.

The more often you look at your blood sugars, the earlier you find the high numbers and the earlier you head off the lows and that narrows the thing down and brings the Time In Range for a lot of people.

There are a lot of people with Diabetes who were running really high blood glucose levels, struggling with diabetes.

One of the key things for them is seeing what's happening and this helps us as clinicians to help them.

COVID

COVID has really transformed the way clinicians work, we've been able to look at data coming from Libre and Continuous Glucose Monitoring and, and we've been able to talk about real data using telephone and video appointments.  Before we had Libre and CGMS we never really had that full, complete datasets which has transformed, not just the lives of people with Diaabets, but also the quality of advice that we've been able to give to people as well.

What are the benefits and challenges that you see in clinic of the use of Libra or CGMS

Dr Emma Wilmot:

One of the things which has just come out is alarm fatigue, that’s is a fairly new thing, alarms are great to let you know if you're having a low, but actually that can also be a pain in the backside. If they're going off all the time and it's alerting you to something that's not actionable. I think having alarms that you find worked for you as an individual, and I am very keen for my patients to be in charge of what works for them rather than having clinicians sets targets and thresholds.

I think the other thing that I feel that some people worry a lot about as a discrepancy between the Libre's and blood.

That's a tricky one because actually even if it's off, but often seeing the direction of changing things is almost more important than any difference between blood glucose readings from a finger prick and the CGMS data. Sadly, some people get so worried about that or they actually stopped using it, which can be a shame.

The other thing we need to think about is if you look at all the blood glucose meters that are out there, most of them are actually less accurate than the freestyle Libre's. So you also need to think about what you're comparing your data to and making sure you've got really accurate meter. And that's why they suggest using the Abbott meter rather than one of the sort of cheaper ones that you can sometimes get asked to use. Instead,

Paul Coker:

I think there's probably another element in there as well. And it's not just how accurate the meter is. It's also how accurate and good your own blood glucose testing technique is.

Dr Emma Wilmot:

Exactly, how many people actually wash hands before they prick their fingers? A lot of people forget. Also if you're blood glucose is rapidly changing, going up rapidly or going down, you're never going to get those two numbers to be the same.

Prof Pratik Choudhary:

I think the accuracy story is really key. Isn't it? Because if people are a lot of it in a simple terms, if you feel low, when your sensor doesn't tell you, you treat the way you feel on the whole. If you're saying it's coming down, a simple rule of thumb that I often use in my clinic is that we know that the delay, particularly if you're dropping rapidly, that the sensor will read, might read a bit off. And often people say, well, the sensor miss because I was five and I was three with the sensor that I was five. So if you've got a down arrow, I would always say, you real blood sugar could be anything between one or two lower than what the sensor's reading. And if you've got an oblique area, it might be about one lower. If you've got two arrows or straight down your real good cause could be two lower.

And that's why we always, in our DTN advice, we say, if you're below six and dropping, you have with single [inaudible] to jelly babies, you take that margin out of it. The other bit is that when it says you're low and you're not, which actually overnight is quite common. And you know, I don't have diabetes, I've worn a number of CGMS sensors over the time and I've run down to 2.8, 2.7 on the Libre's. And I think the real important point is that we don't really know what low sensor glucose overnight that is asymptomatic means there's two or three small studies would say that if you have a blind sensor on and you wake up in the morning, and if you didn't know you were low, actually people don't report quality of life or how they're feeling or headaches any different. So low that wakes you up.

Prof Pratik Choudhary:

Of course, that has a negative impact. A really, really low one that lasts for a long time has a negative impact. But a lot of these soft lows, if you like, which the sensor says you wake up in the morning and it might've told you that you were low, but you didn't feel anything. We don't think they're of any harm actually, because they happen so often. It was one in 10 nights, one in eight nights. If you look across the UK and I think they cause a lot more anxiety than, than actual hypoglycemic homes. So it's an error, it's an error and tricky one to tread about being, trying to reduce the overnight lows. But if the w if you get one on the sensor, not being too alarmed or scared by it, because they, it could well be, you know, I'm sure part of the night we'll have those, you know, one night in seven,

“How can I get the most out of the data that I've got in front of me? “

Paul Coker :

I was lucky enough to be get some training from Partha, Emma and Pratik taking an in-depth dive in using Continuous Glucose Monitoring and I was just astonished by how complacent I was about my own data.

I thought that I knew how to interpret it with the material that you presented on that course, it made me go back and re-evaluate what I thought I knew.

That changed the way in which I manage my diabetes massively. So I think that can be really quite important for those that have been using CGMS even for some time, it's worth asking yourself the question, perhaps, and even asking your clinicians, how can I getting the most out of the data that I've got in front of me?

Prof Pratik Choudhary:

To add that, Paul a lot of the stuff we talked about with Emma and I, and Partha you know, it'd be great to post a link to the DTN you know, videos where we talk a lot about this, there's some really simple rules that help you get the most of the data.

Your blood glucose level vn be over 10mmols/L (180mg/dL) for upto 8 hours a day and you will still get great results on your HbA1c

Prof Pratik says that “the way people talk about your target range of being 70% time in range, actually to my mind, what that means is that your allowance to be over 10 is 30% of the day, which is eight hours.

You know, you'd being judged by that line every minute of the day and  it is kind of relaxing saying the main problem is that Novo sluggish (NovoRapid) and Human Slug (Humalog) are so slow that once you've made your action, it's going to be two or three hours when it comes on. It doesn't matter because people have had 17 years of diabetes without complications.

The data tells us 70% time and range is okay to have a lifetime without major complications. So you've got that allowance and you've got to give yourself that room you know, for the, for the, for the nervous sluggish or humanslug, love to work,

Prof Pratik Choudhary:

• Your Data 1 Hour After A Meal… Tells you about whether you injected early enough or not.

• Your 2 hour after a meal data… Tells you whether you've injected enough or not.

• Your 3 hour after a meal data… And then the three hours sugar often tell you, are you stressed? Have you been sitting around an inactive or have you eaten a lot of dietary fat or protein?

Plan to Scan when You Are Likely To Take Action Based on The Result

Many people do a lot of libre scans close together, particularly post meal when they're high but they don’t act on the numbers.

Instead of thinking about it all the time focus your on the times when that scan or check your data on times when you will take some action.

• Pre-Meal judge what you're going to do.
• A couple of hours later, just check, are you in range? If you're dripping too quickly, you can head it off.
• You're a bit high. You can think about what you need to do.

Generally, check about every two hours you want to, you want to check and have a look, and those are some of the quick tricks I've got, and I'm sure you've got some more embedded ones.

Paul Coker:

What about Time In Range vs HbA1c – Which Should I Use?

Dr Emma Wilmot:

I absolutely love time and range. Oh my goodness. With that, we used to have conversations in clinic on trying to get HbA1c down. And what does that mean? A clinical blood test that you have no control over and it's just going to spit out whatever number.

I think what we're starting to understand is actually in some people, HbA1c is a rubbish marker of glucose control.

HbA1c is basically a measure of how much glucose is stuck onto the red blood cells in your body. And we'll use that because we had no other way of looking at glucose control.

We now have Libre's and continuous glucose monitoring (CGM) that can directly measure glucose. So I would be more focused on what you're glucose that's on your Libre's or your CGM, then some blood tests that your doctor is doing. And I'm a doctor saying that!

With Time in Range you can see how things are going from day to day, week to week, month to month, rather than this horrible blood tests that your doctor meets should get done every so often.

Paul Coker:

I love the answer for many years, I've been working really, really hard between clinic appointments. and I'd go along to the clinic appointment only to My A1C had gone up not down, and I just had no way of actually analysing what that metric was going to be between appointments. And it can get very demotivating. It did for me, at least,

Why is my estimated HbA1c different from my actual HbA1c?

Prof Pratik Choudhary:

So there's a couple of things.

The first thing is that often when you look at your estimated A1C on your Libre view, right, that's over a two week period, and we know that, you know, you can have a two weeks when things are really good, then something else happens and you have a couple of weeks period where they are not so good, and actually everyone's control kind of bounces up and down a little bit so what you need is to see what your overall the pictures is like.

That's one of the reasons why your A1C is always different from the estimate.

So we know that for any A1C, your estimated A1C could be about 1% either side.

Ultimately what you're going to work towards is your time and range.

The way I look at it is it for some people have got a low A1C, but the time and range, isn't great. Fantastic. We know that complications are linked to A1C. So that's good on you.

If you've got a very good time and range, but your A1C is high. We call that high glycosolated. For some reason, that A1C just reports higher. Look, you can't drop your glucose any lower. You've already got 65, 70% time in range. So in that scenario, if the A1C is higher, it might mean you've got some high risk, but you can always address those with cholesterol or blood pressure.

Medications are other ways to drop your risk of complications, but you can't push your glucose any lower.

The outcomes that really matter are you, your risk of complications and the overall clinical picture.

Prof Partha Kar:

 In clinic we often put too much pressure on people to achieve great numbers.

“Most of the people that come to clinic and they think that all of their numbers should be between 4 and 7mmol/L (80-135mg/dL)  all of the time, but nobody humanly can do that. So I ask then what do you want to do? And, it was always a big light bulb moment for my patients when I take the pressure off of them.

Look at me, I can't get in between 4 and 10mmol/L  (80-180mg/dL) all the time and I don't even have type one diabetes. I'm supposed to have a fully functioning pancreas. So the best technology in the world, let's say, I give every one of you, artificial pancreas, AKA, the hybrid closed loop. You still won't get to a hundred percent. So why are you trying to do it with instrument from outside?

I think those conversations are quite important because that's particular to put in the chat. When you talk about look, Hey, listen, I'm putting you guys said 60%. I started with 50% and my response is, Hey, listen, you get a 50%, that's amazing 4 to 10mmol/L  50% of the time let's go with that.

And then we see people coming with a time and range of 20% and my approach is, Hey, listen, let's catch up again in four weeks, let's get you to 25% time in range.

Let's do it slowly. What's the rush?

You know, then we get to 30% time in range. A

When people  come back and invariably, because you've given them some tips, it's not 25%, there are 31% and know they are delighted and I tell them, wow, this is amazing. Great work.

Let's, let's now take it to 35% time in range.

So I think support, and I think people need to, we don't do that enough. And I think that that's one of the fundamental problems that we have in this country. So I'm probably getting there. I think there's a lot of good people. A lot of clinicians who are starting to understand the concept, we talked about language matters.

Prof Partha Kar:

It's a hundred percent, isn't it? I mean, you take anything in life, you know you take the example of Pratik or Emma and me, you know, we were where we were about 10, 15 years ago. We were trainees. We were sitting around and we've all evolved. You know, we, and I'm not going to second judge them, but people don't see the failures. You know? I, I, most of my projects actually don't work. People don't see that people always see the good things. So but you keep trying, you adapt UMN, then that that's how it is. So diabetes is going to be no different than, you know, my dad's got type two diabetes. That's what I keep saying to him. So any sort of [inaudible] and you go like, yeah, why can't you have, who don't, you can't have a mango when he's 81.

How do you deal with the increased anxiety from scanning repeatedly?

I'll just start and then get the other side. I basically tell people to take a break. I genuinely do I say, take a break, take a pause. This is for you with your life two weeks, three weeks. Fine. We'll chat again.

When you feel comfortable in that space, switch off your alarm. So if we need to, again, we talk about the time in range. We talk about what you're trying to achieve quality of life. And I think it's about the end game. So I always say people have a lot of things.

It's about that whole expectation that's built, which causes the anxiety. Isn't it? Because you're trying to get there. And I think we, you know, that's where we professionals have a role of supporting.

Lets avoid binary messages, context is important

Dr Emma Wilmot:

I was just going to say, and I guess this is really difficult, particularly for some individuals more than others, but do whatever you can to not have an emotional reaction to the number, because you're all trying your best to do, to get where you want to.

I've seen people becoming too scared to look at the number and getting stressed if it's still high.

Diabetes is a beast, an absolute beast. Your job is to tame that beast, but it will do whatever it likes, in spite of your best efforts to tame it.

Even the best technology; hybrid closed loops can't keep those numbers in control all the time. So do not put unreasonable demands on yourself to be able to do it.

Look at the pattern, standby, learn, think what can you do? Definitely, but do not beat yourself up for those individual high glucose.

You know, the readings you don't want to see because that repeated feeling of failure, that repeated feeling of I'm not doing well enough eats away at you overtime and destroys you; you're living with diabetes. If you can find a way to be at one with your diabetes, then you've arrived.

Never talk about testing your blood glucose

Prof Pratik Choudhary:

I was told never to say the word test, and I know a lot of you will have grown up saying, I'm going to test my glucose because when you measure your blood test is not the result of the test. Did you pass or fail?

The point of scanning or measuring your glucose to decide what you're going to do in the next few hours, what action do you need to take any action or not?

 That subtle change from the word from test to measure can have a difference for some people. And finally, of course, it's a long, long, long game, isn't it? One reading of 24 has no impact on your life. It's about it's, it's about zooming out. And when you've got this library of data telling you every minute, but if your time in range is 55 or 60%, you're in a safe zone, you're going to be okay. And those are up and down will even out over time with all the times that you have put in range. So, and that's the message that we need to get out there.

Paul Coker :

Pratik, I have heard you describe time in range as being like a game of golf, would you care to share this with the audience here?

Prof Pratik Choudhary:

Paul is talking about a slide that I've got, and you'll just see on the DTN website that I, that came to me late at night in a bar somewhere after many, many drinks and it’s the only time I've ever been close to golf, which is this video game and this Irish pub in Washington.

It struck me that when you tee off on the golf course, you know, the golfer chooses how hard to hit at which direction, based on the wind and the length and whatever you do it. And that's a bit like you counting your carbs and looking at glucose and choosing how much to take insulin, but even Tiger Woods, the best player we've had for generation does not gets a hole in one every time.

As long as you get it, four hours later, some have between four and 10 half the time. It means your settings, your ratios, your basals are probably the right.

So you know, even if you hit the right shot, something's going to happen between now and three hours, maybe it's activity, maybe it's you didn't finish your meal. That's going to put you down to hyper and be a bit crazy for a while. It's not because you did something wrong. It's because only happened. And even if everything is right you expect that one in three, one in, you know, 30 to 40% of the time, you're going to be over 10, a couple of two to three hours later, and you're going to hit a birdie

When you have to hit an extra shot to get it onto the green? So if you're getting it in range 50% time, that means one of the key things is because you're not quite, you know, it's 50% of time people keep changing their settings and you put your carbohydrate ratio up a bit and down a bit, you, your Basal up a tiny squirt down a tiny squirt and you ended up going round and round in circles. And you're reacting to things that are just different that day, you know one day to the other.

You've got to be a bit reactive, see the measure, the glucose, and react to it.

I would look at your data for a week and then you can adjust your ratios and you get everything perfect.