Paul Coker (00:00):
Welcome to this workshop on getting the most from your freestyle Libra, the materials we're going to cover here apply equally to all types of continuous glucose monitoring system. My name is Paul Coker, and I'm going to be your host tonight, and I'm delighted to introduce an expert panel. So we have Dr. Emma Wilmot. We have professor Pratik Choudhary and we have professor Parth, Kar, the workshop goes on for about 45 minutes and is just packed with loads of value. I hope that you find it useful and that you enjoy it.
Dr Emma Wilmot (00:28):
And my name's Emma Wilmot and I'm a consultant diabetologist and Darby. And I mainly do type one diabetes for type one diabetes clinics a week. 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, which might be a nice introduction to pre-teach introduce themselves.
Prof Pratik Choudhary (00:51):
Well, I think so. Yeah, so, so I'm Pratik Choudhary. I'm a consultant in type one diabetes in type one diabetes. I worked almost exclusively in type one diabetes for the last 20 years. I used to be in London at King's 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 making people, taking people down to 2.5 mmols/L in an MRI scanner to see what happens to their brains. And in my spare time, I try and run the DTN with them.
Paul Coker (01:22):
Yeah. All. Okay. So for those that are not familiar, that DTN is the diabetes technology technology network. Thanks. PatFlynn thanks for taking on committing crimes. So over to you, part of that. Yeah,
Prof Partha Kar OBE (01:38):
I I'm, Partha, I'm a consultant in diabetes in Portsmouth. Thanks very much for the invite. I didn't know there was an option I'm not coming along, but now that I knew, but no, thanks very much for organizing it or is a pleasure. So yeah, I'm a consultant, as I said, that's my main job. And I also work as national specialty advisor with NHS England leading on technology type two diabetes, et cetera.
Paul Coker (02:03):
So we, we've got a fantastic panel here and I have some questions for you. So the first question I have is what have been the main benefits of Libra and Partha of why don't you tell us about what's going on in the national data?
Dr Emma Wilmot (02:26):
So I can start off by telling you about, so, I mean, we're speaking to people with diabetes, CRR thing, you know, we're preaching to the converted, y'all understand what the benefits are, but 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 order across the UK of no about 15,000 users of the freestyle Libre's. And 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 that your people's HbA1c, just the number of severe, where people needed help from somebody else to treat their hypos. They reduced the number of hospitalizations that reduced the number of diabetic ketoacidosis reduced, and most importantly, diabetes related distress. So feeling overwhelmed with your diabetes, feeling like you're feeling with your diabetes also improved over time. So really useful insight. And the reason we did that was with haired people like yourselves, coming back to clinic telling us about the benefits. And we wanted to capture that in an academic way that needs, you know, sort of policymakers and doctors across the country to really understand what the benefits are, but parts that really 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 OBE (03:41):
Yeah, thanks so much. I think for me, if you take a step back type one diabetes, I've always stuck to a principle that if you improve three things, you'd improve type one diabetes care, which is, you know, better self management, better peer support and access to trained professionals. And I think in a one way, Libra does all three, you know you know, people have always talked about when we had 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 and it's fundamentally, it's 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.
Prof Partha Kar OBE (04:24):
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 (05:44):
So what are the main benefits that you hear in clinic? I guess that's kind of a nice follow on from the quality of life.
Prof Partha Kar OBE (05:53):
Yeah. So I personally, so I'll tell you what I find. And then I think I'll over to Pratik and Emma to give their views clinically. I always, there are few people who will say it didn't work for me. The majority of people feel it towards you here has 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.
Paul Coker (06:33):
So any reflections on lunch? I think the overwhelming
Dr Emma Wilmot (06:38):
Message. When people coming back to clinic and says, this is absolutely life changing, you know, so many people will see that you know, that's what, you know, I'm a diabetologist. I, the way I look at it, my job is to support people, to improve their quality of life. I mean, part of it is see that so many times 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 care that we as clinicians and the demands that we put on you as individuals to manage our diabetes, the NDA make sure like rubbish, we've completely lost the plot. What's the point in what we're doing. So for me, we need to get a balance between getting the best quality of life. You're also, 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 (07:40):
If I can, maybe what I hear in clinic, I think in my head, I think people with diabetes, you know, look at their diabetes from that perspective. And of course we have the advantage if you like of looking at across the board. And I think people in different places on the journey with diabetes might find different benefits. Some people were really close to the edge, working in really tight control. They want to be know what's happening all the time, so they can be aggressive with what their dosing is doing and they can, they can run ties and they get the awareness of hyperglycemia. They can see when the dropping and they can take preventative action. You've got to, you've got a large group of people. You know, the UK average of A1C is about eight and a half percent or in the mid what is that in the mid, late fifties, early sixties and in new numbers.
Prof Pratik Choudhary (08:26):
And 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 values people look at because all the data says that the frequency of scanning maps to how well you go and people were on fingerprints, might do, you know, the average fingerprints was two to three a day. There were a lot of people doing six and seven, but the average number of scans per day is about 14. Internationally, the UK slightly lower about 12 when you look the international database. So the more often you look at the sugars, the more the earlier you find the high numbers and the earlier you head off the lows and it's that, that narrows the thing down and brings the Terminator for a lot of people in that middle chunk that's what's happening.
Prof Pratik Choudhary (09:09):
And then for a lot of people were running really high, who was struggling with diabetes. One of the key things is seeing what's happening and kind of not wanting to do it. And some of those people might occasionally struggle with it, but again, it just helps them. It helps us help them. And I want to make a point about one of the things during COVID that's really transformed the way clinicians work is we've been able to look at people on Libra and, and we've been able to talk about real data. So for years, you know, you might've had the experienced people on the corner of going to the clinic and the doctor saying, well, what's your blood sugars are between seven and nine or between 10 and 12. And I take so many units and then we kind of make these, oh, well, put your lunch time on it by one, or because we never really had that full, complete datasets actually Libra is transformed, not just your lives, but also the quality of advice that we've been able to give to people as well.
Paul Coker (09:58):
That's wonderful. Thank you. So I guess the counter reaction of that is what are the benefits and challenges that you see in clinic of the use of Libra or CGMs?
Dr Emma Wilmot (10:15):
So I can open up with that. So, and I guess one of the things relevant to the freestyle Libra too, which has just come out is alarm fatigue. So that is a fairly new thing, I guess not everybody on the call necessarily beyond. Please tell Libre's too. But as clinicians with experience with real-time CGM, no 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. And so I think having alarms that you find worked for you as an individual, and you're very much would be keen for you guys to be in charge of what works for you rather than having clinicians sets that we might suggest a starting point. That's ultimately about what worked for you.
Dr Emma Wilmot (10:54):
I think the other thing that I feel that some people worry a lot about as a discrepancy between the Libre's and blood. And that's a tricky one because actually even if it's off, but as particularly mentioning, like you've got so much data there and seeing the direction of changing things is almost more important than whether it's one or two millimoles per liter, but some people get so worried about that or they actually stopped using it, which can be a shame. Cause 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 competing at to 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 (11:38):
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. Yep.
Dr Emma Wilmot (11:51):
How many people actually wash hands before they pick their fingers? A lot of people forget is a lot of smiles there. See? Yeah, exactly. It's very true. And also you're on periods of rapid change. If you're rapidly going up rapidly going down, you're never going to get those two numbers. And as you know, being exactly the same, it's just trying to bear that in there.
Prof Pratik Choudhary (12:12):
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.
Prof Pratik Choudhary (12:57):
And that's why we always, in our DTN advice, we say, if you're below six and droping, 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 (13:43):
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,
Paul Coker (14:36):
Any reflections on this one Partha?
Prof Partha Kar OBE (14:39):
No, I think they've covered most of the things. I mean, there's lots of questions, but I think in short, you know, unique, we need to stop be careful that we don't fall into the trap that carries a device, and then we would solve your diabetes. I think that's very important, right. You know w w as clinicians, we need to do that as people living with diabetes. I think it's important that you have, it's a bit like, you know, you get a new car, you need to know how the manuals and how to drive it and how it's going to help your life. So I think those bits are all important as part of it. And I think that's where peer support groups can be so powerful. You know, you, you can, you can share the data and sort of pick tips as you go along. So that's the power of it, I would say.
Paul Coker (15:18):
Yeah. So speaking personally for, for people watching that may not know this, I'm doing a master's degree in diabetes practice at Swansea university. And earlier this year, I had a residential where Partha, Emma and Pratik each did a day on that residential. And we were talking a lot about the use of CGMs and Libra, and I'd been using CGMs in one way, shape or form since 2011. 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 reevaluate what I thought I knew. Okay, what you guys know. And it just 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 for some time, it's worth asking yourself the question, perhaps, and even asking your clinicians, how am I getting the most out of the data that I've got in front of me? And hopefully
Prof Pratik Choudhary (16:23):
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, this about those things that we talked about you know, there's some really simple rules that help you get the most of the data. There's a couple that I I'm sure Emma has her own tricks and partners or his own tricks, but there's a couple of ones that we use a lot, which is, you know, when you're looking at the, 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. And I find when I say that in clinic, you know, cause when you see that trait going up and you see it over 10, it can generate anxiety.
Prof Pratik Choudhary (17:11):
You know, you'd being judged by that line every minute of the day and 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. And, you know, I can see some of them on the screen here. 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 humans, love to work,
Paul Coker (17:48):
You know, laughing. I love your names for the insulins.
Prof Pratik Choudhary (17:54):
Yeah. Never slightly a sluggish it's slightly better, but it still is. It's still gone sluggish, you know, and then we've got, we have, I have different rules about your one hour sugar tells you about whether you injected early enough or not. Your two hour sugar tells you whether you've injected enough or not. And then the three hours sugar often tell you, are you stressed? Have you been sitting for your active or have you got fat protein on it? So there's these things on the, on the DTN website that tell you what the same number of different times post-meal has different value, different actions that you, you, that you, you act on them. And then finding something that I use. I don't know if you've had, I, I say to people that the sweet spot is about 10 scans a day, because you want to be doing scan, inject, eat, forget for two hours, and then repeat.
Prof Pratik Choudhary (18:43):
And the way, you know, a lot of people are scan a lot and you see lots of scans and close together, particularly post meal when they're high or alert. And actually, as Emma said earlier, if you're not going to act on that result, then why get on with your life? Diabetes takes up so much time of your life as it does anyway. And instead of thinking about it all the time, you, you focus your, your activity on the times when that scan, you will 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. And then, so it's 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.
Dr Emma Wilmot (19:24):
I was going to pick up on the whole thing about scanning frequency. You know, I think in an ideal world, you would just, you know, scan Jake eat and lake would be that straightforward. But as everyone on this call knows, there are no two days are the same with type one diabetes. And you might think that what you're doing will go according to plan, but there's huge variability. And, you know, people end up scanning a lot because they don't know what an Eric says coming next. You know, I work, I work day to day and I think that's the beauty of the Libre's being deaf and just reassure yourself that things are okay. And, you know, I've had some people in my clinic that maybe scan the 80 times a day or more, and you think, oh my goodness, that's a lot. But actually, you know, some people get anxious about looking at the data, but actually a lot of people just see, you know, during lockdown it'd been sale or adjust quite like checking in and making sure everything's all key and they find it reassuring. So I, I, I don't think we can be judgmental about what the number of scans per date means. Cause actually everybody's trying to get to the CFO, which is more tape and being good quality of life. I think everybody's got slightly different ways of achieving that.
Paul Coker (20:29):
And what about the time in range? The, the GMI difference to the real HbA1c what was most important?
Dr Emma Wilmot (20:39):
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 an does that mean? China sort of blood tests that you have no control over and it's just going to spit out whatever number is that. So, and I think what we're starting to understand is actually in some people, it's a rubbish marker of glucose control. So people get worried to each frequency is not the same as what the Libre's expect and glucose to be your age, see to be. But actually 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 of our long PDFs. We know have Libre's and continuous glucose monitoring that can directly measure glucose. So I would be more focused on what you're good, cause that's on your Libre's or your CGM, then some blood tests that your doctor is doing. And I'm a doctor seeing that, and I'd also tailor an injured, more meaningful D you can keep an eye on it. 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 (21:45):
No, I love the answer I'm around. One of the reasons that I love it is that for many years, I've been working really, really hard between clinic appointments. Yes, it really got this nailed and I'd go along to the clinic appointment. My A1C had gone up or down, and I just had no way of actually analyzing what that metric was going to be between appointments. And it can get very demoted. It did for me, at least,
Prof Pratik Choudhary (22:09):
Just to point out when there's the difference between your so we know. So there's a couple of things. The first thing is that often when you look at your estimated A1C on your library 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 you go and then something else happens and you have a couple of weeks period, and actually everyone's control kind of bounces up and down a little bit and kind of a couple of weeks periods, what you need to see what your overall the pictures are. That's one of the reasons why your A1C is always different from the estimate. They won't stay on the Libra because they're looking at different times. Maybe once he looks in the premature estimate, won't it two weeks. The other thing is we know that for some people, with the same, even the estimated A1C comes up a calculation, and it's an average.
Prof Pratik Choudhary (22:52):
So we know that for any A1C, your estimated A1C could be about 1% by the side. Okay. But ultimately what you're going to work towards is your time and range. So 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 wants 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. Medication are other ways to drop your risk of complications, but you can't push your glucose any, any lower. So that kind of time and range resume. They want to see when you're treating the glucose. That's, that's the outcome that, that really matters.
Paul Coker (23:47):
Okay. Thank you for TIG. Any thoughts? Partho?
Prof Partha Kar OBE (23:53):
I mean, I think has, you know, they've articulated pretty much everything. What I talk about time in range, and I think, you know, you see people and we, we put too much pressure. I think there's a lot of conversation. If you ask most of the people that come to clinic and you say, so what do you think your levels should be four to seven? And you go like, okay, how far do you think it should have been four to seven? And they go like, what do you mean? How, how much should it be between four to seven? And they'd go like all the time. And then the next thing you go like, well, nobody humanly can do that. So what do you want to do? And I think that's all, it was always a big light bulb moment. People go like what? That's not what I want, need to do the pressure on people that we put because of that is phenomenal.
Prof Partha Kar OBE (24:40):
Because I think then when you say, look, if you look at me, I can't get in between four and 10 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? And I think, 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 I were like, Hey, listen, you get a 50, that's amazing. Four to 10 50. Let's go with that. And we see people coming with denature, whatever age, frequency, time and range, 20% any.
Prof Partha Kar OBE (25:23):
So I think it's about how you put it across, because my approach is, Hey, listen, let's catch up again in four weeks, let's get you to 25. Let's do it slowly. What's the rush. You know, then we get to 30. And I think, you know, when people then come back and invariably, because you've given them some tips, it's not 25, there are 31 and he's delighted and you go like, wow, you know, you've done. Wow. This is amazing. What you've done. Let's, let's now take it to 35. 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 OBE (26:01):
This is all intertwined with each other. Right. so don't try and do don't, don't try and judge people whose lives, you don't live as, that's my simple way. I say, you know, forget about type one diabetes for a minute or type two diabetes, forget about that bit. You just don't live their lives. So you don't know what mental things are going on. You know, whether they have to think about the cooking they have to do, or the shopping they have to do, or mental issues going on, contact them, which is why I said very small targets, but everybody I see, I always go 5%. Let's do 5%. And then invariably, come back with higher. Sorry. It's about how you have those communications. I suspect.
Paul Coker (26:36):
Yeah, no, I think that's, that's really good because when I first got a CGMs back in 2010, you know, I was doing this independently. I didn't have any clinical support for doing it on a, saw my numbers. I'm going to be really aggressive about bringing my time in range up. And before I knew it, I was in the clinic with being treated for retinoParthy because of course I'd improved my diabetes control too quickly. So I think that it's really easy to look at these numbers and say, yeah, I'm going to get that. I'm going to do it really, really quickly, but there's probably a benefit in doing it in a more gradual and controlled method.
Prof Partha Kar OBE (27:13):
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.
Prof Partha Kar OBE (27:56):
So you were like, yeah, have your mango, just, you know, just be careful about how many mangoes you end up eating, because I know my dad just, just me, you know, but that's fine. You know, that's life, how it is and what you don't want to tell him is what is a failure. Right. I think that's the important thing. And I, you know, Bernie has put a really good question. Are we too, are we too strict on ourselves? I'll be unrealistic dancers. Yes. You know, that's the expectation we set. Doesn't sometimes social media sets the expectations and it, you look at social media and you could see these perfect graphs of people and he'd be like, well, that's not happening for me. So what do I do? So I think it's about that. It's about, I think empowering is the word I use, rather than saying, you have to be that if all of us could run, like you said, boats, there wouldn't be a Usain bolt would there. So it's one of those things.
Paul Coker (28:41):
Thank you. I think it brings us on nicely to the next question of how do you deal with the increased anxiety from scanning repeatedly and ever touched on this a little bit earlier?
Prof Partha Kar OBE (28:52):
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 and 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. And I think boutiques or Emma economists said that in a talk, which was about, we have guides, you know, that's all we do.
Prof Partha Kar OBE (29:33):
We've got a, here's a road, you know, we can try and help you on it. So that's what I say. So anxiety is driven a lot by circumstances around you, but people are saying, and you know, we sold it in COVID what was the message? And we tried a lot to try and handle the messages about the message was very binary. Wasn't it. If you've got poor control, you're pretty dead. Right? And everybody's like, okay, this is a bit worrying. And you go like, no, it's in context. So what we want to do, or it's not as straightforward as that. So I think we all have a role. And I think peer support, I talked about peer support, peer support. I've got a massive role here as well. You know, looking after each other, don't put extra pressure on people by saying that if you eat a cost, if you eat a custard cake, your foot's going to fall off tomorrow. Things like that. People need to relax those things.
Paul Coker (30:28):
Any thoughts on that? Mr. Fatigue? Yeah,
Dr Emma Wilmot (30:31):
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. But don't, you know, cause I've seen people start going on scandal too scared to look at the number I'm really, it's going to stress me out. If it's still high, you know, diabetes as a beast, an absolute beast. And your job is to tame that beast, but it will do whatever it likes, the spate Toby, or you try and team it. And you know, as we said earlier, even the best technology that cools loops can't keep those numbers in control all the time. So do not prepare it 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 as four eats away at you overtime and destroys your you're living with diabetes. If you can find a way to be at one with your diabetes, then you've arrived.
Prof Pratik Choudhary (31:39):
Yeah. Thanks Evan. Can I just do small things? 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? You didn't get whatever number you scan. Even if you did everything, right? 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? And so actually that subtle change of changing the word from test to measure can, can, can have a difference for some people. And finally, of course, it's a lot, it's a lot, it's a long game, isn't it? And that 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 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 (32:36):
I think that it brings us quite nicely onto your Gulf model. You describe in the past
Prof Partha Kar OBE (32:43):
Try changing the game because apart from rich people in kind of London, not many people play golf. Can you say something that other people play like games that like normally people from the deprived backgrounds can play. I know you have London and now you're a professor in less. What about things? Games that like Ludo?
Prof Pratik Choudhary (33:03):
Well, actually father someone was talking about why don't we make it beach volleyball. It would visually much better. But then we go, but let's, let's the, an idea that Paul is talking about a slide that I've got, and you'll just see on the Legion website that I, that came to me late at night in a bar somewhere after many, many drinks. But it kinda, I that's the only time I've ever been close to golf, which is this video game and this Irish pub in Washington. But apparently 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 generational whoever's your idol never gets a hole in one every time.
Prof Pratik Choudhary (33:52):
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 basles are probably the right. Correct. And 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 cabaret shows and top counting is perfect. 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 and you've got, is it radio Eagle? What do you call it?
Prof Pratik Choudhary (34:34):
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 carburetor up a bit and down a bit, you, your Bazell up a tiny squirt down a tiny squat 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. And so you've got to be a bit reactive, see the measure, the glucose, and react to it. This kind of mythical thing, I would look at your data for a week and then you can adjust your ratios and you get everything perfect. It is
Prof Partha Kar OBE (35:14):
Turned on that three, take some of the questions, Paul.
Paul Coker (35:23):
We, we go through them too. Do you want me to read them or are you
Prof Partha Kar OBE (35:26):
Well, I've got it open. I can pick a few. I don't know whether I am. I'm pretty ponder to pick a few. I'm going to pick one, which is more about the type two beyond the type one was, I think that comes up a lot. So think we are, we have talked a lot about type one. So I think all the people who are type two on insulin, I think you're absolutely right, because there are lots of forms of type two diabetes and other types of diabetes, which are very insulin dependent, right. And there's no different from that concept about having to procure things. So that is something we are certainly looking into. We are discussing with nice and other bodies to see whether we can move into a space whereby we can expand the use of any noninvasive glucose monitoring further. So that is something, a work, which was certainly looking into we started with type one simply because it was a smaller group and it was definitely people who needed this as sticks, according to every type two depends on the type or the journey you are in. And thereby it's about being the cost detective, but it's certainly on the radar and stuff, something they're looking at. So that's something I wanted to pick up and answer, because I know there was one, a couple of questions on that.
Dr Emma Wilmot (36:36):
Yeah. And the other one that I've just picked up on is a discussion about what the target range for time and range should be. So in 2019 and a bunch of experts on diabetes from across the globe and put together an international consensus and time and range, and they've set the range of 3.9 to 10. And so, you know, there are visuals that would set their own personal range, but when we're talking about aiming for 70% team region, it's okay. If you're above 50% payment rates, we're talking about between 3.9 and 10, but the key thing well about time and range, which I think has fundamentally changed how we approached diabetes management as they also have a target pertain below range. And they recommend that people should be less than 4% table orange. So it's just checking where you're at. And the reason for that is we know that the more hypoglycemia you have, the higher, the risk of having a nasty high point, you might need help from some deals on the longer term, the higher, the risk of losing your awareness on your symptoms. I forgot. So keeping an eye on it and trying to keep it less than 4% is really a solid don't know, particular hypo expert. You might have more to say on that.
Prof Pratik Choudhary (37:46):
And it's, it's linked to why is that 3.9 to 10 picked? And actually it was some really complex math about how they took data from studies that had both time and range in A1C. And we know that the A1C of 7% minimize the risk of complications that maps to 70% time between four and 10. And then we also know that post-meal help to 10 for that initial one. Our spike is within normal ranges. So that's, you know, when you've, for a long time, we've said your premium targets are four to six, but we say that because we know that post-meal the average rise after Wheaton is around about five, five mmols/L. If you start, you meet at an eight you're average wise about the team for an average sized meal to get up to 13, if you start at four. So take that into account.
Prof Pratik Choudhary (38:31):
That's where that number comes from. And there's a lot of really maths that went into it. So that it's not just something that, you know, clinicians drove too. There was a lot of data behind them. It says, this is where the target should say. And for the hyperglycemia again, I think there was less evidence. We're just currently doing a study with 600 people across Europe, where we're giving blinded census to people who were trying to work out, you know, because only half of the events you see on Libre's you would have felt if you didn't have to leave right now, you see it, you know it, and you feel it. And you're, you're aware of them, but actually if you put a blinded sensor on people, they only pick up between 40 to 50% of those sites. And what we don't know is did the other ones really matter if you didn't feed them?
Prof Pratik Choudhary (39:17):
So a lot of these, and we also know, you know, we've been told for the floor with fingerprints, but actually you, nothing harmful happens until you get down below three for a reasonable time. You might feel unwell, but in terms of impact on the heart, the brain or, you know, awareness or anything else that read that time between three and four is actually normal. A lot of non-diabetic people get down there without any negative impact. The reason why we want to cut it at four is because we know the accuracy of these things, isn't that great, but I wanted to make that point that the time between three and four if you felt okay, probably isn't harmful, isn't worrying is the one, the threes for prolonged periods that is when your, your brain function starts to slow down. It has an impact on the heart, you know, potentially. So those are the ones that we want to avoid. So that, that's just a, kind of a comment about the lows.
Paul Coker (40:13):
Thank you. Critique just, just reading through some of these comments on here still. So Victoria is saying I'm type two on insulin with some form of genetic diabetes. I self-fund my Libra to, would there be funding for patients like me in the UK, in the future? I think that's probably one feed for you Partho.
Prof Partha Kar OBE (40:41):
Yeah. The short answer is yes, because I think people, what we have done is that we have now devolved all the criteria down to the local systems and, you know Emma, Pratik, they've all come up with criteria as to where they should be. And we expect all the local systems to have that discussion with their, with their payers to say, our job from the central was to embedded into the system, which we have. And now we would, then we are encouraging all the clinicians to have the conversation saying if it works so well for people with type one wine on wider. So I think it's starting to happen as well. Some areas is already starting where we are as well. So I think that's going to be a work in progress, but no reason not to, as I mentioned earlier.
Paul Coker (41:24):
So Pratik just sent me a message saying that he's got a dash. So I'd just like to say, thank you Pratik. You added a lot of really great value tonight and it's been an honor to host you. Thank you. So wonderful. What else have we got? Some is asking how they'll be able to watch the, this latest. So it's been live streamed onto the YouTube not onto YouTube, sorry, onto the freestyle Libra user groups. So you'll be able to see it in there.
Dr Emma Wilmot (42:04):
There was a comment on there about positive experiences from local peer support groups. And again, that's something I've put out to everybody. So in Darby, a couple of really keen people approached us as clinicians that asked us if we'd support that. So they set up their own independent Facebook page and because it's difficult for clinicians to actively be in the page at the same time, you know, cause it gets a bit tricky, but so it's easier for it to be separate. They set up what we did was hand out cards and clinic. There was no 600 people with type one diabetes and diabetes that are on the same Facebook page. And it means that they've got, you know, before COVID they were a region get togethers. You know, but I've had people, you know, with sort of mental health issues, seeing it's been great to have a place to go that they can feel safe to talk about their diabetes or somebody has ketones in the middle of the night.
Dr Emma Wilmot (42:50):
If you want to get advice from other people, you're all, when there's no other diabetes support services are running over the guy that went to Wembley, forgot his NovoRapid pen and was able to post on the grip. And by magic, somebody appeared with a spear of pain from so lots of potential benefits from that peer support. And if you haven't got that locally, you know, if you had maybe another person, you know, with diabetes or brave enough to set that up and speak to your clinicians about supporting it, I think there's definitely a huge role to play there. Partha I know you're a big advocate of peer support as well. I don't know if you've got anything to say on that. Yeah.
Prof Partha Kar OBE (43:21):
Yeah. We just about to launch a national program because the idea is that we want everywhere to have peer support groups. So we're working with people who already are, have created patient peer support groups as well as diabetes, UK JDRF. So that's a big project we are going to start off on. And we'll, we'll see where it takes us because that's what I want to have. What am I and others have to have that sort of approach everywhere in England, at least I think I've seen a couple of questions about what hap, what what's going to happen with. For example, is the CGM in pregnancy going to Northern Ireland, et cetera. The short answer is it's now nice approved and anybody who want to, you know, we are starting the closed loop work or the artificial pancreas work as well.
Prof Partha Kar OBE (44:08):
I have always said that my job title is NHS. England is not NHS UK, but the plans and the approach and what we have done is available to all the other countries, whoever wants to have it. So we did that with Libra. So that just one thing dimension, somebody mentioned at the beginning of our mail. Now I find it to be people who use as not authorized. We can't officially recommend it, but I have no issues with it. People it's a bit like DIY always say that if it works for you, it works for you. But I think you need to understand that unfortunately is not something we can recommend because of our regulations as professionals, but we wouldn't stop it. Wouldn't take anybody off it that's the way we look at it. And Bernie asks, is it just for the Dexcom with closed loops? Well, at the moment, that's the only one which is available. So commercially I think the habits Libra looking at it by the Medtronic have got their own, which isn't a Dexcom that's their own as well. So you have all the options, commercial options, all of them will be on the table to be used as part of the trial.
Paul Coker (45:17):
There, there was a basic question back in the beginning that I missed and somebody had actually asked for clarification what CGMs waltz. So they've answered that one. Yeah. So it's continuous glucose monitoring system. I think it's worth just pointing out that what we have with LIBOR at the moment is it scans CGMs. And what you're talking about with Dexcom is real-time CGMs and the two are very different, but freestyle Libra is promising to close that gap. So if we got any clue of when freestyle Libra might come along.
Prof Partha Kar OBE (45:52):
Yeah, I mean, I had said earlier that I would like it to appear in this year. And I've said to the company very clearly the door is open. They need to make the decision, but there's no, there's definitely no obstruction from us. We are ready when the company is ready. So we are definitely pushing them. And my position on the negotiation position is that it should come this year because Libra two came at the beginning of this year, I think January. So hopefully by the end of this year, I would have thought,
Paul Coker (46:23):
Thank you. There's a question here from, I think it was saying this like tasting any tips for preventing false alarms from compression lows wearing the freestyle labor to in recommended areas back of arms,
Dr Emma Wilmot (46:42):
No specific tips, other than, I guess everyone knows how do they sleep? And just tried to put it somewhere. That's not going to get compared to if possible, but yeah, that is a tricky one.
Paul Coker (46:57):
Well, when you find the answers to that one, let me know because it's not, it's not just a freestyle Libra, I'm using Dex common. It happens there too. Just scanning film, not seeing any, anything else. I think we're coming to a close on these questions. So for me, any other sort of burning advice, simple tips that you might be able to give to people just to, you know, even if it's just talk to yourself more kindly about your diabetes or or some reflection on, is it possible to get some traces up so they can share them in the group of people that don't have diabetes on a, wearing a LIBOR or CGMs so that people with diabetes can actually see what normal looks like, because we've all been saying you cannot, you're never going to achieve a hundred percent time in range. So what does normal look like?
Prof Partha Kar OBE (47:56):
I think there's some data out there on that one, as far as I'm aware, which, you know are available publicly to say so. Yeah. I mean, that sort of rate makes the point that it's not always possible to do that. So, yeah.
Dr Emma Wilmot (48:09):
Yeah. And just to say as well, that both and I myself have posted the link to the diabetes technology network Libre's modules on it. Your poet puts it as well. Paul, so there's a range of modules on there. I know somebody asked a question about exercise. That's a whole different list of talks at separately, button two of the top leading experts in exercise and type one diabetes have put together a sort of half hour module on exercise and Libre's and provide some really practical, good advice about how, what insulins to change and what considerations, depending on the type of exercise, et cetera. So that's available in the diabetes technology network as well.
Paul Coker (48:47):
Thank you. So and unless there's any last minute burning questions, I'm going to wrap up by saying thank you to Partha and thank you to Emma.
