Getting that knowledge, getting that immediate biofeedback, knowing what, oh, if I eat this, this is what happens. If I eat that, this is what happens. If I go for a walk, this is what happens. If I don’t, this is. All of those things are incredibly powerful and we may teach it, but it’s one thing to hear it and it’s another thing to see it. I completely agree with what you said, And more so with a policy-hat point of view, you’re suddenly going like, oh, this might work, because sounds less expensive than a full year. How would it work practically? Hi, everyone, and welcome to this Diabetes Perspectives episode on decoding continuous glucose monitoring in type 2 diabetes. I’m Alice Cheng, an adult endocrinologist from the University of Toronto in Canada. Primarily clinical, seeing lots of individuals living with type 2 diabetes, so obviously an area of interest of mine, and I am joined today by the esteemed colleague, Dr Partha Kar. Thank you, Alice, as ever, very kind of you. It’s my absolute pleasure to be here with you. And my name is Partha, I’m a consultant in diabetes. I work in Portsmouth, in the United Kingdom. Areas of interest are type 1 diabetes, type 2 diabetes as well, and of course a very important focus on technology, which is in a big passion area. So those are me to begin with. So It’s been a huge progression of the role of continuous glucose monitors in type 1 diabetes. It’s become standard care. Five years ago were talking about: How can we get it to people? What about type 2 diabetes? Does it feel like it’s bit of a neglected sort of side and we need to do more in this area? I think it’s getting better. I think there’s definitely been a shift, as you’ve already alluded to. I think those living with type 2 diabetes who are on basal bolus insulin regimens, people could wrap their brains around: Yeah, absolutely. CGM makes sense. There’s a risk of hypoglycaemia. We should totally do it. Then it became the basal-only individuals and thought, yeah, it still makes sense, they’re at risk of hypoglycaemia as well and it could help. But then there was resistance to the idea of using CGM in those who were not on insulin therapies living with type 2 diabetes. But I think the world has changed. We’re starting to see some randomised control trials in that space demonstrating benefit. And as a Canadian, I’m proud to say there was a recent publication looking at a systematic review and a meta-analysis of randomised controlled trials in non-insulin using type 2 diabetes individuals of CGM and it demonstrated what we clinically hoped to see, and do in fact see: less HbA1c, more time in range, sort of some evidence behind it now in terms of what I think we’ve clinically been trying to move towards. So that’s in the non-insulin-using type 2 diabetes space. That’s very broad. I think there’s certain populations where we would want to particularly think about this. There’s advantages and disadvantages. So specifically, I’m talking about the frail individuals, the older population. Partha, what do you think about them? I think we seem to move away from the population of elderly because we say: Well, what should we provide them? I think we forget that this is not necessarily about improving HbA1c all the time, it’s also about protection, it’s about safety. And I think age is not a barrier. I think frailty is an issue we need to keep in mind. And I think if we’ve got devices that can give us directional trends, that can give us alarms on it, it completely makes sense. Because if we look at the UK data now, what has happened because of this explosion of technology, DKA rates have dropped, but it’s the hypos in the elderly across the board which has gone up. And some of it is because without sort of taking frailty into notice, we are driven by guidelines, which say we need to get better HbA1c control. Well, if you’ve got devices that gives us alarms and just stops you from going hypo, it makes complete sense about what we should do to sort of get people there. And I think that’s where the challenge is as to what we do. Because if you think about it, we’re talking about different groups, right? And it seems like we pick and choose groups which would fit the narrative to begin with. And there sometimes seems to be, are we missing out people? So you talked about insulin, we talked about groups. But then we also have people who are very early type 2 diabetes. Now, anecdotally you’re thinking, look, they’re newly diagnosed early, why can’t they get a device which gives them trends? Yeah, I personally think that’s a great group to be using this. Because if you think about what is the value of CGM, yes, there’s a safety piece which would then apply to those on drugs that could cause hypoglycaemia. But beyond that, it gives you eyes on your sugars, it gives you eyes on your glucose all the time, which then allows one to make decisions. And we say, so knowledge is power, but that’s not entirely true. It’s applied knowledge that is power. But first of all, you need the knowledge to apply it, and particularly for those who are newly-diagnosed or perhaps even prediabetes, so early on in their diabetes career, if you will, getting that knowledge, getting that immediate biofeedback, knowing what, oh, if I eat this, this is what happens. If I eat that, this is what happens. If I go for a walk, this is what happens. If I don’t, this is. All of those things are incredibly powerful and we may teach it, but it’s one thing to hear it and it’s another thing to see it. And then when you see it, and we’ve hopefully taught the tools about what to do with the information and then you actually do it and get the feedback, I mean, that’s incredibly powerful. So to me, I think it’s only logical that it would be highly useful in those earlier on in their diabetes to learn what to do and potentially make lifestyle modifications that result in remission or changes in their glucose for the better. And then there’s also the question which is perhaps controversial, but around: How often does that particular population need to wear this? Does it in fact need to be continuous? Obviously it’s continuous for the lifespan of that sensor, but is it a back to back to back, or could one potentially use it intermittently in order to allow them to learn and then maybe take a break and then learn again and then maybe take a break? I completely agree with what you said, for example, if I had prediabetes or early type 2, I would love to know my trends and I would change my behaviour accordingly. It’s interesting, you talked about intermittent scanning, which anecdotally and instinctively feels right, and more so with a policy-hat point of view, you’re suddenly going like, oh, this might work, because sounds less expensive than a full year. How would it work practically? So if, let’s say I came to you and I had either early type 2 diabetes or prediabetes, what would you say to me? How would it work in that setting? The concept of intermittent use would be to use a sensor, not back to back to back , but let’s say once every two months, once every three months. And the whole purpose is to learn and gain feedback. S,o time points that to me would make sense would be, for example, prior to an appointment with a clinical team and immediately after the appointment with the clinical team. So the sensor prior to the appointment makes sense. You gather information, gather insights, sit down, discuss it, look at it together, figure out a game plan, and then check to see if implementing said game plan actually works. So that would be a targeted, purposeful, deliberate use of the sensor technology and information at set time points, as opposed to continuous back to back to back, doing that and then not using the information, in my mind, is wasteful of the sensor technology. Now, this of course, applies particularly in those who are not on therapies that can cause hypoglycaemia, because in those individuals we’re also using CGM for safety, in which case it does make sense to use it continuously. But for those who are not on any drugs that can cause hypo, the newly-diagnosed, even maybe in a prediabetes situation, that’s where I really think targeted use can be useful. What we unfortunately don’t have is evidence in terms of a randomised control trial or that kind of rigour to back it up. But as you said, I mean, intuitively, clinically, it just makes a lot of sense and I think is something that we need to try to pursue and get evidence for if possible, because I suspect it would be attractive to policymakers and to anybody who actually has to pay money to get the sensors. Now, Partha, you are famous for doing lots of wonderful policy work and allowing people to access technology. And I’m going to ask you, what are your thoughts on that? Is it for everybody? If you go back, I would say, seven, eight years ago, and when GLP-1 analogues came, it wasn’t for everybody, was it? We said, you’ve got to have that BMI and you’ve got to do this and you’ve got to stop it if it didn’t work. We have moved on from that world as more and more evidence is accumulated. If I take my clinical hat off for a minute and I put on a policy hat and people’s normal response is, well, we don’t have money for everything. But I think the whole point of healthcare policy has to be: Where are you investing your existing money to get the best return? And it seems quite natural for us to get there, and I personally believe that continuous glucose monitors in type 2 diabetes is probably a matter of time across the board. I think, what we are doing right now is that I think we are trying to little bit push it down the road. We are asking for more evidence, but I think everybody knows it’s coming, So I suspect as more and more evidence accumulates, it will be more attractive with the shifting price points, and I think from a policy point of view, I always talk about the importance of knowing what’s the coming tide, So I always encourage all policymakers to say if and when the evidence will come, which it will come, and we know anecdotally, patients using it, are you ready to deliver it? So where are you shifting the money from? And I would say that if there is evidence, for example, we talked about hypos, if you are saving that, that can be rerouted back into this early stage. And such a lot of focus, as you know, is on type 2 diabetes prevention at the moment. Well, if we’ve got one more tool to make it happen, while we’re talking about all these diets and calorie counts, et cetera, it can only be a good thing. What will happen is that, because of the more and more competition, I think the price points will shift and that’s what will change the game. And without putting too fine a word on it, what I always say to people when I have this conversation, I say, if you take price out for a minute, just not think about the price, would you do it? And everybody goes, yes, of course we would. So the science is less of an issue, it’s more about how do we do it. And I think it will shift. So we’re already shifting. I think the only one word of caution that I would have, and I’d really value your opinion on this, is: Is it fair to say that we need to be absolutely sure that the CGM we are using has also got the right quality? That not all CGMs are the same. Because obviously we’re getting flooded with the market, which is good from a policy point of view, but from the sensitivity and the specificity, would that worry you that they’re making changes without the validation of the sensor? I think, there absolutely needs to be standardisation or well, standard setting, I think, is the best way to describe it because we are asking people living with diabetes to trust the number and make decisions based on those numbers, therefore they need to meet minimum standards in order, and frankly surpass minimum standards, in order for us to be comfortable using them. So you’re right. I think that’s one of the things that those who make those types of decisions, from a government perspective or approval perspective, regulatory perspective, really do need to have those standards in place so that the clinician, and more importantly, the person living with diabetes can believe what it is that they’re actually getting and feel comfortable actually accessing it. Now, my question to you, Partha, is, I mean, we talked about what about for everybody, and over time we may eventually get there, but right now there are guidances that exist. So tell me about NICE in the UK. With type 2, there’s the NG28, which said that you need to be on twice insulin at least to sort of qualify. And on that segment, we are at about 60 % of the eligible population on it. The problem is when you then look a little bit deeper into areas, just where do you live, there is some area where the uptake is 82 %, which is the highest, and there is another area where the uptake is 24 %. The problem there is the variation within the country and it’s UK, it’s, I don’t know, it’s a small fry compared to the size of Canada. So that’s the situation of UK. So the problem in the type 2 diabetes uptake has been the variation piece. And that’s what we’re trying to get clinical leaders in every area to go like: Why is it dependent on which postcode you live in? What's it like in Canada? So in Canada, we have different provinces. Each province has their own reimbursement body that decides and reimbursement is different. So one has to understand wherever it is that they work. Where I work in Ontario, the reimbursement is actually quite good for individuals who are using insulin without the differentiation of type 1 versus type 2. But then that still leaves those who are not on insulin. And what do we do for those individuals? I think it could certainly get better, there’s no question about it. Our Diabetes Canada guidelines are out of date, like many guidelines are. It takes time to update. We will look to other guidelines from around the world and take guidance from there. So the point that you made, though, about how there’s disparities or differences, I think, a lot of it has to do with us, with the healthcare providers perhaps having biases around certain populations and not offering technology to this person sitting in front of me in the clinic, because I have unconscious biases. I may have explicit biases where I assume they will not want it, will not know how to use it, I assume they don’t want to wear it. So I’m making a lot of assumptions, and assumptions are dangerous. Yes, I’m glad you said that, because I think one of the work that I do is looking at biases within medical staffing or medical personnel, and I think we don’t talk about it enough because we shy away from that. And it’s a very difficult conversation to have with a colleague. I’ve always said medical healthcare professionals don’t leave their biases outside, whether it’s about misogyny, or racism, whatever. So you don’t have a doctor’s white coat and suddenly leave everything behind and that reflects in us. I think it’s important for us to also raise that in a polite way and say, look, this is something that needs to be challenged, because it’s also important that we don’t make that and deprivation the same thing. Okay, explain. So what we say is a lot of people assume that certain communities are deprived and thereby you say ethnicity and deprivation gaps are the same and you go like, they’re not. Because if you look at the UK, actually, some of the most deprived are the north of the country, who are white Caucasians. Now, if you’re saying deprivation is only if you come from the Afro-Caribbean community or the Black community, you’ve now done a real disservice to the white kids. Correct. And I always say that: Continuous glucose monitors, technology, drugs, right? The best one is the one that gets to the person. But if you’re struggling to put food on the table, which is your deprivation, getting a sensor to look at that regularly is not your priority. So it’s that appreciation, which also is quite important. That's the way I would look at it. Slight curveball for you. Do you think we also have biases against people or the elderly assuming things about them? Do you think that’s also part of our problem? Lots of assumptions. Especially around technology. There’s this sense that if someone is older, they’re going to be less tech savvy. They’re going to be scared of technology. First of all, I would not make that assumption at all, because technology is everywhere. You’re going to see people of all ages with a smartphone and playing with a smartphone. And when I say that, including younger people who do not like technology as well. So I don’t think we can make that assumption. I think one of the ways for us to address biases that are sometimes unconscious and that we don’t think about is to have a systematic way of addressing it. In other words, at every visit to every person I will offer or I will have this conversation, then I don’t become that gatekeeper. That is not necessarily appropriate. But I agree with you. I think the older population in particular, there’s an assumption made about not being able to. Not wanting to learn it, but in fact: Completely not true. One other question for you is that: if you had a magic wand and you could change guidelines around continuous glucose monitors in type 2 diabetes, would you sort of turn around and say, forget about insulin, forget about anything, it is diabetes. Would you look at it and go like, that’s what I would like to do? If I had a magic wand, there are many things I would like to do and if I were to choose within the CGM space, I think it would be, yes. If you have diabetes, you should use continuous glucose monitoring with appropriate education that allows one to apply that knowledge. Because the simple act of putting on a sensor will not improve anything. It’s the act of wearing a sensor, looking at the information and then applying that knowledge that actually affects change. Within this magical guideline that I would write, 469 I would not put in it that it has to be back to back to back, but that more importantly, it’s applied. And then for certain individuals where hypoglycaemia is a real risk, then yes, I would say continuous use does make a lot of sense in that population for safety reasons. But I think adding that need to apply the knowledge piece needs to be within it. That would be my take in the magical world. Where do you see us as a diabetes community? Let’s say we’re back in three years time, where would you see this sort of sitting, the whole picture? I think the evidence generation will be greater. I think we will have more, either randomised controlled trials or more analyses and stronger, hopefully, recommendations from the guidelines perspectives based on that evidence. I hope that the price points may be different. The other thing, though, along those lines is, we as a community, I think, need to be prepared to educate effectively and efficiently so that sensors are also not wasted. Because one of the things that can happen, and we see it clinically, is someone puts on a sensor but they do it so they don’t have to poke their finger. Well, yes, that is true. However, if it’s only used like that then we’re missing out on 99 % of the value that’s within the information from sensor-based technology. So it’s about teaching in an easy, understandable way about what to do with the information. So I hope we are further along in that. And teaching needs to be scalable, right? So it’s not just one-on-one teaching, because that’s very time intensive and resource intensive, but taking advantage of the wonderful internet, and social media, and other means of getting that information out in sort of easy bite-sized kind of chunks is something that I hope we get further and further along. But I look forward to chatting with you in three years to sort of see where we’re at at that point. Yeah. And I think I would probably say to all the listeners is that, as we said, there is an inevitability around it and I think we need to appreciate for a moment that if this was our loved one and they had type 2 diabetes or early type 2 or prediabetes: Would we want them to have it? And the answer in my mind is yes. We probably need to do all the work that's needed to make sure that's available to all the population we have, and I think that's where continuous glucose monitors are going in the world of diabetes, full stop, irrespective of type. And at the end of the day, it's something when we talk about fluctuations of glucose and what better way to do it or try and adapt your behaviors or medications based on what you can see. So look forward to that chat in three years, Alice, it will be interesting. Thank you everybody and thank you, especially, Alice, for this conversation. It’s been absolutely brilliant and thank you to everybody for watching this Diabetes Perspectives episode on decoding continuous glucose monitoring in type 2 diabetes. Thank you for your time and goodbye.