36: CGM Series - CGM Accuracy, DSN Reality Checks and the Future of Diabetes Technology

CGM Series | The Glucose Never Lies Podcast

Three of the UK's leading diabetes specialist nurses on why CE marking is not a quality standard for CGM accuracy, why data sufficiency must come before device comparison, and what ATTD 2025 revealed about where diabetes technology is heading. A frank, clinical conversation grounded in years of front-line practice — and the story of how the DSN Forum's five-point accuracy scoring system was built.

In this episode:

• Why the DSN Forum created its CGM comparison chart and how it has evolved
• Why CE marking is not a quality standard for CGM accuracy
• How the five-point accuracy scoring system works and what it requires from a device
• Why only four devices currently meet the data sufficiency standard
• What 20/20 and 40/40 agreement rates mean in real clinical terms
• Why everyone using CGM for insulin decisions still needs a working finger-prick meter
• The calibration debate: does the option to calibrate add safety or risk?
• What ATTD 2025 revealed about fully closed loop systems — and who may not benefit
• The case for GLP-1 in type 1 diabetes and why priority access matters
• Abbott's continuous ketone monitor: opportunity, unknowns, and risks
• AID system optimisation, insulin on board, and the GNL AID System Explorer

Chapters:

• 00:00 — Introduction: meeting Amanda, Beth and Tamsin
• 02:14 — Why the DSN Forum CGM comparison chart was created
• 06:47 — Turning complex CGM evidence into a practical scoring system
• 16:23 — How CGM choice works in real clinical settings
• 20:36 — Why finger-prick testing still matters — and the calibration debate
• 29:26 — What stood out at ATTD 2025
• 44:03 — AID systems, insulin on board, and the GNL AID optimiser
• 49:49 — Where to find the DSN Forum, the chart, and closing thoughts

Guests: Amanda Williams (Lead Diabetes Nurse, East Kent), Beth Kelly (Clinical Lead DSN, Wiltshire), Tamsin Fletcher-Salt (Lead DSN, University Hospital North Midlands). All core members of the Diabetes Specialist Nurse Forum UK.

Links:

• Full show notes: https://theglucoseneverlies.com/episode-36-cgm-accuracy-dsn-forum/
• DSN Forum CGM Comparison Chart: https://www.diabetesspecialistnu

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Transcript

SPEAKER_00 0:10

Welcome to the Glucose Never Lies podcast. This is the second in the CGM series, and I am delighted to say I am joined by the three favorite ladies in the diabetes space: the Diabetes Specialist Nurse Forum. So we've got Beth, Amanda, and Tanzim. So do you want to introduce yourself, guys? I'm sure most people know you, but um, do you want to sort of say hello?

SPEAKER_03 0:30

Yeah, shall I go first? So my name's Amanda Williams, also known as Epps in a previous life. And I am a lead diabetes nurse in East Kent. Name's Beth. I'm the Clinical Lead Diabetes Specialist Nurse in Wiltshire.

SPEAKER_04 0:45

Hi, my name's Tamsin Fletcher Salt, and I am the lead diabetes specialist nurse at the University Hospital in North Midlands.

SPEAKER_00 0:52

Perfect. So obviously they're the official titles, but uh usually everyone who comes on the glucosnevelise is a backstory to how the the first time you kind of meet and get along with people, and only good people who are a laugh come on the show as well. But I met these properly in the ATTD, it must have been 2024, around a manufacturer's night out, which was such a good laugh when we were drinking plenty of cocktails. I think uh it was um Espresso Martinis or the order of the day. And then we got into a conversation and we got into a conversation about continuous glucose monitoring. And I guess they probably didn't know that um they had a comparison chart, which is brilliant for comparing all of the devices that were available on the features that they have and the bits and pieces, and me being an absolute nerd on data and things that I was like, you know, I'm missing something on the front layer about kind of whether it's actually got data to kind of thing. It's like, yeah, but it's got C marking, it's got um indications for people. It's like, ah, okay, let me tell let me begin. And then obviously got on my soapbox for a little bit. But I want to take you back to sort of those conversations before that when you were putting your chart together, which is very well received. Um what was your thought process around that? You're obviously trying to provide something for the nursing community to show them about continuous glucose monitoring. So I don't know who's the best person to answer that.

SPEAKER_03 2:11

So the idea behind it was just to allow nurses to understand the differences between the CGMs because there were so many coming on the market with different features. And so we wanted people to know, you know, w how many days does it last? Is it licensed in certain groups, you know, children, pregnancy, that kind of thing, and all the kind of features that go with it so that people could make an informed choice, and also for people with diabetes, not just nurses, to make an informed choice about what the features were that they liked. Obviously, now we know better about the data and whatnot. But at the time, it was a handy chart looking at features.

SPEAKER_00 2:55

Yeah, I mean it still is more than more than a handy chart from that perspective because it allows people to see what alarms things have, like you say, the length of um it's how long it lasts, the interoperability with different devices. So actually, it's extremely useful because if you're thinking, well, we like this device, or these are the offerings that we've got in our area that's on formulary, there isn't one size fits all. You need to be able to understand what's available so you can meet the needs of the people you serve. And I guess then sort of when we had conversations and I sort of said, look, you just can't trust CE marking, not because the devices with CE marking are not safe, just because you can't use that as a like a pass, like you could do with the blood glucose meter ISO standard. So I guess it just sort of sometimes get mixed up, doesn't it? Kind of, oh, something's got approval, so it must have the equivalent to like a an ISO regulatory standard, but with CGM, there isn't anything like that. Um, but you just assume that that was the case. So what was your understanding of, if any, of CE marking at the time, or did you even know what that term meant? I don't know. Beth, do you want to answer that?

SPEAKER_01 3:53

Yeah, I mean, I think we knew what CE marking meant, but I think the other thing that we had is MARD, and I suppose at the time that was a new term to DSNs and that like CGM, we were all learning about it from you know its sort of existence in the NHS. So I suppose we were all working together as DSNs in 2018 when it kind of blew up. So we're all learning from then and having to just pick it up as we went along. So I would say CE marking, I think we're all kind of used to that because we're used to general things that we buy and understanding CE marking and stuff. But I suppose Marge was the other thing that came in, and we thought that was a trustworthy thing to put on the chart. We were looking at the Marge, you know, all the training that we do with companies, a lot of that was based around the MAD, and we were told a mod of this is really good. And so we were like, great, okay, we got our heads around that and just about understood it. Um, and then, you know, suddenly more and more of these things are coming to the market and you're just flooded with it. Um, so when we met you, and yeah, we had an education fairly quickly, didn't we?

SPEAKER_00 4:56

Yeah, I guess yeah, I mean the thing is you you'd join the point where I think I've been three years deep into the weeds of actually getting to the bottom of C marking and understand what it meant with CGM, and to find out that people could come or manufacturers could come into our office where we have kids from the age of two, have a device that's approved for insulin dosing, yet the only data they can provide you with is for people with type 2 diabetes at adults, and I was like, like this, just like the disconnect was so massive. I was like, that's got to be like this, this can't be right. But then when there's three or four other companies, you're like, this just is not okay. It's just not okay. So then I think from that point I was took a deep dive within there, but then when you've got the knowledge yourself, it's then kind of like, how can you explain it in a simple enough way? And it's really difficult because it's really complex in terms of study design and things that most people, number one, don't want to go through the pain of understanding it all. And also, number two, is like, how do you develop something that can be instantly recognized as okay, fair enough, then that's that's kind of good enough. Uh, and I guess that's the journey we set out on together to kind of go, okay, so let's put a front end to this chart because we know that CE marking alone is not going to be a clear indicator. We need something before you get to the features to say you're only allowed to look at the features if you've got data that's good enough for understanding the risk of insulin dosing, and then you can have a look at the features, but you've got to get past the first thing first, and then we said, okay, let's put a chart at the front of it, and then that's where the three o'clock in the morning started for about for about two weeks straight, trying to work for you everything.

SPEAKER_03 6:37

We were just getting messages at five, maybe, yeah, when we wake up.

SPEAKER_00 6:43

It was really interesting for me because I had all this knowledge in my head and I was like, how do we distill this into something that most people working on the front line are going to understand? And that's where it was amazing to kind of have a sit down with yourselves and go, does this make sense? He's like, nope, like that's that's like way too complicated. It's got to be simple. And I was like, What about this? He's like, no, no, it's still too complicated, it's got to be simple. It's like, okay, I'm gonna have to proper challenge to get it as down to five things that we could do, but then we eventually got there with a grid of sort of five, and then we had a simple score at the end. And I guess you kind of didn't even need to know what the criteria were in some ways, as long as there was trusted people such as yourselves and the diabetes nursing community, obviously, myself involved in the CGM accuracy, strong enough voice to say, look, this is just simple enough for you to kind of get a good understanding, which I think we sort of achieved towards the end. So Beth, you've got your hand up so you've obviously got something to say about that.

SPEAKER_01 7:33

Yeah, I was just gonna say, I'm just interested, obviously, your dietitian, we're nurses, like how much actual sort of research-based education you get in your undergrad training. Because this is something that we raise quite a lot as nurses, in that we don't have much education in how to read research, how to read studies, how to understand all of this, like population design, that kind of stuff in studies. So like you said, it's trying to get that understanding of make make that sort of stuff accessible to nurses, which is I suppose what we've tried to do with the chart now and make it a lot easier. But I think something needs to be done about uh, you know, these professions coming through, and we really need to be able to not just trusting what was put in front of us, oh, that must be fine, but actually asking these questions and understanding and analysing data and things because I don't I don't think it's something that certainly in undergrad training you're taught at all.

SPEAKER_00 8:25

So yeah, I'd I totally agree with that. I guess from my perspective, because I've been on the other side of things, I know what it's like. So I worked for a a medical device company for five years, and it is very it's like on that side of things, like when you're on the sales end, you get sold to you from the people above you. We've got this great product, this is the data, this is how you're gonna go out and sell it, and this is sort of the study design, but they only tell you the good stuff. But because I'm a really nerd nosy and nerdy, I used to be like, I don't think that's really true. Actually, I think that there's a bit more to it than that, and used to hate that because like it was trying to sell a story to the employees to kind of go out and you know, this is how we sell it and it's all rah rah rah rah. I was like, Yeah, I don't think I'm gonna go into that consultant and say that because I know I'm gonna get torn to pieces because that's like on dodgy ground. Um, so I think there definitely needs to be within the education just to just I guess you have critical appraisal training, but a little bit more on it, especially with relevant things that you use, because no one wants to learn research design, it's so boring when it has nothing to do with what you actually do. But around CGM it's pretty important. So I don't know, Tamsin, when you were seeing that chart come together for the first time, we're thinking about okay, how many people with type 1 diabetes, what percentage do we do in low and high, and have they had meal and insulin challenges? Had that ever been discussed with you by any of the companies coming before? Or was it just like a we've got this new product, it's got a mud less than 10%, and actually we're cheaper than this, and we've got this, and we've got you a nice lunch, and you know, kind of, oh yeah, we really love you, blah blah blah blah. Is that kind of like how it used to go? Or did did kind of how did your meetings used to go?

SPEAKER_04 9:58

Pretty much 100% the the the latter. And like Beth said, I think that nurses aren't particularly taught to necessarily question people that are coming in like that. Maybe because it's as a ward nurse, you don't tend to see those kind of people, you don't see reps really on wards, do you particularly? If you do, it's because they're coming to train you on a new piece of equipment that the trust has already purchased and and they've gone through all of that process. So they you're you don't have that need to question why we are using that. Whereas I think as a specialist nurse, you should be doing that, but actually you've come from an environment where you've never done that. So how do you learn to do that until somebody says to you, wait a minute, why do you think that device is good or why do you think that medication is good? So yeah, I think it was, as as I think as as Beth and Amanda said, it was a bit of an eye-opener because obviously we'd we'd looked at the features that were useful in a sense, useful for us, useful for patients, but actually we hadn't delved deeper into actually was that device actually, you know, the was the data there for what they were selling it for, which is obviously insulin administration, isn't it, in the in pretty much 100% of cases?

SPEAKER_00 11:21

Yeah, I mean definitely. I think that's the bit that's um it's really tricky because I think once when it used to be when we had the Freestyle Libra One and we had the even the Medtronic and the early DEX comms, it was always a confirmatory finger prick to make the the like the actual insulin dose. Now, whether people decided to do that or they didn't, that was their choice. But the reality was that's the way it was taught, that's the way it was indicated for. But when it made that big leap to no longer need a finger prick and it's straight to insulin dosing from it, it's amazing. It's absolutely like one of the best things in the world for people with diabetes, but it also then the risk level goes from you get taught that actually good fingerpricks are that's the gold standard, and you can really trust that. We're gonna say now that you can bypass that and go to the CGM. It does take the risk level because you're getting these readings all the time. If you have significant errors for a long enough period of time, the consequence is very dangerous. So the level of data that you require then also should scale with that in terms of safety. It's a little bit like if you had a medication that was doing something benign and all of a sudden it was doing something that was very, very risky. You would have expecting randomized control trials, like safety and efficacy studies and things like that. And these things are adjusting insulin doses, which arguably is one of the potentially the most dangerous self-administered medications. Yet you can have get an indication for a kid from the age of two with data on adults with type 2 diabetes. Like the mismatch is just it's so wild that it kind of it sort of begs belief. And the early players within the market never did that. There was never a discrepancy between the data that they have and what indications they have. But all of a sudden, there was just overnight in 2019, four companies rolling out with in insulin indications from the age of two with data, it was just like a tumbleweed, but then expecting you to go, well, and I remember one of the reps said to me, He's like, Well, why don't we just try it? Why don't we just try it a couple and see what it's like? I said, if it was your kid, would you try it? Would you be putting your kid's life at risk of taking an insulin dosing because we think it's good on adults with type 2 diabetes? I don't think you will. So, like, don't come in and say, just give it a go. Like, you need to be a little bit more, have a bit more to do with that. So I had some interesting conversations over a few years, that's for sure. Um, but yeah, I mean it's been it's been interesting to see how the chart has progressed. So we obviously released that first chart, which was really well received and I think helped a lot of people get an understanding that maybe CE marking isn't what it says it. Well, it's not what it says it is, it just isn't a quality standard. So that kind of brought the conversation to light, and that was seemed like it was we'd got everything covered, but then there was a bit of a loophole within there in the fact that you could get a score of five out of five, but we didn't have an amount of data that you would need. So you could get a five out of five with as little as 10 people in the study, or as many as 300 people in the study. So that's kind of when the we made an upgrade to the chart in this sort of January and sort of said there has to be either at least 50 people in your study, or if it's going to be as low as 40, the number of data points that you have has to be really high for us to kind of be trustworthy, which is kind of like the final, I guess the final piece of making sure that the quality of the data is good, but there's also enough of it to make sure that the accuracy that we find from it is fairly generalizable for to more than just a few people. Um, and that obviously took it down to what, four main players, which was Dexcom, Abbott, Rosh, and Medtronic. Yeah. So they're the four that are currently on it. But I do have to say I have seen off the record data ATTD that there'll be two other people, two other companies very soon in the next couple of months that will be joining that, which is fantastic. But like anything, yeah, the data has to be published first. And the way that I see it, it's a bit like catfishing. You know, kind of someone shows you something on the internet, a picture of them, and you're like, Are you sure that looks like you? And you see him in real life, like, God damn, you've put on 50 pounds since then. So I need to I need to see the real thing first before I'm absolutely going to change the chart. But it's it's also encouraging, I think, that it's pushing companies to say, okay, there is going to be a basic bottom line standard that we're going to have to meet. And I think the chart that that well, that together we've managed to put out there has really helped people, you know, at least get a baseline sort of sufficiency from there. So I guess with that, that kind of charts where where it's at. We've got four main players, two about to join, and then that becomes the better question of, okay, now we've got this understanding, what do these devices actually do? And that's where the chart really comes into play. So you guys work in different places. You've probably got your favorites, or maybe that's on formula or whatever. I'm just interested, do you use in a range of them? Do you use some of them more than others? What kind of drives the CGM choice in your in your particular area for the patients that you see? So take in whichever turn you want. Like Amanda, do you want to go first?

SPEAKER_03 16:18

Yeah, so I think it's it's it's quite tricky. People get their favorites, don't they? And they kind of stick with what they know. The two main players are probably Abbott and Dexcom that people are used to using. I think Abbott probably more so. And so I find that nurses I work with will just use that and they won't even look at anything else, even if it's got different features that might be better for that patient. They won't even look at anything else because they're used to that device and they're used to all the features, they're used to the platform, they used, they know how to set it up, yeah, and and they can be quite reluctant to use other devices. So I do feel quite sorry for for CGM companies coming in, new CGM companies, because I think they've got their work cut out for them to kind of get into this market.

SPEAKER_00 17:03

Yeah, so in your areas tends to be sort of more Abbott-based, but then you've obviously got, I know you do a range of obviously hybrid closed loop systems, so presumably you've got some on the Medtronic centers, obviously some on the DEXCOM as well. But Beth, you've got your hand up, what is that similar to you, where? Or are you slightly different?

SPEAKER_01 17:17

I was just gonna say it is pretty similar, and I suppose I'm in the community, so we do a range of bits and pieces as well, but I would say a lot of the kind of we're trying to get primary care a bit more upskilled with CGM, and I would say they're quite reluctant to try other things as well, because I suppose ABBA have got the largest market, they've used that the most. They're very reluctant to use other platforms and have other logins. Um, and we kind of just have to deal with it because we've got things that work with different pumps and that kind of stuff. Um, but yeah, I would say similar to what Amanda said, it's we try and do it based on what the patient so I would always have a range on the table and say this is what's available, um, and obviously let let the patient choose a make those decisions. But yeah, similar as Amanda, really.

SPEAKER_00 18:04

And you sort of obviously a range of things, then if you felt like there was a a particular feature or a particular set of alarms that would be useful for that individual context, you would kind of like, look, this is you know, maybe the one that's kind of got the most benefit for you in that that case. How about you t how about you, Tamsin?

SPEAKER_04 18:19

Um, yeah, we're we're one of the ICB outliers that doesn't have uh CGM on uh policy for type twos.

SPEAKER_02 18:28

Okay.

SPEAKER_04 18:29

So at the minute we tend to use Libra, I would say for I think they've got like 87% of our market when it comes to type ones and some type twos, because obviously we we were prescribing at some point, but then we have had to stop. Um Dexcom came in a bit later, didn't they? And I think that they just have not got cut, they just haven't been able to get a hold of the market really, uh, because Libra is definitely there. Um and then we, although Libra 3 is obviously um on FP10, we're not allowed to prescribe it on FP10, so it goes through supply chains. So all the other CGM, obviously DEXCOM, G6, G7, Libra 3 Plus, all go through our supply chain. So that's the only way we can supply them. So we would only supply those for pump patients, really. And then I believe uh that pair cents have just gone on for us on Formerie in the last few weeks. So obviously, I am waiting for that data to come through to see uh whether it'll get the it'll get the score to get on the chart. So uh so yeah.

SPEAKER_00 19:38

Well, if if if what I've seen comes out in the literature, I think you'll be fine. I think there'll be about a five pretty soon. So it's so interesting to hear you guys say that because you've got different experiences obviously in the community. A lot of people with type 2 diabetes. I deal exclusively with people with type 1 diabetes, obviously, and we don't really have an issue because it just kind of comes from the hospital as opposed to FP10. So we get to choose kind of what we want as such, and most of ours have historically been on DEXCOM, um, mainly for the reason that you can get optional calibration, particularly for school kids, because you obviously teach if the kid feels different to what they're saying, do a finger prick. And then if you've got a discrepancy, you need some way to be able to close that discrepancy because teachers do not like ambiguity between well, what do I do here, what do I do there? So for us, it obviously that's really helpful. But I can imagine for adults who don't really test the glucos level that often, it's like it's it's that's not really a big thing, but it's just so interesting to hear. Well, no, serious on a serious point. And this actually comes to the 2020 and 4040. It's a point that I made and often made really well in the last one, is kind of like look, uh the 2020 performance, which is basically if you've got a the percentage of readings in 2020, there that's a percentage of readings that would do absolutely a fantastic decision. You will not make a bad decision there, and all those current CGMs are anywhere between 90 to 95%, so pretty much exclusively very, very good insulin decisions. And then the percentage of readings above 4040, which is way out, which is like more than 40% out, where you're going to make an error with either an insulin dose indecision or a hypertrank is somewhere between half a percent and one percent. But the key thing about that is if you never, if you never test your finger prick ever with a CGM, it means that that 1% of the time poses a really big risk for you because like a lot of people with diabetes know, like it looks like they're low and they know they're not low, so they just ignore it. But you keep doing that all the time. Occasionally you are going to be really low and leave yourself in a bad position. Similarly, if you're kind of like you're high and you don't really think that you're high, or you're in target and you feel a bit higher and you don't occasionally check, you could run into DKA, and we've maybe seen a bit of that recently with some of the instances and some of the large profile things. I just feel for me personally, I feel like CGM's pushed us so far forward, which is brilliant. We've got a hundred steps forward. Maybe with educational. We just need to take half a step back and say, half a percent of the time you are going to get a reading which is going to be out. So having a finger pricker with you in those instances is actually really important. It's almost like, especially if you come into diabetes nursing or diabetes education now, it'd be like, these CGMs are so amazing. Like you don't need to finger pricks anymore. They're more accurate than finger pricks. That's actually bollocks. That's not true because the ISO standard finger prickers are 95% within 15-15. They are miles more accurate across the board. Now, are they as useful? Hell no. But I almost just kind of feel like from an education perspective, it really does need to be drilled in. You've got there is the occasion on time where you need to finger prick. And if you don't have one with you and you never have it with you, you are going to be putting yourself at an unnecessary risk. So I don't know what you feel, what do you guys think about that? That's my position, but I'm just interested to see what you think about it.

SPEAKER_03 22:47

Yeah, no, I totally agree. I have done lots of even with pump patients who you tell them to have a ketone meter to make sure that they can check ketones as part of the sick day rules. And so many of them don't have working ketone meters, don't have working glucose meters, don't have in-date test strips, don't even have backup insulin pens a lot of the time because they'll let them go out of date. So people have got so used to relying on the technology that they are putting their health at risk, I think, by not having all these backups.

SPEAKER_00 23:20

Yeah, yeah, Tanzin, what's what's your position on that?

SPEAKER_04 23:23

I I I'm probably quite controversial, and I actually say that I am quite sad that calibrating of CGM is not seen as, you know, a good thing, really. Everybody, everybody took away calibrating, and this was like amazing. We took away calibrating factory cali factory calibration and all that malarkey. And I actually don't agree, and I'm and I know I'm in a mina minority about that, but I just do not agree with that at all. And I think that you should be able to calibrate your CGM or even actually be forced to calibrate it at times because I do think that people rely on it. I mean, I had I had a gentleman, he was a police officer who was a very intelligent man, and he looked at his CGM, his CGM said he was high, he gave himself insulin, and he was found in his garden by a neighbour, and they had to call 999 for him. And and it just goes to show it it doesn't it doesn't matter how clever you are or intelligent you are, you become reliant on a figure that is coming through a device that can go wrong.

SPEAKER_03 24:35

The issue is the issue with calibration is that people don't do the finger prick to calibrate it, they'll calibrate it with the sensor glucose. So my son, I know for a fact, does not do a finger prick when the uh Simplera asks him to check what his blood glucose is, and he literally enters exactly what it says on the sensor to calibrate, which is totally pointless, I know, and really dangerous. And I keep telling him not to do that, but people are lazy and they will do that. So what's the point in having a calibration if they're just gonna calibrate it wrong?

SPEAKER_01 25:09

Yeah. I do tend to agree. I did like the calibration, and I did, you know, a lot of patients now see that as a negative if they have to calibrate. I know when we had the smart guide, the Roche Smart Guide, I was like, oh, it's it's quite nice to be able to calibrate it in the first 24 hours or whatever, because you can actually be sure that it's you know working. Um a lot of that comes from, you know, like Amanda alluded to, that people I think there still needs to be more education in primary care that, you know, but people are having that stuff taken off of their prescription because they're not using it enough. Certainly in adults, I I doubt it would be the same. I hope it's not the same in children, but in adults they have keto strips removed because they haven't ordered them in six months, or they have glucose strips removed because they've got a CGM and they have this. So a lot of that relies on those healthcare professionals in those healthcare settings, having that education and you know, not taking that stuff away, making sure when they are doing an annual review, have you still got a meter and all that kind of stuff? Because all that back to basic stuff seems to be uh being forgotten about or left behind, and it does still need to be there for those safety reasons, and it's always that one time when you least expect it, isn't it? You know, you're on holiday and you haven't got anything or whatever when you really need to be able to calibrate or something that is gonna happen.

SPEAKER_00 26:25

Yeah, I think I I think I think it's really interesting point, and I don't think there's a a right or wrong. Obviously, this we've got a two for two here. Me and Tamsin are on the calibration we're training used to be kind of like, no, no, that's yesterday's news. But I think I think we'll regardless of whether you we whatever position you sit with that, one thing we're all saying is you need to have an indate meter, you need to have indent strips, you have to have in the back of your mind that 1% of the time you are going to need to do that finger prick. And people with diabetes know, like they'll look at the thing and they're kind of like it just doesn't smell right. Like, there's no way it should be there at this point. That is the time where you need to go, do you know what? I just need to do a finger prick. And thinking about your man who'd given that big dose of insulin uh on the high reader. I'm pretty sure when he looked at it, he probably went, it's unlikely that I'm actually 15. There's nowhere I should be 15 or 16 at this point. That's the time where you just need to do it and be like, okay, you know, kind of. And I think that I also almost like the lost art of finger pricking and testing. It's like wash your hands properly. And if you are gonna calibrate your machine, you have to be nerdy. You have to be like, I want to wash my hands properly, I'm gonna do two finger pricks, I'm gonna take the average. Because if I chuck a random number in, it's gonna mess the whole thing up. So there is that to chuck in, and also like people just calibrate based off where the sensor is, that's fine. So there is a kind of a bit of a skill and an art to it, and I guess that's where you know, if you've got a machine that does give the option calibration, you do have to do a proper finger prick, wash your hands properly, don't squeeze it to death, milk it up, and you know, kind of do do two if you're gonna calibrate your machine. Um, but yeah, it's just interesting. I think given recent events and given that we are making insulin dosing decisions and that there's more players coming to the market with different levels of quality and and different levels of data. I think as a as a diabetes community, it's probably just a little note to go, okay, needs to have a finger pricker, need to have a glucose testor in you know, in date, and occasionally I will need to do it. It might only be twice a month, but that twice a month might save me a situation like Tams and described and or that other people have encountered. So not saying to have a fingerprint every day, I'm just saying, have the ability to do. So I think we've done that to death. So we've talked about you need a five out of five. We talked about we've got four players, we're soon gonna have six, which is great. And we talked about 2020 and 4040. So we've kind of covered the basics, and if people want to kind of know more, they can go and check out the charts. So that's kind of like CGM where it's at now. But we've all just come back from the ATTD uh and had various different experiences. Some people saw more talks than others, some people did more partying than others. Uh, we won't see who that is, but I am I am interested because people who'll be listening will be thinking, like, okay, so the ATTD is where things happen, it's where the latest information comes out, it's where the future is kind of being put in front of you. What are kind of maybe your one or two things that excited you or you found interesting, or you may think for the future this thing's coming up is is really what you're excited about.

SPEAKER_03 29:21

Um, the biggest thing that I saw, um, which we we all went to was the mini med flex fully closed loop pump. So that looks really exciting. They don't want us to say it looks like a vape. It doesn't look like a vape. It looks like uh a pen. Okay. A lipstick. A lipstick. So it's yeah, it it means that the person will not have to enter the announce their carbohydrates. That's a that's a game changer. So it's had FDA approval.

SPEAKER_00 29:56

Okay.

SPEAKER_03 29:58

You know, we're waiting to see how long it's gonna take to get over here.

SPEAKER_00 30:01

And and what was the sort of presumably they did a test against their current standard um system where you're entering stuff in, or did it just present the results of what it achieved in general? What kind of timing range percentages were you looking at?

SPEAKER_02 30:15

I don't know. See, this is where we don't look at the data. We just saw it was fully closed loop and we just went, oh my god, that's amazing.

SPEAKER_04 30:24

I I think no, no, I I did I did listen to be fair. I think that when I sat there, I and I was and I was listening to them, I did think, hmm, they're telling me all the data from people who are are probably not doing well on a hybrid closed loop. So those young people that perhaps are not bolusing, not pre-bolusing, not announcing carbs. And actually for those people, it did improve their timing range and it did improve it like by quite a significant amount. It was like something along the lines of like 15-20%, which is is significant. Yeah, but I would say, and I asked this of my life because I went to the My Life presentation, um, and obviously they have got a fully closed loop system called Liberty, which is coming very, very soon. And I asked the same question to Roman Havorka, and I said, if you've got somebody that is actually doing really well on a hybrid on a hybrid closed loop pump and they want to go onto a fully closed loop, are they going to get a reduction in time in range? And they were a bit cagey, I will say, because they wouldn't sort of give me an idea of like a percentage drop, but he did say almost certainly they will get a drop in time in range. If you are at 80 plus time in range, you are going to get a drop, which I think is fine, I suppose. If, for example, you're going on holiday and you've got a good time in range, and actually you want to go on holiday and you just want to relax and not have to count carbs when you're at the buffet and eat what you want, drink what you want, and let the pump do its work for two weeks, and then you come back home and you start announcing carbs again. I think that would be okay. And but yeah, I don't know whether and I think with the and also he was saying with the fully closed loop, you can still announce carbs. So you can announce and not announce, and it will still, and obviously it will still try and do its thing. So, and we know the my life algorithm is an exceptionally clever algorithm, so and I'm and I know that they'll be working on it all the time in the future to get it better and better all the time. So I think I think it's an amazing starting point because who thought even maybe five, six, seven years ago that we would be at fully closed loop so quickly from being at hybrid closed loop, to be honest.

SPEAKER_01 33:00

Yeah, didn't you ask Roman that question? And he was like, I never thought I'd see it.

SPEAKER_04 33:05

Yeah. He said he thought it was going to be too difficult to actually do it safely without causing more hypos. So I think I think I just think it's a really exciting time in diabetes, isn't it really?

unknown 33:16

Yeah.

SPEAKER_00 33:18

So do I was that yours as well, Tamsin, or did you have another one lined up, or was it were you on a fully closed loop train as well?

SPEAKER_04 33:25

I was, but I also we also, Amanda and I went to the um type one and GLP one uh consensus, which was like a really early morning. We we had to drag ourselves out of bed really early on a Friday morning to uh go to the starting. Yeah. Um I mean they I don't know, I don't feel like they actually did come out with a complete, like it said it was going to be a consensus, but they I don't feel they came out with a consensus as such. They just showed that in America they were using it a lot more, obviously, than we are in the UK, and how they were sort of managing putting people on it. So a 20% reduction in insulin right from the start, not really going beyond 7.5 or 10 milligrams. That was probably the maximum they were doing. Um, yeah, so but still getting the benefits, but also making sure that you were aware of the risks of the fact that people were having a much um more reduced appetite, so a higher risk of ketosis and things like that. So it was interesting in a sense that obviously America had got a lot more people probably than we do. So hundreds and hundreds of people in in one centre, they'd already tried GLP1s on. So um they've got they've got the evidence base, which hopefully supports us down the line when we try and do it in in the UK, because we know that people living with type 1 diabetes have nothing out there really to help them with weight loss. So that was quite interesting.

SPEAKER_00 34:53

I mean, yeah, I've got to say, from that point of view, I'm miles more excited about GLP ones than a fully closed loop. I mean, I think the fully closed loop's okay because all they're good doing is they're creating an algorithm. As soon as they see the glucose level start to rise, it's super aggressive, super, super, super aggressive, which is great until you've got a load of insulin on board and you actually want to move around and not sit on your ass all day, and then you're gonna be in trouble because then you're gonna go low. Like that's just the way that I see it. I also see that if you're currently doing well on a pump and closed loop, why are you gonna go to a fully closed loop and take a hit on the timing range? I just don't see people doing that. I think it'd be great for the people who are don't bowl us, who are struggling a bit with a HVMC still, of like, you know, 8.5% and 8.5, 9% on a hybrid closed loop, then that kind of aggressive algorithm to me makes total sense. But I don't know. I just think it's a bit more, it's a bit more marketing than reality for me in terms of what difference it all makes. But GLP ones on a different level, like I had Viral Shar on the podcast and he was talking about the difference that it's made to their patients, mainly from a weight loss perspective, because when you've got type one and you're shoveling in one 1.2 units per kilo, weight loss is just impossible. Whereas if you take this thing and you get your units per kilo down to 0.7, 0.8, all of a sudden you got a chance. And he was saying, like, the postprendal control is amazing, the weight loss is like brilliant, and the pit the people are loving it because they're able to actually finally lose weight despite trying like really hard before. So I I am really looking forward to seeing people in getting the opportunity. I know quite a few people, loads of people actually type one. I've tried I've used it for um a portion of time just to see what it did to my glucose levels and insulin dose, and straight away 30% reduction um in insulin doses and much easier post post-meal control. So I'm I'm definitely excited to see, hopefully, at some point in the future, people with type one. And I actually think that people with type one in some ways deserve it more than anyone. And the reason why I say that is you're putting insulin from the outside from a very young age, your chances of weight management are really it's really hard. It's really, really hard. So to actually, if there's anyone who deserves the opportunity, if it's going to be a cost fight, if you're overweight with type one, I feel you should be personally allowed the opportunity before people maybe who uh haven't been putting insulin from the outside all their life because you've had it harder for a longer period of time. But I guess that's just my personal bias from there. But I'm excited for that. Beth, what's yours? Um what was your highlight?

SPEAKER_01 37:20

Yeah, I suppose thinking with my community hat on and maybe giving something for any type 2 people that might be listening. Um, I quite enjoyed the session about using hybrid closed loop for people with type 2 that need to get started on insulin and getting them titrated up really quickly to get their dose because it's an age-old problem that we all really struggle with titrating people up. It takes weeks and weeks and weeks, I think the data showed. Can't remember, can you remember times what it's something like a a year or something plus to actually get them to their basal, their right basal dose? And so they were putting people on hybrid closed loop, and in about two to three weeks, they'd got their basal dose right, and then they took them off the hyper closed loop, but it cut out all of that faff of a nurse ringing them every week, going, yeah, go up by two units, go up by two units every three days. And there's a lot of inertia, both the patient doesn't want to do it. If you try and ask them to do it for themselves, they often won't. They rely on a nurse ringing and then a lot of nurse time, primary care again. Certainly in my era, I know Tamzin has the same problem, primary care don't touch insulin. So a lot of DSN time is spent just ringing these patients, going, go up by two units. And so cutting all of that faff out, getting them on the right basal dose for them, I think within like three or four weeks, they said was pretty astonishing and could really help improve not only for the patient, their outcomes and stuff, but also cut down on the time spent for nurses needing to ring them. So that was quite exciting. Again, I'm not sure how how easy that will be to actually do it in clinical practice. I can't see it yeah, being something done. But I just thought it was a really interesting concept, and if we ever do get there, then that'll be quite an exciting thing. Um, I was concerned that they didn't mention anything about retinopathy and anything like that, or if they had those kinds of people in the their population. But yeah, I thought that was quite interesting. Quite excited as well about the ketone and glucose CGM coming out from ABBA. That'll be a bit of a game changer, I think, for certain patients. Obviously, not for everyone, but for patients like frail elderly patients in the community that are district nurses are going out to see them, that could be really helpful for those sorts of patients because again, we're getting lots of phone calls to DSN services every day about do I need to check their ketones? Do I need to do this? Um so that would be quite helpful, I feel.

SPEAKER_00 39:39

I do worry So you're you're gonna have ABBA and the punk companies knocking down your door. Brilliant.

SPEAKER_01 39:46

Yeah.

SPEAKER_00 39:46

Yeah, the ladies are seeing.

SPEAKER_03 39:48

I do worry about the continuous ketone meter for people with eating disorders and who are, you know, manipulating their insulin to lose weight and and having that yes, it might keep them out of DKA, but it's it's it's not gonna help, is it, with that eating disorder?

SPEAKER_01 40:06

It'll definitely be for certain patients, won't it? I think we'll have to come up with those, but I it's an interesting tool, isn't it?

SPEAKER_00 40:14

Because I think there's there's a lot of pros for certain populations, especially your frequent flyers and DKA, the LDL as you mentioned, the potential populations. I think what I'm interested to see is when you start sticking these things on people, is what's the ketone level like for the average population with type 1 diabetes across the day over a week, months, whatever? Is it that you're hitting 0.6, 0.1, 1.5 with no concern regularly, or are you not? Like it'd be interesting to see to find out what's the magic level on this continuous level or how long you need to be above that level before you should be giving you guys a call. Otherwise, this time's gonna be going off when people are gonna be going, I'm gonna phone you and be like, I don't know what you're gonna do. So I don't know what you're gonna do either. Exactly what you're gonna do.

SPEAKER_01 40:58

Exactly. It's gonna make care plans very hard.

SPEAKER_04 41:00

Yeah, I I I agree because I I think we see that in hospitals a lot, because obviously, for in hospital, they they do random ketones for absolutely no reason. Um, you've got somebody with a blood sugar of like four point something and they check their ketones, and like weirdly, they have ketones of like one point something, and and you're a bit like, oh well, what do what do I do with that? Because they've got a normal blood sugar, but they've got raised ketones and they're in hospital, it's probably illness, it's probably starvation, but it absolutely freaks out the healthcare professionals on the ward and things like that, because obviously you've drummed into them for however many years that ketones are really bad and you don't put people into DKA and all that sort of stuff and everything else. So I think it I it's it is going to be interesting. I mean, I I would um I'll be very happily sticking one on myself and seeing exactly what happens to to me and how quickly, how quickly I start going into key ketones actually, depending on where my my sugar levels are uh are really and or even you know an illness or something like that, how quickly it happens because I think it's actually really fascinating because uh you know, when you see these people don't you who have come in in DKA and and they say, Oh, I was fine, I was fine an hour ago or something, and you're like, Really? It really happened that quickly, and uh and I think with that with that you'd be like, No, it didn't happen that quickly, actually. You were ticking along with a a keto level of this for about two days or whatever, and then all of a sudden it it did go crazy because it just got beyond what it could deal with. And so I think it will be fascinating to see what you get from it.

SPEAKER_00 42:47

Yeah, no, definitely. I think it's sort of the next frontier of sort of measurement will be there'll be there'll be a continuous keto monitoring chart with all sorts of data analysis at the beginning of it before you get to find out what the features are. We'll look we'll look forward to that. I think my highlight actually, I mean, I'll hold my hands up, I don't think you actually saw a session. I did way, way too much partying. But what I did, what I did get from um the um the thing was about the the current hybrid closed loops and thinking about how they all diff are different in terms of the way that they register insulin on board and how it's such an important thing because the way the algorithms are set up is if it recognises a lot of insulin on board, it doesn't allow the system to give extra insulin when you're high, which really annoys people if you're on a control IQ and it says, Oh, you've got loads of insulin on board, therefore I'm not gonna do a correction to start doing ghost carbing, which is really annoying. But actually, when I went to the their ad board, it was showing the data to us, if you get their basal percentage, about 60% of their total daily dose, and you weaken the carb ratios, it basically allows the algorithm to perform really, really well. So if you've got people out there who are currently on like 30% basal and 70% bolus, and they're thinking I'm having to ghost carb all the time, it's the wrong way around, you need to kind of get the basal at 60%. And weaken the carb ratios, give the algorithm a chance because you get that incident on board right down. And that's the same principle of why you set the 780 G, the type the active incident time at two hours, because you're trying to register no incident on board to allow the algorithm to be really aggressive. And that's also if you're an Omnipod 5, you want to get the active incident down to two hours. So then the user boluses are gotten rid of straight away, so the algorithm can be aggressive. So it doesn't really matter whichever system that you've got. What you're trying to do if you want the algorithm to be very responsive is get the incident on board down. And actually, that's great, but then for the user, that does become a problem because it makes it look when they look at their device, they're like, I've got no incident on board, so I'm fine to do exercise. Then like, oh no, I've gone low really quickly because actually, physiologically, I've got a load of instant on board. So I've been working hard behind the scenes at the Glucos Evelise to try and develop some calculators and some explorers so people can have a go. So if they go to the site and go to the AID optimizer, you can start having a play around with. Oh, if I had these settings and I was this weight and I wanted to get the optimum algorithm, what would I set it at? So as DSNs or um healthcare professionals, you can go and have a play with how to get the best out of these algorithms by manipulating the so-called instant on board, but then also what's the trade-off if you do that for the education pieces. It's like, okay, we're gonna make this algorithm really aggressive, but you can't trust the number of instant on board it tells you on the screen because it's gonna be way higher than that realistically. So um that's that's been my fun of nerdiness in the background. Tamsin, you got yeah, you you want to say something on that?

SPEAKER_04 45:28

Yeah, I just wanted to say that that that's really quite interesting in a sense of like how the systems work and things like that. Because um, when we were talking to um to the people at my life, they were saying about obviously swapping obviously people are now swapping, aren't they, between pumps? Because obviously people have been on pumps for quite a while now, and we're getting to the point where those people are coming up for their warranties and moving over. I've done that quite recently. So uh last year I was on a 780G, I've now moved over to a My Life, and and mainly just because I do like trying different pumps and stuff like that and things like that, and it gives me the opportunity to be able to say to people, I've tried the 780, I've tried this pump kind of thing. And I swapped my settings. You know, I'm I'm a DSN, I didn't need training. I did, I did the whole thing, do as I say, not as I do situation. And I I swapped myself over. So I put I took my settings off my Medtronic, I whacked them in the my life pump, and I literally hypoded all over the place. And and it's and it's the actual thing that they handed over this training, and they said, do not use the settings that you put in your Medtronic pump to put into your my life pump because it just does not work. And I mean that was I mean that was obvious straight away. It was obvious to me. My hypos went from like 3% to 30 something percent within like 24, 48 hours. I was hypoing all over the place. Um because genuinely I think this algorithm is super aggressive. Um, and I had to dial everything right back. My carb ratios got dialed back, and everything got dialed right back, and even my even my target, my BG target, I had to raise for a while just to stop it working so hard. So it's really interesting because obviously we I suppose we don't necessarily think about that when we're doing it. And now, because I've experienced it, it's made me realise I don't do that for people now. I actually set them up right from as if they're starting on a pump. Fresh. From from fresh.

SPEAKER_00 47:34

Uh go and go and have a go of the uh the AID optimizer and maybe put what your settings were on your 780, what your total daily dose is, and have a play around with it. I'd be interested to know whether it would have saved you 30% lows or not. But because I was speaking to Candice actually from um from my life, and I was saying, so basically, if someone's trying to get the optimum out of your algorithm, what's the situation? So you're saying, well, you want the algorithm delivered instant to be at least 60-65%, which means you've got to really relax the carb ratios compared to what you would do in other places, because if you put too much in with the bolus someone, you're probably hyper, but you'll also reduce the flexibility of the algorithm because you've just got so much instant on board from the boluses, it can't really do what it's supposed to do. But on other systems, that's what you want it to do. So it's kind of like if you understand how the different systems work, you can optimize it, but then you've got like four different things to think of, and you're in a consultation in a half an hour, or you're swapping something like how I'm meant to do that, it's impossible. Um so I've tried to develop something where you can plug some numbers in as a healthcare professional, kind of have a play around with how each system is meant to optimize things. So I'd be interested to get your feedback on that and um see what you reckon. So as a rat, I want to say thank you, first of all, for dealing with my nerdiness and hassling you guys to be like, you know, can you just check this out? But I think between us we've done a pretty good job at helping diabetes nurses, people with diabetes, people who pay the bills of CGMs understand it should be data sufficiency first and then feature second. Um, and then as we move forward into the the sort of arenas of continuous keto monitoring, GLP ones, getting the best out of AID systems, maybe we'll be able to cook something else up that we can um help them with. So I just want to say thank you for your time uh for tonight and thank you for the great work that you do. I know loads of people listen to your podcast and you're you're the place to go to for diabetes nurses, and you've put a lot of hard work in. I know you put a lot of hard work in because I'm on some WhatsApp groups with you and you never stop. It's like I thought I thought I liked a message. You guys like a message. You guys love a message.

SPEAKER_01 49:38

Not at 3 a.m. though. We we do sleep, but we're just manic when we're awake.

SPEAKER_00 49:44

Is there is there anywhere that you would like to send the listeners to to find out more about what you guys do, what you're up to, the sort of things that you do, just because they might have listened and thought, you know what, these these leaders have got some like some reality checks for for things and pieces. So what where would you send them to?

SPEAKER_03 50:00

Our website. Um Diabetes Specialist Nurse Forum UK. And if you subscribe to us, you'll get more content via our newsletter, especially if you're a healthcare professional, because we there's only there's certain things we can only send to healthcare professionals, so they're under a you know subscription only. So do subscribe to our newsletter.

SPEAKER_00 50:21

Absolutely, and obviously there's the the CGM charts. If you go along to the Diabetes Specialist Nurse Forum website, you'll see them there. You can click on register. The purpose of registering is not because we want to send you stuff, it's just because when we update the chart, we would like you to have the most accurate update information, and that certainly will be changing in terms of the number of CGMs available over the next couple of months for sure, with a score of five out of five, of course, they're available, but uh certainly a score of five in terms of sub design. So I'll let you guys get off and um do what you're gonna be doing on the evening, but I appreciate your time for an hour, and I'm sure this episode will be really helpful for a lot of people in terms of just getting some reality checks on CGM, thinking about carrying a fingerprint meter, what's cool to come in terms of fully closed loop GLP ones, continuous ketone monitors, and where they can find you. So I am no doubt we'll catch up with you soon.