Webinar – Understanding LibreView

good evening and welcome to our FreeStyle webinar on understanding LibreView we would like to thank you all for joining and hope you find the information presented useful and informative if you have any sound problems during this evenings broadcast you can disconnect and reconnect which should sort this problem out for you now on to today’s webinar the purpose of today’s webinar is to take you through a practical guide on LibreView and help you to feel more confident using all the elements of the software and understand how it can improve your care by sharing your data with your diabetes care team during tonight’s webinar you’ll first hear from Dr. Matt Withersby from Abbott who will be giving a live demonstration on setting up an account and the different reports that were available on the LibreView system this will be followed by Julie Brak who’s a Diabetes Nurse Consultant at the Royal Liverpool University Hospital she will be demonstrating the benefits of her experience of using LibreView with the FreeStyle Libre system and how her patients have used it to help manage their diabetes she’ll be talking through a couple of patient case studies and what to look out for on your own reports and the discussions you might want to have with your healthcare professional moving forwards. At the end of today’s webinar we’ll have time for questions for both Matthew and Julie you can ask a question by typing it into your chat window on the right-hand side of the screen on the questions tab we will attempt to answer as many questions as possible but we’ll leave these until the Q&A sessions so we don’t interrupt tonight’s presentations please note we’re not able to answer any clinical or individual healthcare questions during today’s webinar but you should contact your health care team if you do have any specific clinical questions following today’s webinar we will email a questionnaire to everyone for feedback on how you found today, please do take the time to complete this as it really helps us shape the education that we offer in the future well hopefully by the end of tonight’s session you’ll all be using LibreView and sharing your data with your diabetes team now let me pass over to Matt to introduce himself well hello everybody I just want to add my thanks for joining tonight the introduction and I’ve worked for Abbott for about twelve and a half years and I’ve been fortunate enough to work with FreeStyle Libre and LibreView since well before they were available for people like yourselves to look and use so that’s not just from the UK perspective but also we one of the first teams to to usually review worldwide a few years ago and so we’ve really seen the change and how this has helped people over the last few years so what I’m going to do tonight is I’m going to talk to you about LibreView give you an introduction to how to use it how to register how to share your information with your your healthcare team and especially right now and it’s really useful to be able to share your information remotely with them so I’m going to talk you through that and I’m also going to walk you through a couple of the reports and in lis review just see if got an idea of some of the information that’s available to you and also some of the key points you might want to look at so I’m just going to switch over now and I’m going to go into LibreView on the internet so just to give you I guess an introduction to where you’re where you end up if you google LibreView or you put LibreView.com into your browser this is the page that you’ll see so this is the login page and this is where if you don’t have a LibreView account you can sign up for one in the first instance now if there any of you out there using the FreeStyle LibreLink app you will already have a password and a username to log into LibreView it will be the same one that you used and when you set up your app if you don’t then what we need to do is sign up for an account so I’m going to talk you through how this how this works so when you click on sign up you get presented with two options so this is where you get to choose the type of account you’d like to set up so the one where you’re interested in if you’re at home and you’ve got your your reader or if you’re trying to share your information what you need is this LibreView account and when you tick you’ll see it goes green and then we can continue you’re asked which country you live in and so you can see we’re on the United Kingdom and then you’re presented with and the Terms of Use and the privacy

statement that goes with this now I suggest you read this and scroll through and when you’re happy with what you’ve read you click accept at the bottom you then get presented with the privacy notice so this is to tell you how the data is stored and used and gives you information around and the state security around sharing your information so again you read this and when you’ve read through it all you hit accept so now this is where we go to start putting in your information so if I see you want to put your name in here to start with so I’m going to name it and then you’re asked to put your date of birth in now it’s really important that you put an accurate date of birth in here because if you decide to share your information with your healthcare team they can search for you within their their group of patients by date of birth so you put your threat date of birth in and when you’re done you hit next and now this is where you put in the email address that you’d want to use and this is your gonna be your username for the LibreView system so you put your email address in and then you’re asked to put in a password so this password using this test email it’s just what I’ve made up so that piece here now you put your password in and you can see that as you’re underneath that your password needs to be between 8 and 36 characters it needs to have mixed case letters so you need to have one capital on one lowercase letter and it needs to have at least one number in it and then the last thing here is an option for you to tick and to hear more information about Abbott diabetes care and the products and services that we do this is for you to opt into if you’re interested please take that if you do take that you can unsubscribe at any point now the next thing you do is hit next and what will happen is you’ll get sent a verification email to the address you put in here I’m not going to click next because this email address isn’t a real one and but when that email comes through to you there’s a big button in the middle that you click on that says verify my account and then you’re able to log into LibreView so I’m going to come back to the home screen here now so come back to the LibreView console and I’m going to log in so as I said to earlier on if you’re already using FreeStyle LibreLink so you’re using the app to scan your sensor if you use the email address and password that you use when you set up that app actually all of the data you’ve been scanning will already be in side LibreView for you to see so I’m going to log into my account you can stay here if you forget your password at any time you can always request and a reset on your password and when you log in this is the screen that you’re presented with so before I go any further what I just want to say too is this is actually data that’s come from a sensor that I’m wearing right now so I have a FreeStyle Libre sensor on my arm I’ve been scanning it over the past couple of weeks and the information is now here in LibreView I don’t have diabetes but hopefully you’ll be able to see and from the example that I’ve got for you here tonight this is real this is me and and hopefully and it’ll give you an idea of what you can see so I’m going to talk you through a few things so we’re going to start at the top so you can see you’ve got a couple of symbols here at the top and you’ve got three lines up here in the top right hand corner now they will start on the left and we’ll work our way across so if you have a reader a FreeStyle Libre reader that you want to upload the information from this is where you would do it so with the FreeStyle Libre reader you get a yellow cable in the box it’s the one that you use to charge your and your reader up with you can plug it in to your computer using that cable and this is where you would upload information from your reader into the LibreView you can see there’s this big button here that says press to begin upload and we’ll do that in a second I’ll show you what it looks like and then at the bottom you can see there’s some tips here to help you if you have any trouble uploading your device so I’m just going to plug a reader into my computer you’ve probably heard the noise there that it’s plugged in the screen

will come on and tell you that the reader is connected to the computer and you hit press to begin upload and what Libreview will do is it will look for the reader to be plugged into your computer you can see here is searching for the device and you’ll see in a minute that it’ll find the device and then start to upload the information so I have already got information in here so I actually cancel this upload because I don’t need that information just to walk you through this evening and I’ve also been scanning my sensor with my mobile phone so every time I scan my sensor and I have a data connection so whether that’s on my Wi-Fi at home or on my 4G every time I scan if I’m connected to the the Internet in any way that data automatically populates into my LibreView account so I guess the next step is to show you where to see this data so that’s what this little symbol is here the one that looks like a weight line graph and when you click on this it takes you through to this page which is a summary of your glucose history so you can see I’ve got some new glucose data in here and what you then see underneath is a series of different prompts around different dates but I’m going to start up here so right now my glucose data is sliced in two week portions but I’ve got the option to change that I can look at it from anything from a week to 90 days so if I click ninety days this now shows you my glucose data in slices of three months if you like so you can see here between the 7th of March and the 4th of June underneath nzv8 to December to the 6th of March you can see I’ve got no data in these time periods then you can see some more data from earlier last year now where this is really gives a really nice idea is it shows you the difference between these two time periods so that you can see what the average glucose was and how many days worth of data I had in that 90 days so you can see I didn’t scan very much in that time and you can see the number of hyper events that I experienced and likewise you can see underneath for that period between December and March now what you might want to do is when you’ve been working with your your team or you’re changing your insulin or you’re looking at how you’re managing your diabetes you can see really clearly these sort of these charts here and the difference between the two so if you make a change it shows you can see quite clearly two things side by side it gives you an idea of the impacts of any changes that you make so I’m going to go back to two-week periods it’s quite nice to look at your data it’s almost sensor by sensor and I can then do is click on this says glucose reports and what this will do is it will take me into more information so when I click on there you can see I’ve got this little message saying my data is merged from two sources that means data that I’ve got on my phone from my app and on a reader which I’ve been scanning at the same time it’s being pulled together in one place for me so if we look down the left-hand side you can see there’s a number of different reports that are available and I’m only going to talk about a couple of them because because of the time tonight you can also see a date down here so this is the date of the last data upload and if you click on this you can see you can change the dates that you want to look at your data from so right now I’m looking at two weeks back from the most recent data upload and you can change it if you want if you want to see what things are like a month ago you can change those dates by using this customized so let’s start with this first report this is a newly reporting leave review so if you’ve been using lis ready for a while this might be new to you as well and what this is is a report with the a GP report and what it tries to do is give you an idea of what your glucose control has been like over you can see here the last 14 days and what it tries to do is it tries to give you an idea of how often how long you’ve been in a target range and so you can see on the right-hand side here you can see the time in target range here how much I how much time I spent low so that’s between three and three point eight and if I was below that you see some more information here and likewise at the high end you can also see that information underneath that lets me just go back up a little bit seasons here you have this graph which is called an AGP ambulatory glucose profile and what this does is it takes all of your glucose data and imposes it on top of each other as if it was one day so what you get is this dark blue line

in the middle and this is the what’s called the median and what this means is that 50% of your glucose results over this time period were above that line and 50% were below that line and what you start to see is that other trends around your general glucose control if you look at the dark blue line but then around that you see these wider blue bands and then if you can see outside of that and a lighter blue band and what this is showing you is in that dark blue band that’s where you half of your glucose readings have been so 25% there 25% below so that’s the middle 50% of all of your glucose readings and then outside of that in the light blue you’re seeing things that happen less stop less often so you’ll see anything seen out between the next or 20% out in your glucose and anything that’s really real sort of random excursion isn’t shown on this but this is trying to give you a chair trend of what’s happening and then underneath you can see what this would look like on a day-by-day basis so you can see that the sense I’ve got on at the moment I started last Thursday and you can see this is what everyday looks like the the eagle-eyed amongst you will see there’s a few breaks in the graphs there’s one there there’s one here so that’s where I’ve not scaled my sensor within eight hours of the previous scan and you start to lose a little bit of data so if you want to see the complete picture make sure you scanning at least once every eight hours the other thing you can see here is the graph highlights in red and that’s when a hypo events occurred so from this you can see if there’s any changes day to day or if certain days are worse than others and then again back to here this gives you that overall trend so because this is quite a new chart that has become available and Julie I’m going to ask you just to talk through and how you’re using timing range and in the clinic with the people you see yeah so with time and Rangers becoming quite popular now I know quite a few people on the questions and we will try and answer a lot of those questions as we go through the presentation and quite a lot of people will be away about time and range and how that equates to HPLC and but I’ll try to address that now the the belief is that if the blood glucose readings on your on your lever on that AGP graph in 70% of those are between 4 and 10 then your haterecy will probably be between 48 and 58 which is six and a half to seven half percent which is the the general target now for people with diabetes the reason the upper limit has been moved to ten is that post-meal you’ll know that your blood glucose level rises post-meal and actually in people without diabetes this can rise up to 10 quite easily so I know some of the questions have been around why is that is it up to 10 but actually that that’s why so your time and range should be 70% between a both for and below 10 even if your time and range that you can see from your leave of you it is not 70% on very few to be fair is that any change even a 5% change in your time in range so for example 60% up to 65% is is a meet is meaningful and it translates into more than an hour a day spent in range so anyway before and typically time and range is is in people with type 1 diabetes it’s between 50 and 60% and generally but remember your goals are set individually so you can you can change those targets on your libra to suit your circumstances at this time or at any time you can change them and really if you’re that time spent out of range your priority then as those read low ones you we always try to get used to have a look at reducing the percentage of time you spent below your target before you address those above your target because as most of you know if you have a hypo you can then have them rebound high-paid I see me and afterwards that can last a considerable amount of time and this is one of the reasons why time and range has been looked at more than HP on seeing a lot of clinics now because a reasonably a reusable HPLC it is like an average so you can spend your your time having rats that look a little bit like the Himalayas so to speak and we’re looking for grafts that are more like the Netherlands so we rather than having those big fluctuations which give you an average H for the C that’s relatively good the time in range does give you a better idea of how the stability that your your blood glucose levels have if you’re concerned about improving your

time and range too quickly we’ll normally say aim for a time and range of around fifty percent between four and ten and try and get less than one percent below four and less than 10% over source of 30 in a fourteen so just discuss with your team because more teams are looking at time in range now and this AGP report can provide quite a lot of useful information for you really thanks Julie so yeah there’s lots of useful information on this chart and it’s in one place which makes it really nice if you if you want to start with lead review with one report this is a brilliant place to start but they may have you sleeve review before or want to do a little bit more exploring I’m just going to touch on a couple of the other reports on the left-hand side for you so some of you may have seen this one called snapshot and you’ll see some of the things that we were talking about before as shown on here but actually the one I want to draw your attention to is this one so this little graph here looking at low glucose events talks and shows you and how many high posts you have the duration and how deep they are so you can see here you’ve got the 3.9 you’ve got the red line there and then every time you see red shading below that it shows you the hypo episode but it also shows you how low that went so as you see if you start to have repeat high at the same time everyday they start to overlap and so the red gets darker and some of you may have seen this little bit here was a bit darker where you can see that I’ve had a couple on top of each other but again it gives you an idea if something’s happening consistently it will start to show up and in this chart here it’s a really nice way of being able to see if your hypoglycemic episodes are happening at the same at the same time and then speak to your team’s to work out the best way to manage that I’m also going to show you this one which is called glucose pattern insights and this shows you the AGP that we saw before the ambulatory glucose profile here and but it gives you a bit more information so underneath you see there’s a set of traffic lights that go with it and this gives you an idea around where your likelihood of low glucose is so if your blue lines or your blue shaded area are coming close to that low threshold of 3.9 this will start to turn yellow for you and then it will go red so when you look at the look at this line for instance if you’ve got any red that’s probably a place to start talking to your healthcare team or thinking about how you manage that your diabetes in those situations you’ll also see this this one around the median glucose so if you remember the medians that dark blue line in the bot in the middle there so how is that compared to your goal if that’s around your goal this will go green if there are times where it’s above and below consistently again it will start to go orange and red so very clearly and easily you can see and times of day that you might want to think about what you’re doing and then the last one is this variability below them below the median so what this is is from that blue line how wide it’s like the river that runs along runs over it and if this is wide and if it starts to touch that low threshold what you’ll start to see again is that these start to change because again what this is trying to do is show you trends and patterns from all of that glucose data that you’ve been collecting with your sensor and then the last one I’m going to show you is this one’s a monthly summary and this does exactly what it says on the tin so this gives you a summary of what your month looks like so you can see this is where I started wearing my sensor and what you get is an average glucose the number of scans a day that you’ve done but even when if you see one of these red arrows it shows you that there was them a hypoglycemic episode so you were below 3.9 and for more than 15 minutes and what this is really nice to be able to do I’m just going to go on to this week is you might see that certain days of the week and your control level is very different to other days it might be that you see on a Saturday or a Sunday or Friday or a Friday night if after a Friday night that your glucose levels are different or you have more hypos so allows you to pick trends across a longer period of time in a very simple way we’ll also show you as you can see the number of times a day that you’ve scanned you might have a number that’s recommended by your team and very quickly and easily you can see am i scanning that number of times so those are just a few of the reports and I’m not going to go into any of the others in any depth if you want more information what you can do is you can

go up to these three lines and the top right hand corner and if you click on it at the bottom you’ll see there’s this thing here for customer support and when you click on there it will take you through to a section where you can search for common things and you can download guides which taught you through the reports but if you’ve got any other questions and it tells you how to contact our our teams that can help you now the other thing from here than these three dots that’s probably the most important thing and if your team are asking you to share that your glucose data with them and that’s how do you connect up with your health care team so they can see the data as you upload it or you know if they want to pick up the phone to you and talk to you they can see what you see and vice versa if you want to pick up the phone and talk to them right now you can talk them through what’s on your screen then they can see the same thing what we’re gonna do is talk about this how do I share my data was the health care professional team and what you have to do is go sis here called account settings and in account settings on the left hand side you’ll see this thing here called my practices when you click on it it will show you the practices that you’re linked to so in essence this is your clinic your diabetes team whoever it is that has asked you to share your information and each of your teams will have what’s called a practice ID and it’s normally a string of numbers and letters or it could be a specific name of the hospital but they will have that for you and they should be able to tell you what it is and you can manually add this in so I’ve got a mother and clinic here that I want to join to you put your code in there and you hit add and you can see underneath that this pilot practice which I just put in I’m now sharing my data with you can see the address and you can see the contact number so when you put your code in just make sure that that is your hospital and it is your team because that’s where the data is going to move to if any point you want to stop that sharing you just hit remove you’ll get the prompt to say if you do this your data won’t be visible to your care team and you hit remove and it’s gone so this is if you want to join up using libre view to your your healthcare team there is another way though if you’re using free start Libre link app on your phone so I’m going to stop sharing my Libre view right now and I’m just going to show you one slide so if you’re using and freestyle Libre link what you can do in the app is choose to share your data so what you need to do I have an Android phone and it’s very similar on an apple is in the app itself there is three lines or three dots you can click on and within that you’ll see a little Zoar cloud with an arrow that says connected apps it’s probably a bit at the bottom it will look like this but it’ll be at the bottom and when you click on that you’ll get this prompt to say and manage my connections with Libra view and Libra link-up so some of you may have usually relink up this is where you can share data with their you know husband wife partner it might be your children want to share data with you and you can have like Libra link-up which is a companion app and share the data across the way of talking about sharing into Libra view so your healthcare team can see it on there if you click manage it will tell you if you’re connected to any practices if you’re not also no practice connected you hit connect to a practice you put in that practice ID that your your team will have told you you hit next it will show you the name of the practice and you just hit connect so if you’re using the app and you’re using freestyle Libra link it’s really really easy one to connect up with your care team but remember every time you scan your sensor with your Libra link on your phone that data is automatically going into your Libra view cloud into your Libra view account that can be shared with your cut with your your care team and it means you haven’t got to plug a reader into your computer or anything like that the data just flows automatically and so the data is as up-to-date as it can be as long as you’ve got a connection so hopefully you found that useful and having a little walkthrough and again there’s lots of information in there so when you first start to use Libra view maybe pick one report maybe pick that ADP report and have a look at it and see how it changes especially if you’re working on the timing range and good luck good luck working with your care team good luck using the review and hopefully you can see how this will

really help you get to grips and maybe understand more about the way that your glucose is controlled so with that I’m gonna have back to Julie to give a real introduction to herself and about some of the cases that she’s and practicing different I thank you sir I’m trying to answer some of the questions and my typing skills aren’t like great to be vain the comma too quite thick and fast but I hopefully join my presentation I’ll answer quite a few of the questions that come up anyway so I do apologize random typing and answers seven questions have come off as well so do apologize but I’ll try and get through some of the questions during the presentation anyway so my name is Julie break I live in Liverpool I’ve got two daughters the dark rooms strict instructions to keep the noise down whilst I’m doing this I’m a member of Diabetes UK Committee for the conference which unfortunate was cancelled this year but obviously due to the covert pandemic I don’t know whether any of you have seen the diabetes 101 on Twitter support group so remember that that’s been very successful and really a lead on the carbohydrate counting course that we run in the hospital at the moment which obviously is on hold so I’ve been a diabetes specialist nurse for 25 years this year surprisingly and was a child when I started and so as I go through the case studies that I’ve got got three case studies and the typical examples of libre profiles I don’t want anyone to judge themselves on the data that we’re presenting or even on max Libre if you because obviously hasn’t got diabetes so everyone’s an individual you’ll have your own targets and just work towards trying to improve your goals and your time rage and your hatred see don’t be comparing yourself to to anything on here please or anything anywhere else and so the first case study this is this is quite common really you may well you may well be able to relate to this and this lady is a 32 year old lady with type 1 diabetes type 1 diabetes for eight years she’s on multiple daily injections or basal bolus regime as you may well know it she’s taken 32 units of her basal and three to five units with with her meals she’s she’s carbohydrate counting now her fasting glucose levels in the morning are nine to eleven throughout the day look who’s control is pretty good really and so her can say and was that she had high fasting levels and also if she missed her lunch or went too long without lunch so shallow breakfast around eight o’clock in the morning and didn’t get lunch too late and weights are about two o’clock then she found that she was going hypo and she couldn’t understand why she was no more active than normal or anything like that if we looked at her and graph that’s on the screen now you can see that her glucose levels are pretty stable overnight she seemed pretty flat and then about 5:00 a.m. you can see that the glucose levels are starting to rise up in the morning and she’s asleep at this time and so she’s having she’s not eating she’s not doing anything she’s fast asleep a blood glucose levels are starting to rise so when through the night they’re sort of fives and sixes but when she wakes up the nine to eleven now what’s probably causing this is something called dawn phenomena so some of you may well be aware of this I think with the uptake of freestyle Libre that what happens overnight when you normally sleep and you were completely unaware of in the past is now obviously a more accessible and dawn phenomena really is the release of all your body’s hormones in the middle of the night when you asleep so all your all your natural steroids your catecholamines your adrenaline your your testosterone and your estrogen your body just releases these and it’s all based on day and night light and dark you can’t have you don’t really have any control over this so it’s all to do with light and dark so while you’re asleep your your body releases all these hormones which actually block the action of insulin in your liver and therefore your glucose levels start to rise and this is called dawn phenomena obviously fast raise fasting glucose can be caused by number things can be caused by nocturnal hypose can be caused by a rise over night so this is how the three Sally but helps

you see exactly what’s going on over night so in this lady you’re asking to say she was pretty good throughout the night 5 a.m. she starts to rise and that’s dawn phenomena so what what has been happening is her long-acting basal insulin has been increased on a fasting glucose levels we all know we’re told if your fasting levels are high increase your basal insulin that’s what controls you lucas overnight however what’s happened to here you can see she’s not quite a large dose of basal insulin compared to a mealtime doses so when she goes without eating through the day the basal insulin is actually working on a glucose levels I’m bringing them down when it should actually keep them stable so that’s why she’s suffering from low blood glucose levels if she misses her lunch in the day dawn phenomena is quite a difficult thing to deal with really because I wouldn’t expect anybody because I I wouldn’t expect anyone to do anything that I personally wouldn’t do myself I wouldn’t expect anyone to wake themselves up but half was fall in the morning to give themselves a little bit of insulin to deal with a rise in glucose levels overnight so dawn phenomena actually is is probably the the only way to deal with that successfully is with an insulin pump however if people if you don’t want an insulin pump where you don’t have access to an insulin pump then it’s a correction dose with your breakfast when you wake up to bring that glucose level down and as well as your mealtime insulin so for example I know quite a lot of people skip breakfast in the morning so you may well find if your blood glucose levels are pretty stable overnight with this rise from 5 a.m. in the morning oh sorry I apologize if your blood glucose levels are quite stable overnight and you wake up and the pretty-pretty got and you skip your breakfast and you wake up and you DeLuca’s level is about six and pre-launch it’s 15 and you think well I’ve had nothing to eat I’ve not done anything different why is it 15 well it’s all to do again with those with the hormone release and your insulin sensitivity through the morning um so and some of you who are carbohydrate counting may well have a different ratio in the morning than you do and all the terms of the day and anyone on this webinar is on a pump you might have a different basal race and it’s all due to this hormone release in the morning I know some of you have mentioned on the questions about splitting insulin doses to try and address this problem but once again if you split the insulin dose so you have half in the mall and 1/2 in the evening it wouldn’t address that rise at 5:00 a.m. it’s in his dorm phenomena so again the the only way without a pump is probably to do a correction dose with your breakfast to correct that loop goes down to what you would like it to be and then obviously add on your carbohydrate insulin and for your breakfast if you haven’t it and so I hope that explains a little bit about the the dawn phenomena and you can if you have a little look about dawn phenomena online source on diabetes UK or JDRF websites there’s quite a good explanation on there as well ok the dawn phenomena it is not always consistent and there’s another thing called foot on the floor phenomena as well just to confuse things even more some people find that Lucas levels of perfect through the night but as soon as they wake up the blood glucose levels rise so they might wake up at 7 a.m. 8 a.m. 9 a.m. 6 a.m. and that’s when they get that sudden increase and that again is the release of stress hormones as your body is waking and so that’s something some of you may well have seen as well okay so for this lady what we did and she didn’t want to go on an insulin pump so we would use two basal insulin down and she did a correction dose with a breakfast of a couple of units on top of what she’d calculate for her car behind with Paget with the breakfast and that worked quite well it brought her down so that lunchtime she was back in a target range and if she did miss a launch oh it was late she didn’t go hypo okay so it’s probably something if you’ve noticed it on your Lieber to discuss with your team so I’m going to go on to the next and case study that’s okay and so we’ve talked about dorm phenomenon okay and so we’re going to just talk about this 42 year old gentleman here he has type 1 diabetes he’s up type 1 diabetes used for 23 years okay he’s again on a multiple daily injections of insulin or basal bolus regime his basal insulin is 18 units any carbohydrate counties on a 1 to 10 ratio so you can

see that he’s got relatively reasonable control is having some hypo hypo episodes as well and it’s pre meal glucose levels are within his target 5 to 7 millimoles that’s for him but his hatred see is raised so this is why we were talking about timing range okay rather than just pre meal glucose levels so his pre-meal glucose levels are actually pretty good but hey t 1c is high so when we looked at it in more detail actually his post meal spikes were what was causing his raised hates real c.m so what we did with this gentleman is we looked at how he was taking his insulin with his meals so one of the commonest times to get a post meal spike is after breakfast so I don’t know whether anyone out there is experience that especially because the your breakfast is a total carbohydrate meal normally especially if you have cereal and milk or or toast or bread so there’s nothing really to slow that food down so it gets into your system pretty quickly and can spike her glucose level up pretty quickly after your breakfast so what we did with this gentleman is he changed his breakfast and added in some protein with his breakfast so and some fat with his breakfast so he’s have Greek yogurt and and fruit always have a burqa on toast or or he might have some eggs with his bread scrambled eggs on toast the other thing you can do if you don’t fancy any of that or you think I haven’t got time to be faffing around with that for me breakfast in the morning the other thing you can do is even though the rapid-acting insulins work quite quickly even some of the newer insulins that are even faster acting especially before breakfast you you might need to pre bolus and this is something that you probably could do with talking to your team about so many people will inject and eat straight away especially at breakfast but if you’re finding you’re getting these quite steep post meal spikes after your breakfast it might be with pre bolus in about ten minutes before your meal to give your insulin time to get into your system before the food gets absorbed and this can help dampen down that spike after you’ve eaten and can then keep your time in range down a little bit more as well so rather than creep and up above the ten twelve thirteen range sometimes a 17 after your breakfast and then she’s coming right back down again before your breakfast before your lunch it can dampen that spike down because the insulin is active at the time that you need it with your breakfast and this is what we did with it with this gentleman he he had some fats and protein added to his breakfast to slow it down and on days that he did and he pre bolus his aim is insulin ten to fifteen minutes before his breakfast which helped considerably okay so I might be something you could do with them discussing with your team but the problem is that if you haven’t post meal spikes after your breakfast increasing your insulin especially if your pre next meal glucose is back down again like this gentleman’s is if it’s if it’s the if it’s the area under that spike between the two meals that is the problem then increasing your insulin will just cause hypose later on it’s the fact that the insulin is not worked in line with your food absorption and that’s why we talked about pre bolus and so basically pre bolus and means taking the Bo dose of your Humalog novo Rapids appeared Rafi ass whichever you take taking that bolus dose approximately ten minutes before you eat and that means the insulin can get into your system at the same time your foods also you know any meal you notice that spike happening and as I say especially after breakfast breakfast the pre bolus pre bills before breakfast can help quite a lot and you probably do need to take your full dose some people split the dose even with injections before you your breakfast rather than splitting that because you probably need that full dose to wait with the cereal and the toast if it’s a total carbohydrate meal okay I’m trying to talk slowly because being a scouser sometimes I know people can have difficulty understanding me without an interpreter so okay so this is a case study number three okay I don’t want to talk too much as well and not have time for questions as well hmm so case study number three okay so this person has type 1 diabetes and has had for five years and they’re on a base of bolus regime again as most people on a Liebherr because NHS England’s one of the criteria isn’t it as a base of bolus regime so 24 units of basal insulin so

that might be leva me Atlanta’s – Jo – c-bear one of the long acting Basil’s and fixed doses of a bolus rapid-acting insulin so they’re not carbohydrate counting now and fixed doses 12 at breakfast breakfast 8 at lunch and 12 evening meal so if we look at these this data here that’s on screen you see that the fasting glucose or when they’re waking up in the morning and the pre meal readings all a little bit all over the place and a little bit erratic okay and the ranging from hypose to quite high actually – over forty fastened and free meal three point six to twelve point five so the Freestyle leave what can can show you sort of those fluctuations and also can show you what’s happened a sort of overnight with nocturnal hypose I think the problem with fixed doses of insulin that it’s a fixed dose of insulin a fine if you haven’t fixed amounts of carbohydrates so anybody who is having the same breakfast every day like my husband was exactly the same every day his corn flakes is meld and it’s banana every single day it’s lunch it’s pretty much the same every single day but evening meal is different every single night and depending on the type of carbohydrate you have with your evening meal or how hungry you are the carbohydrate portions don’t vary so for example I’m not a big lover of potatoes if we have potatoes it would have a great deal but if we have rice I’ll have quite a lot because are quite light rice so my carbohydrate portions of an evening meal can range from 20 grams of carbohydrate to 120 grams but if you’re having the same dose of insulin it makes sense doesn’t it same dose of insulin with that meal then of course there’s blood glucose levels of a night time or at any other time with varying carbohydrate meals they’re going to vary quite a lot so if you’re on fixed doses of insulin and then that’s fine but if you’re noticing that using the lever your blood glucose levels are fluctuating quite a lot okay or if you are carbohydrate counting and you’re finding your blood glucose levels are starting to fluctuate quite a lot revisit your carbohydrate count and make sure your portion sizes haven’t grown with time and as it will changed as as your eating patterns change if you’re not carbohydrate counting that it may well be that those times when you’re having different meals your portion sizes of carbohydrates are different and if you speak to your diabetes dietitian then they can give you some advice on what constitutes sort of 10 grams of carbohydrates so you’re not necessarily carbohydrate counting but you can make sure that during that meal of you’re have a fixed doses of insulin that you’ll having the right amount of carbohydrate okay so you know it’s quite important that if you’ve not got your carbohydrates and your insulin doses sort of married up together then this sort of fluctuation in control is going to is going to continue and really it can be quite have a quite dramatic effect on people with the lows and the highs it’s not very nice at all so have a little have a little think about that and also have a think about if you find suddenly that your blood glucose levels are starting to become quite erratic and that they weren’t before have a think about you injection sites it’s quite easy isn’t it to inject in the same places were creatures of habit and even if you are making a conscious effort not to inject in the same place all the time when you go to do your injection you do injection think oh I didn’t really mean to do it there so I have a look at your injection sites make sure they’re not lumpy and bumpy in lipo hypertrophy it’s called it can have a real significant effect on your blood glucose levels and so yeah be insulin insulin injections savy really am fat and the same with the cannulas if you’re on a pump as well so I’ve tried to whistle through that so that we can have time for questions thank you so much Julie so we’ve had hundreds of questions in so we’re just gonna Whittle through some of them just because we’ve had so many questions on this I’m just gonna quickly go over the fact that you can use both a free cell Libre reader and Libre Lync free Sally running app to scan a sensor if you do want to use both devices you need to make sure you scan first with your reader and then with the free celebrating app if you’re using just the app you don’t need to upload any data into libre view it automatically transfers into the libre view system you just need to make sure that you’re logging on to libre view using the same details that you’re using on that and if you’re using a reader you will need to

connect the reader to a computer to be able to get the data into libre view and then it will merge together if you want it to do so we’ve had loads and loads of questions on that so I’m really hoping that clears that up okay so now I’ll go to the other questions that we’ve had Julius one for you so why has the target range been changed from three point nine to seven point nine up to three point nine to ten right yes so the the target range that the three the sort of the four to seven and four to seven point eight generally was always looked at for pre-meal readings and so we always used to say those without diabetes quite a long time say four to seven four to seven make sure you DeLuca’s levels are four to seven they were always pre-meal readings but now with the libra obviously we’re getting data even when we’re not scanning constantly 24 hours a day so your target range post meal is will always really unless you’re on a pump and got quite tight control your post meal readings will will will be higher and can be up to ten just like in people without diabetes so that’s why it’s changed its change really for the time and range function so the if you look at the time in range you you can see areas they might need to improve if you don’t want to use the term and range and you want to keep your target levels wherever you want to speak it’s your diabetes then your targets you might want your target range to be seven to eleven for whatever reason you know that that is completely up to you will have a target and try and keep your glucose levels as much in that target as possible and any reduction is a good reduction that’s great thanks Julie and well you just mentioned that the report that Matt showed earlier on the AGP that will never change the target range that is set on that report so that report will always show the target range is three point nine to ten and this target glucose range follows the recommendation in the consensus paper in the diabetes Journal published in 2019 even if your target range that you’ve got set in your device is different to that just as an FYI so someone’s asking about their breakfast so after their breakfast their sugars normally go up to fifteen to eighteen and then they come back down into rain what can they do to kind of stop that big peak that they’re having so that’s an example of if your blood glucose level before your breakfast and four hours after your breakfast is is in range it’s telling you that the amount of insulin you’ve taken for that amount of carbohydrate was correct so the amount of insulin is correct the spike in between those two readings is telling you that the insulin hasn’t worked with your carbohydrate correctly okay so really if you’re spiking quite quickly after breakfast this is where we talk or after meal this is why we talk about the pre bolus in so we always say take you insulin just as you’re about to eat and that was always the thing but now really with Libra and all the real-time glucose systems that we notice really actually the insulins are not as quick as we thought they were so probably if you’re noticing these post meal spikes try pre bonus in your instance i’ve tried giving your rapid-acting insulin about 10 minutes before you go in to eat obviously discuss it with your team but try taking it 10 minutes before you eat and the best person to deal with post meal spikes is your dietician speak to them they’re not the diet police they’re not horrible people they are really good at supporting you with dealing with those post-meal spike spikes and suggesting management plans or changes you might want to make Thank You Julie and another question that I’ve seen quite a few of is about the low glucose events so what what is a low glucose event on the Freestar Libre so anything less than four is classed as a low blood glucose level isn’t it even if you’re not symptomatic it’s still a hypo and and you should be looking out for those on on your Libre one thing to think about is the a load Lu Coast level and one event could possibly last an hour sometimes you can notice that you know you can be in a in three-point-eight for an hour and if you’re not feeling that as a hypo then you may well have some hypo and unawareness a degree of hypo and awareness and that can be caused by typos every day so have a look back to your data and have a look at your hypo episodes on your libra and just have a look and see if you are going low every day because if you are you you need to take steps toward bringing your glucose levels off

at least for six to eight weeks possibly to try and bring back some hyper awareness and just quickly no longer you’ve had diabetes for the the more likely you are to have some hypo and awareness and your hypo symptoms can change as well so I’m sure some people have noticed that and but yeah that’s that’s what I would say about that okay lots of people questioning why it’s been put up to ten yes it’s a really interesting debate that I think everyone’s gonna be having it’s just for the time in range it’s not the or targets you know if you’re all your pre-meal readings a tenth and obviously there’s something wrong you’re looking at the whole picture you’re looking at trying to see that that your time and range is between four and ten and obviously if your time and if you’re ten 24 hours a day seven days a week then your hatred see is gonna be high so it’s just another way of using your libra to look at your diabetes control and see if you can make adjustments somewhere and while we’re talking about setting your own target range as opposed to time in range and a lot of people are asking how you do that so you can on the reading you can press the settings and you can go in and adjust your target range in there and on the phone you can also do the same going into the burger menu on the right hand top of the screen and resetting your targets in there but I’m sure Julie would say the same is speech your healthcare professional before making any changes to those yeah no no as I say I’m trying to choose the ones that we’ve had the most of people are asking the question around estimated hba1c and the difference between that and a lamp anyone see where you know give a blood sample and that gives us to be tested and there’s something called GM I’ve Lucas management indicator which is also in the new May GP report that we’ve just been talking about now obviously when you go and you give a blood sample and you’re at HK one sees that is calculated and in the lab that is your H be able to see and what we what you we are able to do based on all of the glucose results that you get from scanning is there there are a couple of calculations that can be done to give an answer of what the estimated hba1c might be and that calculation and it doesn’t give exactly the same number and it’s slightly different and it’s slightly different and if you’re not in in and around a normal hba1c the further away from that you get the bigger the difference is likely to be between the two and the other point is that GM I so the glucose management indicator which is a calculation that’s made and the estimated hba1c will also be different because they use different maths in the backgrounds and the the GMI results or the GMI calculation is the the one that’s been recommended by the American Diabetes Association in June 2019 it was recommended that that calculation was used and I would I would say if you’re going to look at these don’t look at them and compare them to your hba1c from the lab use them as an marker for yourself to see if igloo pose level is improving on that which over time great thank you so much for that map there’s lots of people asking lots and lots of questions on timing range which is great we are going to run a webinar on time in range later this month so definitely look out for that one and we will go over it in more detail and why the science is behind the 3.9 to the 10 Don phenomenon and foot on the floor Judy I have some nights where I’m stable throughout some where I have risen from as early as 6 a.m. and some where my rise comes much later not actually till I get up any advice to try anything it’s difficulty now because even on a pump obviously if it’s not consistent then it’s equally as difficult to manage however on a pumpkin often deal with dawn phenomena and foot on the floor a lot more easily than bolus injections can so we if you if you’ve got taiwan diabetes unused and you feel a pump would be a solutions we’re talking to your team about it and accessibility to pumps depends off and on where you

services based unfortunately but and NHS england support pump you so you know if you feel a pond or suitable for you then do that if if not then it’s about doing appropriate correction doses in the morn and so once again discuss this with your diabetes preciousness or with you your diabetes team and i’m sure they can give your you some advice on that we’ve also had a lot of questions about people adding notes to their readings and how important they are for the diabetes team obviously when you’re analyzing have you got any pointers or tips on that julie yes yes i have some quite some interesting interesting notes on some of the yeah we do because if you if you make a note about something you’ve done differently so the gentleman who was changing his breakfast you’d make a note on what he had for his breakfast so we can see and the changes to his post meal spikes everything so that came and really useful and also for any missed doses of insulin Mis bolas make a note you know not the insulin policia it just we can see that oh well that’s why that’s happened or if you’ve over corrected I had a hypo you don’t exercise if we’re looking at that data before we do our virtual clinic or telephone clinic with you it’s very very useful fantastic sorry I’m just trying to post mail spikes again right yeah it’s just that your insulin hasn’t worked with your carbohydrate the way it should do so if your pre meal and pre next meal or for four hours later at Lucas levels are the same or in range and there’s that spike in between its how the insulin has worked that’s the problem not necessarily the dose so it’s looking at the the quality of the carbohydrates meaning sort of how complex it is and what you’ve got with it that can make and that can make the difference so speak to your dietician and your diabetes team thank you so much Julie we have actually run out of time this evening I know you’ve there are so many more questions and we’d love to we’d love to get through them all tonight and I would say this webinar would be available on demand in the coming days we’ve also had done previous webinars on exercise and diet as well as pregnancy and trend arrows and all sorts so please visit our website WWE style diabetes co uk and you can find the webinars there on free style progress they’re all available on demand and as I said we will be running another webinar later this month on specifically on timing range so please register to join that one and Thank You Julie and thank you Matt for your time this evening I hope you’ve enjoyed presenting and as much as the listeners seem to have enjoyed listening and yeah see you again soon thanks for the questions everybody and thanks everyone bye