DYNAMIC: Dynamic glucose management strategies delivered through a structured education program improves time in range in a socioeconomically deprived cohort of children and young people with type 1 diabetes with a history of hypoglycemia

Abstract

Objectives Create and evaluate the effectiveness of a structured education program in children and young people (CYP) with type 1 diabetes using continuous glucose monitoring (CGM). Design and methods Step 1: CGM devices were evaluated for predetermined criteria using a composite score. Step 2: The education program was developed following review of international structured education guidance, dynamic glucose management (DynamicGM) literature, award‐winning diabetes educators' websites, and CGM user feedback. Step 3: Program effectiveness was assessed at six months by change in time below range (TBR) (<3.9mmol/L), time in range (TIR) (3.9‐10.0mmol/L), time above range level 2 (TAR2) (>13.9mmol/L), severe hypoglycemia and HbA1c using a paired T‐test. A DynamicGM score was developed to assess proactive glucose management. Factors predicting TBR and TIR were assessed using regression analysis. Results Dexcom G6 was chosen for integrated CGM (iCGM) status and highest composite score (29/30). Progressive DynamicGM strategies were taught through five sessions delivered over two months. Fifty CYP (23 male) with a mean (±SD) age and diabetes duration of 10.2 (±4.8) and 5.2 (±3.7) years respectively, who completed the education program were prospectively evaluated. Evaluation at six months showed a significant reduction in TBR (10.4% to 2.1%, p<.001), TAR2 (14.1% to 7.3%, p<.001), HbA1c [7.4 to 7.1% (57.7 to 53.8 mmol/mol), p<.001] and severe hypoglycemic episodes (10 to 1, p<.05); TIR increased (47.4% to 57.0%, p<.001). Number of Dexcom followers (p<.05) predicted reduction in TBR and DynamicGM score (p<.001) predicted increased TIR. Conclusion Teaching DynamicGM strategies successfully improves TIR and reduces hypoglycemia.

An effective and cost‐saving structured education program teaching dynamic glucose management strategies to a socio‐economically deprived cohort with type 1 diabetes in a VIRTUAL setting

“…11 We demonstrate that teaching Dyna-micGM strategies virtually to CYPD experiencing hypoglycemia issues using flipped learning is cost-saving and clinically just as effective as face to face teaching. 11 Teasing out the most effective strategies to improve TIR such as short bursts of exercise, using TAAT, adjusting pre-bolus timing and tailored hypoglycemia treatment; and incorporating these into a visual teaching aid can ease implementation of complex concepts.…”

“…11 However, we did not scrutinize to assess the most powerful DynamicGM strategies from the seven individual strategies taught. 11 Teaching the most impactful strategies could prevent the risk of overwhelming users and carers, which is particularly important in population groups such as ours. Our population group has higher prevalence of socioeconomic deprivation, lower levels of education, lower income and significant barriers in language and understanding compared to the national average.…”

“…The design and development of the F2F CGM Academy and its contents are detailed in a previous report. The workbook 11 was transformed into an interactive PDF using…”

“…The benefit of pre‐bolusing by 20 min before a meal is well‐established 12 ; however, there is no equivalent consensus on changing insulin timing or dose based on trend arrows. Teaching adjustment of mealtime insulin dose using the Trend Arrow Adjustment Tool (TAAT) 13 and altering pre‐bolus timing based on glucose values and arrows have been reported to be associated with improved TIR 11 . However, neither strategies have a sufficiently established evidence base.…”

“…We have previously reported the success of our structured education program, “The CGM Academy” on the first 50 CYPD demonstrating significant reduction in TBR by 8.3% ( p < 0.001), HbA1c by 3.8 mmol/mol (0.3%, p < 0.001) and severe hypoglycaemic events from 10 to 1 ( p < 0.05), while also improving TIR by 9.6% ( p < 0.001) and quality of life ( p < 0.001) 11 . The use of DynamicGM strategies was the strongest predictor of TIR at 6 months ( p < 0.001) 11 . However, we did not scrutinize to assess the most powerful DynamicGM strategies from the seven individual strategies taught 11 .…”