COMMENTARY

Seeing the Big Picture: Transform Diabetes Care With the Ambulatory Glucose Profile

Richard M. Bergenstal, MD; Mark Harmel, MPH

Disclosures

December 12, 2018

Images shown in the video are used with permission of the International Diabetes Center Ambulatory Glucose Profile Report.

Here we are, 35 years into using the A1c, and I am still not satisfied that it's helping us achieve better control of diabetes. It's an average marker of long-term complications.

Now we have continuous glucose monitoring (CGM). We have a report called the ambulatory glucose profile—a way to look at the data that are transforming the way we take care of people with diabetes. We're suddenly putting their life in front of them—thousands of blood sugar measurements organized in such a way that they can instantly spot when they're high, when they're low, and what changes they need to make.

Here's your glucose profile and all of your blood sugars. Let's pick something to work on today.

CGM provides a series of metrics that are really important to understand. Yes, it gives the average glucose over a 2-week period, but it also shows what we're calling "time in range," which is how often blood sugars are in that 70-180 mg/dL range, where you're going to feel pretty good and you're going to prevent the chance of long-term complications or hypoglycemia.

What's your variability? How much are your blood sugars going up and going down? These fluctuations make people feel terrible and they feel frustrated. They say, "I did the same thing yesterday, and yet today my sugar’s low; yesterday it was high."

How do we reduce that variability? Well, first you have to spot it. That's what CGM can do. Then we can home in on markers of hyperglycemia, hypoglycemia, and time in range. Those are metrics that we keep track of to see how things are going.

Seeing the Big Picture

What's really important to me is the big picture. Here's your glucose profile and all of your blood sugars. Let's pick something to work on today. What's the area that's troubling you the most or is most frustrating? Is it those lows overnight? Is it that high after breakfast?

We can talk about it together and decide what is the best treatment. Is it reducing how much insulin you're giving when you go to bed to cover your snacks so you don't get low at night? Is it taking your insulin a little earlier in the morning so you don't have that sudden rise in the morning, when we're all kind of insulin resistant and we need more insulin?

The glucose profile really gives you a picture of areas you need to work on. Then, together with the healthcare team, you can talk about the best approach to get that in control. We need to use these tools and CGM and work together in the office or through remote discussions. The data are stored in the cloud, so it is easy to speak on the telephone or to just look at a profile together.

Yes, we'll always have A1c as a marker of the risk for long-term complications, but let's use these tools that individualize therapy daily for each person with diabetes so that they can reduce their burden of living with diabetes and their risk for complications at the same time.

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