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					<li><a href="#articleinfo">Article Info</a></li>
					<li><a href="#abstract">Abstract</a></li>
					<li><a href="#intro">Introduction</a></li>
					<li><a href="#hypoglycaemia">Hypoglycaemia</a></li>
					<li><a href="#monitoring">Flash glucose monitoring</a></li>
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                    <p class="art-type" id="articleinfo">Review Article</p>
		    <p class="art-title">Type 1 Diabetes Glucose Control related Home-Based Testing: A Mini-Review of Tools and Patient Knowledge and Implementation</p>
		    <p class="art-author"><?php $authors="Alicia J Jenkins<sup>1-3</sup>, Gary Kilov<sup>4,5</sup>, Emma Scott<sup>1,6</sup>, Greg R Fulcher<sup>6</sup>, David N O'Neal<sup>1-3</sup> and Andrzej S Januszewski<sup>1,3*</sup>"; echo (stristr($authors,$coauthor))?str_replace($coauthor,"<a href='".$extpath."authors/".$courl."' target='_blank'>".$coauthor."</a>",$authors):$authors; ?></p>
<p class="art-affl"><sup>1</sup>NHMRC Clinical Trials Centre, The University of Sydney, Australia<br/>
<sup>2</sup>Department of Diabetes and Endocrinology, St. Vincent's Hospital Melbourne, Australia<br/>
<sup>3</sup>Department of Medicine, University of Melbourne, Australia<br/>
<sup>4</sup>Seaport Diabetes incorporated within Seaport Practice, Australia<br/>
<sup>5</sup>Department of General Practice, University of Melbourne, Australia<br/>
<sup>6</sup>Department of Endocrinology, Royal North Shore Hospital, The University of Sydney, Australia
</p>
		    <p class="art-aff"><b>*Corresponding author: <?php $corresponding_author=" Andrzej S Januszewski"; echo ($coauthor!="" && $coauthor==$corresponding_author)?"<a href='".$extpath."authors/".$courl."' target='_blank'>".$coauthor."</a>":$corresponding_author;?></b>,
NHMRC Clinical Trials Centre,
Level 6, Medical Foundation Building,
92 - 94 Parramatta Road,
Camper down, NSW, 2050, Australia,
Tel: +61 2 9562 5000,
Fax: +61 2 9562 5090,
E-mail: <a href="mailto:andrzej.januszewski@ctc.usyd.edu.au">andrzej.januszewski@ctc.usyd.edu.au</a></p>
<p class="art-aff"><b>Received:</b>   June 5, 2018
<b>Accepted:</b>    July 16, 2018
<b>Published:</b>  July 20, 2018</p>
<p class="art-aff"><b>Citation:</b> 
 Jenkins AJ, Kilov G, Scott E,
Fulcher GR, O'Neal DN, Januszewski AS.
Type 1 Diabetes Glucose Control related Home-Based Testing: A Mini-Review of Tools and
Patient Knowledge and Implementation.
Madridge J Diabetes. 2018; 2(2): 55-62.
doi:  <a href="https://doi.org/10.18689/mjd-1000111">10.18689/mjd-1000111</a></p>
<p class="art-aff"><b>Copyright:</b> &copy; 2018 The Author(s). This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p>
<p><a href="<?php echo $extpath;?><?php echo $jres['journal_link'];?>/mjd-1000111.pdf" class="btn btn-danger pull-right" target="_blank">Download PDF</a></p>
</div>
<div class="articlecontent">
<p class="art-subhead" id="abstract">Abstract</p>
<p class="art-para"><b>Background:</b> In Type 1 diabetes (T1D) glycaemic control is key to the prevention of
acute and chronic complications. An increasing array of devices is available for at-home
monitoring. Tools must be used appropriately, and the information gained utilised well
to maximise clinical benefit.</p>
<p class="art-para"><b>Aims:</b> This mini-review describes clinically available home glucose and ketone
monitoring tools and discusses factors which impact glucose outcomes. Additionally,
findings from the authors' surveys of T1D adults regarding glucose self-care are
discussed.</p>
<p class="art-para"><b>Results:</b> Blood glucose strips and meters and urine glucose strips have been available
for decades. More recently available are continuous glucose monitors (CGM) and flash
glucose monitoring (FGM) which assess interstitial fluid glucose levels. Blood and urine
ketone test-strips are also available. In surveys of adults with T1D in two tertiary referral
diabetes clinics (n=205) and in general practice (GP, n=35) self-reported rates of blood
glucose (BG) monitoring and glucose targets were similar, with a mean (SD) of 5.3 (2.5)
tests/day. Deficits in knowledge or practice related to the care of hypothetical pre-bed
BG levels and of metabolic control around illness, exercise or alcohol were common.
Only about one third reported treating nocturnal hypoglycaemia with the recommended
refined then complex carbohydrate. Only 66% reported having in-date ketone test-strips at home. Further education was often desired, but difficult to predict based on
demographics.</p>
<p class="art-para"><b>Conclusions:</b> A range of tools are available to test glucose and ketone levels at home.
Many adults with T1D have suboptimal knowledge and behaviour regarding glucose
self-management.</p>
<p class="art-para"><b>Keywords:</b> Type 1 Diabetes; Glycaemic control; Self-Management; Diabetes Education.</p>


<p class="art-subhead" id="intro">Introduction</p>
<p class="art-para">The incidence and prevalence of diabetes, including Type 1 diabetes (T1D) are
increasing globally <a href="#1" id="ref1">[1]</a>, even in low-incidence countries <a href="#2" id="ref2">[2]</a>. Glucose control is a daily
challenge, and its optimisation is key to the prevention of the acute and chronic
complications, which are costly both personally and to the healthcare system. There are limited data regarding patient knowledge and behaviour
related to glucose control, including high risk nocturnal
hypoglycaemia prevention and care. Most adults with T1D
spend only &asymp;2-3-hours a year with their diabetes care-team,
therefore glucose self-management is essential. Patient time
with clinicians is often limited; hence tools which can facilitate
self-care assessment are desirable.</p>
<p class="art-para">The purpose of this mini-review is to describe currently
clinically available types of glucose and ketone monitoring,
and to review the findings from our novel recently (published)
surveys of T1D adults and their glucose-related self-care
practices. As this is a rapidly evolving area, and different
brands and models of devices are available in different
regions, this article focuses on types of technologies and
gives examples of clinically available brands, particularly citing
the first, or sometimes only, clinically available system of its
type.</p>

<p class="art-subhead" id="control">Type 1 Diabetes and the Importance of Glucose Control</p>

<p class="art-para">As shown by the Diabetes Control and Complications
Trial (DCCT) and its observational follow-up, the Epidemiology
of Diabetes Interventions and Complications (EDIC) Study,
higher HbA1c levels are associated with increased risk of
diabetic retinopathy, nephropathy and neuropathy and
intensive diabetes management leading to &asymp;2% lower HbA1c
levels significantly reduces all microvascular complications
and subsequent cardiovascular disease events <a href="#3" id="ref3">[3]</a>. The DCCT/
EDIC study also demonstrated 'metabolic memory' for
glycaemia, that is the persistence of the body's tissues
responses to good or poor glucose control for many years
after the resolution of that good or poor glucose control <a href="#4" id="ref4">[4</a>, <a href="#5" id="ref5">5]</a>.
The recommended HbA1c level for most adults with T1D is
<7% <a href="#6" id="ref6">[6</a>, <a href="#7" id="ref7">7]</a>. Unfortunately, the mean (SD) HbA1c in Australians
with T1D is 8.5 (1.8)%, with less than 20% achieving the
recommended target <a href="#8" id="ref8">[8]</a>.</p>

<p class="art-para">In affluent countries self-monitoring of capillary blood
glucose (BG) levels at home is common with recommendations
for adults with T1D to test at least four times a day, ideally pre-meals and pre-bed, to confirm hypoglycaemia and recovery
from hypoglycaemia, and prior to insulin dosing for meals or
high glucose correction <a href="#9" id="ref9">[9]</a>. More frequent BG testing is
recommended during sick days <a href="#9" id="ref9">[9]</a> or other circumstances
such as during and after endurance exercise, travels crossing
time-zones and in those with impaired hypoglycaemia
awareness. More recently available interstitial fluid glucose
monitoring, if affordable and acceptable to the user, provides
far more frequent assessments of glucose levels (up to 288
times a day with systems providing glucose levels every 5
minutes), albeit often with differences in absolute values and a
time lag relative to glucose levels in blood (discussed below).</p>
<p class="art-para">The acute complications of T1D include hypoglycaemia,
hyperglycaemia and diabetic ketoacidosis (DKA). Poor glucose
control is also often associated with increased risk of infections
and with mental well-being issues.</p>


<p class="art-subhead" id="hypoglycaemia">Hypoglycaemia</p>
<p class="art-para">The average person with T1D in Australia has two to three
mild episodes of hypoglycaemia per week, and one episode
per year of severe hypoglycaemia (defined as that requiring
assistance from someone else for recovery) <a href="#10" id="ref10">[10]</a>. About 30% of
people with T1D will experience impaired hypoglycaemia
awareness at some stage, which is associated with a 6-fold
increased risk of severe hypoglycaemia <a href="#10" id="ref10">[10</a>, <a href="#11" id="ref11">11]</a>. Nocturnal
hypoglycaemia is particularly likely to be unrecognised by the
T1D patient, as sleep (and also exercise and recent
hypoglycaemia) impair counter-regulatory responses <a href="#12" id="ref12">[12]</a>.
Hypoglycaemia can cause seizures, cardiac arrhythmias and
death, including the so-called 'dead in bed' syndrome in which
an otherwise well person with T1D goes to bed and is found
dead next morning, with no explanatory findings on autopsy
<a href="#13" id="ref13">[13</a>, <a href="#14" id="ref14">14]</a>. Hypoglycaemia-induced cardiac QT prolongation and
cardiac arrhythmia is thought to be the cause. Simultaneous
CGM and Holter monitor studies have documented frequent
associations between low glucose levels and ECG abnormalities,
including atrial and ventricular rhythm disturbances (15).</p>

<p class="art-subhead" id="glucose">Glucose Variability</p>
<p class="art-para">More recently, interest in glucose variability (GV) has
increased. GV can be measured in the short- term (based on
glucose fluctuations across days) usually by continuous glucose
monitoring (CGM) or flash glucose monitoring (FGM) or by
repeated fingerprick blood glucose (BG) levels, or in the long-term, over months to years, based on HbA1c levels. Greater GV
has been associated with reduced quality of life, increased risk
of mild and severe hypoglycaemia, vascular dysfunction,
increased oxidative stress and inflammation and vascular
complications <a href="#16" id="ref16">[16</a>-<a href="#19" id="ref19">19]</a>. As yet there is no consensus with regard
to recommended targets for all the various measures of GV.</p>
<p class="art-subhead" id="assessment">Tools for Blood-based Glucose Control Assessment</p>

<p class="art-para">The commonest laboratory tool to assess glucose control is
HbA1c, which reflects average glucose levels over the previous
2-3 months and is usually the major glucose treatment target
recommended in national guidelines <a href="#6" id="ref6">[6</a>, <a href="#7" id="ref7">7</a>, <a href="#18" id="ref18">18]</a>. HbA1c results
can be interfered with by haemoglobinopathies, anaemia and
ethnicity <a href="#20" id="ref20">[20]</a>.</p>
<p class="art-para">The frequency of home BG monitoring has been inversely
correlated with HbA1c levels <a href="#9" id="ref9">[9</a>, <a href="#21" id="ref21">21]</a>, but of course the test
itself is not the treatment, but rather a tool to guide
adjustments to insulin doses, diet or physical activity, or use of
adjunct glucose lowering drugs.</p>
<p class="art-subhead" id="home">Blood or Urine Ketone Tests at Home</p>
<p class="art-para">Blood or urine ketone measurements are also recommended
during sick days and if BG levels are 15mmmol/l or more,
particularly if elevated for several hours <a href="#22" id="ref22">[22]</a>. Blood and urine
glucose and ketone test strips are available, though blood test-strips are preferred for several reasons: patient preference, because blood tests are more quantitative than urine tests,
because urine levels lag behind blood levels time-wise, and the
renal threshold for glucose loss may vary considerably between
and within individuals <a href="#23" id="ref23">[23]</a>.</p>



<p class="art-subhead" id="systems">Interstitial Fluid Glucose Testing Systems</p>
<p class="art-para">More recently available are interstitial fluid glucose
testing systems which can measure and report interstitial fluid
glucose levels (depending on the CGM or FGM system used)
every 1 - 15 mins for 6, 7, 10 or 14 days. There are both real-time (RT) and masked CGM systems.</p>

<p class="art-para"><b>Real-time (RT)-CGM</b><br/>
With the real-time systems the glucose data are immediately
available to the wearer. The RT-CGM systems can provide
auditory or vibratory alerts for (actual or sometimes predicted)
high or low glucose levels and rapid glucose changes, and
some systems (for example, the Dexcom G5 or G6&trade; and
Guardian Connect&trade;), results and alerts can also be shared
real-time with a third party, such as a parent or carer <a href="#24" id="ref24">[24</a>-<a href="#28" id="ref28">28]</a>.
These CGM systems usually require calibration by BG testing
twice a day (in each 12-hour block). Relative to BG monitoring,
meta-analyses of RT-CGM trials demonstrate HbA1c
reductions by about 0.25% with their use, with similar HbA1c
benefit if used with multiple daily insulin injections (MDI) or an
insulin pump <a href="#29" id="ref29">[29]</a>.</p>
<p class="art-para"><b>Masked CGM</b><br/>
The masked CGM systems, in which glucose results are
not available to the wearer and clinical assessment are of
value as a research educational tool. The sensor device is
usually inserted, removed and data down-loaded by the
clinician, and are commonly used to assess glucose control in
people with Type 2 diabetes <a href="#26" id="ref26">[26</a>,<a href="#28" id="ref28"> 28</a>, <a href="#30" id="ref30">30] </a>and gestational
diabetes <a href="#29" id="ref29">[29</a>, <a href="#31" id="ref31">31]</a>. Both masked and RT-CGM systems can be
downloaded for review and sharing. As the masked CGM data
are only available retrospectively, the results cannot be
responded to by the user in real-time and there are no glucose
related alerts or sharing real-time with a third party.</p>

<p class="art-para"><b>RT-CGM Systems that can Modulate Insulin Delivery</b><br/>
Some commercial RT-CGM systems (currently in Australia only
Medtronic) can be linked with insulin pumps and modulate
insulin delivery. Depending on which insulin pump model is
used with RT-CGM, the system can cease insulin delivery at or
before a specified low interstitial fluid glucose level and restart
insulin delivery on patient initiation, automatically after
2-hours, or when the interstitial glucose level has reached a
specified higher level <a href="#32" id="ref32">[32</a>-<a href="#34" id="ref34">34]</a>. Different glucose alerts, insulin
suspend and restart levels can be set for different times of day.</p>
<p class="art-para">Trials of RT-CGM systems with low glucose suspend (LGS)
or predictive LGS options have been shown to improve HbA1c
levels (by about 0.25%) for insulin pump users, and also
increase time in target glucose ranges and reduce
hypoglycaemia, in particular severe hypoglycaemia, and low
glucose time <a href="#31" id="ref31">[31</a>-<a href="#33" id="ref33">33]</a>. Continuous use of RT-CGM in pregnant
women with T1D using either an insulin pump or MDI has been shown to significantly improve HbA1c levels, time in
glucose target range, GV, and neonatal health outcomes, with
major reductions in large for gestation age babies, intensive
care admissions, neonatal hypoglycaemia and length of
hospital stay <a href="#35" id="ref35">[35]</a>.</p>
<p class="art-para">In 2017 Medtronic released its (Medtronic 670G) hybrid
closed loop (HCL) insulin pump and RT- CGM system in the
USA, which is currently the only commercial clinically available
HCL system. Release in other countries is anticipated soon. The
system is referred to as a hybrid closed loop pump as user
interactions are still required. In this system RT-CGM results
and an in-built personalised control algorithm guide insulin
delivery with microboluses every few minutes rather than flat
basal rates for several hours <a href="#36" id="ref36">[36]</a>, although the bolus nature of
insulin delivery would be dampened by its subcutaneous
delivery and absorption. Such systems still require home BG
testing, such as to calibrate the CGM, and for meal and
correction boluses. In its 3-month pivotal trial (n=129, aged 14
- 75 years) use of the Medtronic HCL system reduced HbA1c
levels by &asymp; 0.5%, significantly increased time in glucose target
range (3.9-10mmol/l) to &asymp; 70% of the day, and significantly
reduced low glucose time. There were no episodes of DKA or
severe hypoglycaemia <a href="#35" id="ref35">[35]</a>. Meta-analyses of trials of artificial
pancreas systems versus clinically available (first and second
generation) pumps and RT-CGM systems demonstrate time in
glucose target range of 70-85%, with 12.6% more time in target
range and 50% less time <3.9 mmol/l (37). Limitations of the
HCL system are that the CGM data and the automatic insulin
delivery functions are not always available, such as when the
glucose sensor signal is lost, glucose levels are outside range or
(as a safety feature) when there are high insulin delivery rates.
Other limitations are that the system still requires user input
such as for meal boluses, exercise and at unexpected times <a href="#36" id="ref36">[36]</a> and some would prefer a more aggressive glucose control
algorithm. These systems will likely improve with new versions.</p>



<p class="art-subhead" id="monitoring">Flash glucose monitoring (FGM)</p>
<p class="art-para">FGM measures interstitial fluid glucose levels every
15-minutes, but only delivers results when the glucose sensor
/ transmitter is 'flashed' or 'swiped' by the specialised (Abbott)
meter, which also can be used with blood glucose and ketone
test-strips. The sensor, which can transmit a signal through
clothing more recently a compatible smartphone can be used
(up to 4 cm), can last up to 14-days and works best when
placed on the upper arm. As well as the current interstitial
fluid glucose level the system provides trend arrows for rising
or falling glucose levels and a graph of the last 8-hours of
interstitial fluid glucose readings. As the system is factory
calibrated no BG calibrations by the user are required. There
are no currently no glucose alerts, real-time glucose data
sharing, nor can it be linked with insulin pumps to modulate
insulin delivery <a href="#38" id="ref38">[38</a>-<a href="#40" id="ref40">40]</a>. FGM approvals differ between
countries, and include approvals for adults and children, T1D
and insulin treated Type 2 diabetes (T2D), and (although not
in Australia) for insulin dosing without BG checking. In a large
multi-country real-world (not clinical trial) study of T1D and T2D (n=50,831 readers and 279,446 glucose sensors) the
mean number of scans per day was 16.3 per user <a href="#41" id="ref41">[41]</a>. A
higher frequency of glucose checking using FGM was
associated with lower estimated HbA1c levels, more time in
target glucose range and less low and high glucose time <a href="#42" id="ref42">[42]</a>.</p>


<p class="art-subhead" id="fgm">Limitations of CGM and FGM</p>
<p class="art-para">Limitations of CGM and FGM Include the need for patients
to wear a device (continuously) and for CGM, but not FGM, for
twice daily BG calibrations. The amount of glucose information
can be excessive for some, increasing distress related to the
time out of target range and glucose variability. If too frequent
or too large insulin boluses are given to reduce high glucose
levels there is potential for insulin stacking and hypoglycaemia.
There are often differences between blood and interstitial
fluid glucose values related to a lag (behind blood) of about
10 minutes and differences in absolute values of about 10%,
usually with larger differences at glucose extremes, with even
greater divergence between interstitial fluid and blood
glucose levels if the FGM is somewhere else on the body than
the recommended upper arm site <a href="#41" id="ref41">[41]</a>. Some oral substances
can affect CGM or FGM readings. Oral paracetamol can
increase CGM sensor (but not BG test-strip levels) by up to
25% for up to 8-hours <a href="#43" id="ref43">[43]</a>. Whilst the FGM sensor claims not
to be affected by paracetamol, salicyclic acid and ascorbic
acid may interfere, and as yet FGM has not been evaluated for
dialysis patients <a href="#44" id="ref44">[44]</a>. Both CGM and FGM have operating
temperature and altitude sensor ranges, but most users are
within the usual limits. For people using such systems at
extremes the specifications of their specific device should be
checked. Similarly, while most currently available sensors are
suitable for bathing, showering or swimming, the suitability of
each specific device for prolonged exposure to water, deep
water diver or sea water immersion should be checked.</p>

<p class="art-para">There are additional time and educational requirements
for both patients and clinicians related to CGM or FGM use. In
most countries, CGM and FGM are not fully subsidised by the
Government or Private Health Insurance companies hence
the out-of-pocket costs for consumers to purchase a
transmitter and scanner can be substantial. In Australia the
standard cost per (disposable 6-14 day sensor) ranges $75 -
$92. Table 1 compares the features of blood glucose
monitoring, and first generation CGM and FGM.</p>

<div class="art-img">
<img src="<?php echo $imgpath;?>images/mjd-111-t001a.gif" class="img-responsive center-block"/></div>
<div class="art-img">
<img src="<?php echo $imgpath;?>images/mjd-111-t001b.gif" class="img-responsive center-block"/></div>
<div class="art-img">



<p class="art-subhead" id="sensors">Next generation interstitial fluid glucose
monitoring - implantable sensors</p>
<p class="art-para">The next generation of interstitial fluid glucose monitoring
devices are implantable (into subcutaneous tissue), with
potential to last up to 1 - 2 years. The first clinically available
system, whilst not yet available in Australia, is the Eversense
CGM system, approved for up to 180 days use in Europe <a href="#45" id="ref45">[45]</a>,
and recently approved by the USA Federal Drug and
Administration (FDA) for up to 90 days use <a href="#46" id="ref46">[46]</a>. The Eversense
CGM system uses a small fluorescence light based sensor
implanted in the upper arm under local anaesthetic via a
5-8mm incision during an outpatient procedure. The user
then wears a rechargeable, removable transmitter on the skin
over the sensor which powers the sensor and sends a signal
which converts to real-time glucose readings (every
5-minutes) on a smartphone app. The device can alert wearers
to high or low glucose levels via the smartphone, and even
when out of range of the smartphone by vibration of the onbody transmitter. Other devices which are fully implantable
(sensor and transmitters) and contact lens type sensors are
still in development.</p>

<p class="art-para"><b>Home Monitoring Devices are Tools</b><br/>
Use of any of the above glucose (or ketone) measuring
devices is a tool. It is how the information they provide is used
to guide drug dosing, food, physical activity and seeking
medical advice that are the treatments. This requires both
knowledge and its implementation. With the rapid growth in
the number of people with diabetes the time available to
explain new technologies to patients, to review the results
and to assess their knowledge is limited. There are many
issues that must be addressed during a diabetes related
consultation, including control of glucose and other risk
factors (such as blood pressure and lipids), lifestyle assessment
and modulation, history taking, physical examinations, mental
health support, ordering and interpreting test results,
prescriptions and regulatory paperwork (such as for licences,
insurance or travel). Any systems that can help the clinician
and the person with diabetes improve their diabetes care and
outcomes merit consideration.</p>

<p class="art-subhead" id="practice">A Survey to Assess Glucose
Self-Management Practice</p>
<p class="art-para">To assist the busy clinician to assess the glucose self-care
practices of his or her adult patients with T1D we developed a
paper-based survey suitable for self-administration whilst in the clinic waiting room. Given the frequency and risks of
overnight hypoglycaemia there was an emphasis on overnight
glucose control. Results have been published <a href="#47" id="ref47">[47</a>, <a href="#48" id="ref48">48]</a>. On
average the 16-question survey, available on request from
the authors, took &asymp;11 minutes to complete. The survey was
conducted prior to the availability of FGM in Australia and
with very few regular CGM users. We believe this is a novel
tool, and may be used and adapted by other users for their
practices, and to incorporate CGM and FGM use.</p>

<p class="art-para">We demonstrated the survey feasibility and similar
responses from adults with T1D in two Australian tertiary
referral diabetes clinics and in a general practice (GP) clinic
with a strong interest in T1D <a href="#47" id="ref47">[47</a>, <a href="#48" id="ref48">48]</a>. Whilst the average
number of self-reported BG tests per day was above the
recommended four tests per day, about one third of patients
reported never testing their BG overnight, despite our
clinicians usually recommending episodic overnight testing
given the frequency and risks of nocturnal hypoglycaemia. In
contrast 9% of patients reported testing their BG overnight
every night. Such patients could benefit from CGM with
alarms or use of insulin pumps with low glucose insulin
suspends options. As usually recommended, to avoid
nocturnal hypoglycaemia, subjects targeted higher BG levels
at bedtime and overnight, but sometimes targeted levels in
the teens. Targeted BG levels were similar for those reporting
impaired and normal hypoglycaemia awareness. Whilst
patients had adequate BG test-strips, about one third reported
not having in-date ketone test-strips at home. A likely
contributor may be that, in contrast to BG test-strips, ketone
strips are relatively costly for the user due to lack of a subsidy
by the Australian Government.</p>

<p class="art-para">We found that suboptimal treatment of nocturnal
hypoglycaemia events was common. Only 37% of the hospital
clinics and 23% of the GP clinic patients reporting eating the
recommended refined carbohydrate to rapidly increase BG
levels followed by complex carbohydrate to prevent
hypoglycaemia recurrence if the next meal was not within 20
minutes. Almost half of people reported consuming refined
carbohydrate only, and often not checking BG levels, as
recommended, prior to returning to sleep. This could increase
nocturnal hypoglycaemia recurrence risk. The 6% of patients
who reported consuming complex carbohydrate alone for
hypoglycaemia may have a delayed recovery from
hypoglycaemia. We speculate these behaviours may relate to
a need for education, lack of nearby optimal foods, a desire to
return to sleep promptly and / or to prevent posthypoglycaemia hyperglycaemia <a href="#47" id="ref47">[47</a>, <a href="#48" id="ref48">48]</a>.</p>

<p class="art-para">A high percentage of survey participants reported that
they would not change their overnight diabetes plan if they
had extra exercise, alcohol or illness (50%, 60% and 48%
respectively), which may increase risk of nocturnal
hypoglycaemia after exercise or alcohol, and of hyperglycaemia
/ ketoacidosis during illness. Many reported a lack of
confidence in adjusting their diabetes care plans.</p>

<p class="art-para">Patients were asked how they would treat pre-bed BG
levels of 4, 8, 11, 15mmol, 18mmol with moderate ketones and 20 mmol/l. Less than one in four patients always
suggested safe responses to these hypothetical bed-time BG
levels. Mid-range levels, where no action was usually needed,
had the highest rates of safe responses <a href="#47" id="ref47">[47</a>, <a href="#48" id="ref48">48]</a>. There is
substantial evidence that education is key in improving
diabetes management, especially in reducing hypoglycaemia
<a href="#49" id="ref49">[49</a>-<a href="#52" id="ref52">52]</a>.</p>


<p class="art-para">Many patients (33 %) desired further diabetes education,
which was provided in this study, but there were few
demographic factors to predict who might require or want
education. The survey we developed and utilised, which could
be incorporated into an annual review, perhaps associated
with risk factor and complication screening, may assist. With
appropriate modifications the survey could be administered
electronically, in other languages, and to paediatric / adolescent
patients and their carers.</p>
<p class="art-para">There are well recognised limitations of self-reporting in
surveys. Whilst participants may report what they perceive to
be desired actions, rather than actual behaviour, nevertheless,
there are still high rates of suboptimal answers in our surveys.
There may also be recall bias. Selection bias risk was small due
to very high rates of patient participation. We recognise that
the suboptimal answers may reflect real knowledge gaps or
may reflect lack of implementation of knowledge.</p>
<p class="art-subhead" id="implementation">Diabetes Knowledge and its Implementation</p>
<p class="art-para">There is much to learn about living with diabetes, and
education should be regarded as an ongoing process and a
shared responsibility of the clinician and the patient. Time
and tools to assess knowledge are important, and the
availability of new home-monitoring systems, as described
above, increases the time and knowledge base required, for
both clinicians and users.</p>
<p class="art-para">There are many sources of diabetes education and they
may sometimes provide contrasting information. In addition
to the various clinicians in the diabetes care team, information
may be obtained from family, friends, other people with
diabetes, support groups, industry, literature and the internet.
There is the potential for both valuable and misleading
information. Clinicians should be aware of suitable information
sources and websites to recommend, and be well-prepared to
discuss divergent information. Websites by national diabetes
organisations and the Juvenile Diabetes Research Foundation
are usually reputable, evidence-based and up-to-date.</p>
<p class="art-para">Although the care of and outcomes for patients with T1D
has improved immeasurably in recent times, many challenges
remain. Barriers to optimal management of diabetes may be
broadly thought of as patient related, clinician related and
system related. Managing and living with T1D is hard work, as
summarised wryly in a type 1 meme: "Type 1 diabetes is a full-time job that we didn't apply for, don't want and can't resign
from, and there's no vacation or pay" <a href="#53" id="ref53">[53]</a>. The relentless nature
of T1D can lead to diabetes distress, depression and burn-out,
which can lead to a relegation of diabetes management in the hierarchy of priorities for the person with diabetes <a href="#10" id="ref10">[10</a>, <a href="#54" id="ref54">54</a>-<a href="#56" id="ref56">56]</a>. As
a result, we often witness both the expected mechanics and
consequences of poorer self-management. Common manifestations
include infrequent glucose or ketone monitoring ('I don't want
to know"), and sub-optimal treatment ("I don't want to do")
including 'guesstimated' or omitted doses of insulin. This can
result in poorer glycaemic control, guilt, avoidance and
depression. Thus, the struggling individual battling for control
over their T1D can enter a negative spiral.</p>
<p class="art-para">T1D imposes significant financial costs on the person with
diabetes and their families <a href="#57" id="ref57">[57]</a>, particularly if care is not
subsidised by the healthcare system. In addition to the cost of
medications there are the costs associated with the various
paraphernalia used to treat and monitor their diabetes such
as syringes, pumps, CGM, FGM, BG meters, glucose and
ketone test-strips. Less visible is the cost in time, effort and
avoidance of otherwise pleasurable activities and / or healthy
activities, such as exercise, due to fear of hypoglycaemia,
hyperglycaemia or embarrassment <a href="#58" id="ref58">[58]</a>.</p>
<p class="art-para">Poor health literacy has been identified as a significant
predictor of poorer clinical outcomes in many conditions,
including diabetes <a href="#59" id="ref59">[59</a>-<a href="#62" id="ref62">62]</a>. People with diabetes may not always
fully appreciate the gravity of their situation or they may struggle
with the complexity of the pathophysiology of their disease and
its management. This may change throughout their life course
with T1D, such as related to their age and cognitive ability,
development of diabetes complications, or the use of modern
diabetes technologies, such as insulin pumps and insulin bolus
calculators. Numeracy and literacy may be inadequate for the
task of carbohydrate counting and insulin dosage calculations.
Patients may experience loss of control, feelings of inadequacy
and a sense of failure, adding to the challenge and burden of
self-management.</p>
<p class="art-para">Clinician barriers, particularly in the primary care sector, may
relate to lack of knowledge, time, experience and confidence
dealing with T1D. Health care practitioners may misinterpret a
patient's poor outcomes as a lack of interest, laziness or obstinacy,
rather than picking up on their patient's distress and supporting
them appropriately. There are also clinician and healthcare system
barriers to acquiring and implementing relevant T1D related
knowledge, including that related to home glucose and ketone
monitoring. Clinicians may themselves be stressed, time-poor and
burnt out. The resulting maladaptation is to accept the status quo,
resulting in therapeutic inertia, allowing a toxic situation, such as
high HbA1c levels, frequent hypoglycaemia events and high GV to
persist. System related barriers may relate to workforce shortages,
proximity to care and hours that the T1D service may be offered.
When demands exceed resources, distress and maladaptive
behaviour can ensue in both patients and their clinicians.</p>
<p class="art-subhead" id="conclusion">Conclusions</p>
<p class="art-para">The importance of good glucose control in people with T1D is
well-recognised. There is an increasing array of tools available to
assess glucose and ketones at home, which have proven benefit in
clinical trials. Cost is often a barrier to their regular use. Patients and
their clinicians must also have adequate knowledge, time to acquire it, and most importantly the ability, finances and desire to implement
it appropriately in order to maximise the clinical benefits.</p>

<p class="art-subhead" id="interest">Conflict of Interest</p>
<p class="art-para">AJJ and DNO have received peer reviewed research grants
from Medtronic and are on advisory boards for Medtronic
(Australia) and Abbott (Diabetes). GK, ES, GRF and ASJ have
no conflict of interest.</p>
<p class="art-para">None of the authors have stocks or shares of any companies
products which are cited in this publication.</p>

<p class="art-subhead" id="references">References</p>
<ol>
<li class="ref"><div id="1"> Cho NH, Shaw JE, Karuranga S, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/29496507" target="_blank">IDF Diabetes Atlas: Global estimates of
diabetes prevalence for 2017 and projections for 2045.</a> <i>Diabetes Res Clin
Pract</i>. 2018; 138: 271-281. doi: 10.1016/j.diabres.2018.02.023&nbsp;&nbsp;&nbsp;<a href="#ref1"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="2"> Weng J, Zhou Z, Guo L, et al. <a href="https://www.bmj.com/content/360/bmj.j5295" target="_blank">Incidence of type 1 diabetes in China, 2010-
13: population based study.</a> <i>BMJ</i>. 2018; 360: 5295. doi: 10.1136/bmj.j5295&nbsp;&nbsp;&nbsp;<a href="#ref2"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="3">Gubitosi-Klug RA, Group DER. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24356597" target="_blank">The diabetes control and complications
trial/epidemiology of diabetes interventions and complications study at
30 years: summary and future directions. </a><i>Diabetes Care</i>. 2014; 37(1): 44-
49. doi: 10.2337/dc13-2148&nbsp;&nbsp;&nbsp;<a href="#ref3"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="4"> Diabetes C, Complications Trial /Epidemiology of Diabetes I, Complications
Research G, Lachin JM, White NH, Hainsworth DP, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25204977" target="_blank">Effect of intensive
diabetes therapy on the progression of diabetic retinopathy in patients
with type 1 diabetes: 18 years of follow-up in the DCCT/EDIC.</a> <i>Diabetes</i>.
2015; 64(2): 631-642. doi: 10.2337/db14-0930&nbsp;&nbsp;&nbsp;<a href="#ref4"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="5">White NH, Sun W, Cleary PA, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19064853" target="_blank">Prolonged effect of intensive therapy
on the risk of retinopathy complications in patients with type 1 diabetes
mellitus: 10 years after the Diabetes Control and Complications Trial.</a> <i>Arch
Ophthalmol</i>. 2008; 126(12): 1707-1715. doi: 10.1001/archopht.126.12.1707&nbsp;&nbsp;&nbsp;<a href="#ref5"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="6"> American Diabetes Association. <a href="http://care.diabetesjournals.org/content/41/Supplement_1/S55" target="_blank">6. Glycemic Targets: Standards of Medical Care
in Diabetes-2018.</a> <i>Diabetes Care</i>. 2018; 41(1): 55-64. doi: 10.2337/dc18-S006&nbsp;&nbsp;&nbsp;<a href="#ref6"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="7">Cheung NW, Conn JJ, d'Emden MC, et al. Position statement of the
Australian Diabetes Society: individualisation of glycated haemoglobin
targets for adults with diabetes mellitus. <i>Med J Aust</i>. 2009; 191(6): 339-
344.&nbsp;&nbsp;&nbsp;<a href="#ref7"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="8">National Association of Diabetes Centers. Final Report ANDIAB 2011. [Available from: https://www.adea.com.au/wp-content/uploads/2013/08/ANDIAB-Final-Report-2011.pdf. Accessed: 28 May 2018.&nbsp;&nbsp;&nbsp;<a href="#ref8"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="9">Murata T, Tsuzaki K, Yoshioka F, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26543543" target="_blank">The relationship between the
frequency of self-monitoring of blood glucose and glycemic control in
patients with type 1 diabetes mellitus on continuous subcutaneous insulin
infusion or on multiple daily injections.</a> <i>J Diabetes Investig</i>. 2015; 6(6): 687-
691. doi: 10.1111/jdi.12362&nbsp;&nbsp;&nbsp;<a href="#ref9"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="10">Hendrieckx C, Halliday JA, Bowden JP, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24513121" target="_blank">Severe hypoglycaemia and its
association with psychological well-being in Australian adults with type 1
diabetes attending specialist tertiary clinics.</a> <i>Diabetes Res Clin Pract</i>. 2014;
103(3): 430-436. doi: 10.1016/j.diabres.2013.12.005&nbsp;&nbsp;&nbsp;<a href="#ref10"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="11">Ly TT, Gallego PH, Davis EA, Jones TW.<a href="http://care.diabetesjournals.org/content/32/10/1802" target="_blank"> Impaired awareness of hypoglycemia
in a population-based sample of children and adolescents with type 1
diabetes. </a><i>Diabetes Care</i>. 2009; 32(10): 1802-1806. doi: 10.2337/dc09-0541&nbsp;&nbsp;&nbsp;<a href="#ref11"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="12"> Jones TW, Porter P, Sherwin RS, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/9614256" target="_blank">Decreased epinephrine responses to
hypoglycemia during sleep.</a> <i>N Engl J Med</i>. 1998; 338(23): 1657-1662. doi:
10.1056/NEJM199806043382303&nbsp;&nbsp;&nbsp;<a href="#ref12"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="13">Hsieh A, Twigg SM. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24972763" target="_blank">The enigma of the dead-in-bed syndrome: challenges
in predicting and preventing this devastating complication of type 1
diabetes.</a> <i>J Diabetes Complications</i>. 2014; 28(5): 585-587. doi: 10.1016/j.
jdiacomp.2014.04.005&nbsp;&nbsp;&nbsp;<a href="#ref13"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="14">Tu E, Twigg SM, Semsarian C.<a href="https://www.ncbi.nlm.nih.gov/pubmed/18676043" target="_blank"> Sudden death in type 1 diabetes: the
mystery of the 'dead in bed' syndrome.</a> <i>Int J Cardiol</i>. 2010; 138(1): 91-93.
doi: 10.1016/j.ijcard.2008.06.021&nbsp;&nbsp;&nbsp;<a href="#ref14"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="15"> Novodvorsky P, Bernjak A, Chow E, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/28213374" target="_blank"> Diurnal Differences in Risk of
Cardiac Arrhythmias During Spontaneous Hypoglycemia in Young People
With Type 1 Diabetes.</a><i> Diabetes Care</i>. 2017; 40(5): 655-662. doi: 10.2337/
dc16-2177&nbsp;&nbsp;&nbsp;<a href="#ref15"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="16">Ayano-Takahara S, Ikeda K, Fujimoto S, et al. <a href="http://care.diabetesjournals.org/content/38/1/e1" target="_blank">Glycemic variability is
associated with quality of life and treatment satisfaction in patients with
type 1 diabetes.</a><i> Diabetes Care</i>. 2015; 38(1): 1-2. doi: 10.2337/dc14-1801&nbsp;&nbsp;&nbsp;<a href="#ref16"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="17">Kilpatrick ES, Rigby AS, Goode K, Atkin SL.<a href="https://www.ncbi.nlm.nih.gov/pubmed/17882397" target="_blank"> Relating mean blood glucose
and glucose variability to the risk of multiple episodes of hypoglycaemia
in type 1 diabetes.</a><i> Diabetologia</i>. 2007; 50(12): 2553-2561. doi: 10.1007/
s00125-007-0820-z&nbsp;&nbsp;&nbsp;<a href="#ref17"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="18">Kovatchev BP.<a href="https://www.ncbi.nlm.nih.gov/pubmed/28304392" target="_blank"> Metrics for glycaemic control - from HbA1c to continuous
glucose monitoring.</a><i> Nat Rev Endocrinol</i>. 2017; 13(7): 425-436. doi:
10.1038/nrendo.2017.3&nbsp;&nbsp;&nbsp;<a href="#ref18"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="19">Monnier L, Colette C, Wojtusciszyn A, et al. <a href="http://care.diabetesjournals.org/content/40/7/832" target="_blank">Toward Defining the Threshold
Between Low and High Glucose Variability in Diabetes.</a><i> Diabetes Care</i>.
2017; 40(7): 832-838. doi: 10.2337/dc16-1769&nbsp;&nbsp;&nbsp;<a href="#ref19"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="20">National Glycohemoglobin Standardization Program. Factors that
interfere with HbA1c test results. 2018. [Available from: http://www.ngsp.
org/factors.asp]. Accessed: 28 May 2018&nbsp;&nbsp;&nbsp;<a href="#ref20"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="21"> Telo GH, de Souza MS, Andrade TS, Schaan BD. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966590/" target="_blank">Comparison between
adherence assessments and blood glucose monitoring measures to
predict glycemic control in adults with type1 diabetes: a cross-sectional
study.</a><i> Diabetol Metab Syndr</i>. 2016; 8: 54. doi: 10.1186/s13098-016-0162-4&nbsp;&nbsp;&nbsp;<a href="#ref21"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="22">Australian Diabetes Educators Association. Clinical Guiding Principles for
Sick Day Management of Adults with Type 1 and Type 2 Diabetes.
Technical document. Canberra: Australian Diabetes Educators Association;
2016  [Available from: https://www.adea.com.au/wp-content/uploads/2009/10/Clinical-Guiding-Principles-for-Sick-Day-Management-of-Adults-with-type-1-
and-type-2-diabetes-Review-2016.docx.pdf ]. Accessed: 28 May 2018.&nbsp;&nbsp;&nbsp;<a href="#ref22"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="23">Johansen K, Svendsen PA, Lorup B. Variations in renal threshold for
glucose in Type 1 (insulin-dependent) diabetes mellitus. <i>Diabetologia</i>.
1984; 26(3): 180-182.&nbsp;&nbsp;&nbsp;<a href="#ref23"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="24"> Danne T, Nimri R, Battelino T, et al.<a href="http://care.diabetesjournals.org/content/40/12/1631" target="_blank"> International Consensus on Use of
Continuous Glucose Monitoring.</a> <i>Diabetes Care</i>. 2017; 40(12): 1631-1640.
doi: 10.2337/dc17-1600&nbsp;&nbsp;&nbsp;<a href="#ref24"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="25">Klonoff DC, Ahn D, Drincic A. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28965029" target="_blank">Continuous glucose monitoring: A review of
the technology and clinical use.</a> <i>Diabetes Res Clin Pract</i>. 2017; 133: 178-
192. doi: 10.1016/j.diabres.2017.08.005&nbsp;&nbsp;&nbsp;<a href="#ref25"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="26">Petrie JR, Peters AL, Bergenstal RM, Holl RW, Fleming GA, Heinemann L.
<a href="https://www.researchgate.net/publication/320646276_Improving_the_Clinical_Value_and_Utility_of_CGM_Systems_Issues_and_Recommendations_A_Joint_Statement_of_the_European_Association_for_the_Study_of_Diabetes_and_the_American_Diabetes_Association_Diabete" target="_blank">Improving the Clinical Value and Utility of CGM Systems: Issues and
Recommendations: A Joint Statement of the European Association for the
Study of Diabetes and the American Diabetes Association Diabetes
Technology Working Group.</a> <i>Diabetes Care</i>. 2017; 40(12): 1614-1621. doi:
10.2337/dci17-0043&nbsp;&nbsp;&nbsp;<a href="#ref26"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="27"> Slattery D, Choudhary P. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28541131" target="_blank">Clinical Use of Continuous Glucose Monitoring in
Adults with Type 1 Diabetes.</a> <i>Diabetes Technol Ther</i>. 2017; 19(2): 55-61.
doi: 10.1089/dia.2017.0051&nbsp;&nbsp;&nbsp;<a href="#ref27"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="28"> Wood A, O'Neal D, Furler J, Ekinci EI. <a href="https://www.ncbi.nlm.nih.gov/pubmed/29464891" target="_blank">Continuous glucose monitoring: a
review of the evidence, opportunities for future use and ongoing
challenges.</a><i> Intern Med J</i>. 2018; 48(5): 499-508. doi: 10.1111/imj.13770&nbsp;&nbsp;&nbsp;<a href="#ref28"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="29">Szypowska A, Ramotowska A, Dzygalo K, Golicki D. <a href="https://www.ncbi.nlm.nih.gov/pubmed/22096111" target="_blank">Beneficial effect of real-time continuous glucose monitoring system on glycemic control in type 1
diabetic patients: systematic review and meta-analysis of randomized trials.</a> <i>Eur J Endocrinol</i>. 2012; 166(4): 567-574. doi: 10.1530/EJE-11-0642&nbsp;&nbsp;&nbsp;<a href="#ref29"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="30">Vigersky R, Shrivastav M. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27818105" target="_blank">Role of continuous glucose monitoring for type
2 in diabetes management and research.</a><i> J Diabetes Complications</i>. 2017;
31(1): 280-287. doi: 10.1016/j.jdiacomp.2016.10.007&nbsp;&nbsp;&nbsp;<a href="#ref30"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="31"> McLachlan K, Jenkins A, O'Neal D. The role of continuous glucose monitoring
in clinical decision-making in diabetes in pregnancy. <i>Aust N Z J Obstet
Gynaecol</i>. 2007; 47(3): 186-190. doi: 10.1111/j.1479-828X.2007.00716.x&nbsp;&nbsp;&nbsp;<a href="#ref31"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="32">Abraham MB, Nicholas JA, Smith GJ, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/29191844" target="_blank"> Reduction in Hypoglycemia
with the Predictive Low-Glucose Management System: A Long-term
Randomized Controlled Trial in Adolescents with Type 1 Diabetes.</a> <i>Diabetes Care</i>. 2018; 41(2): 303-310. doi: 10.2337/dc17-1604&nbsp;&nbsp;&nbsp;<a href="#ref32"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="33"> Bergenstal RM, Klonoff DC, Garg SK, et al.<a href="https://www.nejm.org/doi/full/10.1056/nejmoa1303576" target="_blank"> Threshold- based insulin-pump
interruption for reduction of hypoglycemia.</a><i> N Engl J Med</i>. 2013; 369(3):
224-232. doi: 10.1056/NEJMoa1303576&nbsp;&nbsp;&nbsp;<a href="#ref33"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="34">Ly TT, Nicholas JA, Retterath A, Lim EM, Davis EA, Jones TW. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24065010" target="_blank">Effect of
sensor- augmented insulin pump therapy and automated insulin
suspension vs standard insulin pump therapy on hypoglycemia in patients
with type 1 diabetes: a randomized clinical trial.</a><i> JAMA</i>. 2013; 310(12):
1240-1247. doi: 10.1001/jama.2013.277818&nbsp;&nbsp;&nbsp;<a href="#ref34"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="35">Feig DS, Donovan LE, Corcoy R, et al. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32400-5/abstract?code=lancet-site" target="_blank">Continuous glucose monitoring in
pregnant women with type 1 diabetes (CONCEPTT): a multicentre
international randomised controlled trial.</a><i> Lancet</i>. 2017; 390(10110): 2347-
2359. doi: 10.1016/S0140-6736(17)32400-5&nbsp;&nbsp;&nbsp;<a href="#ref35"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="36">Garg SK, Weinzimer SA, Tamborlane WV, Buckingham BA, Bode BW,
Bailey TS, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28134564" target="_blank">Glucose Outcomes with the In-Home Use of a Hybrid
Closed-Loop Insulin Delivery System in Adolescents and Adults with Type
1 Diabetes.</a><i> Diabetes Technol Ther</i>. 2017; 19(3): 155-163. doi: 10.1089/
dia.2016.0421&nbsp;&nbsp;&nbsp;<a href="#ref36"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="37">Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28533136" target="_blank">Effect of artificial
pancreas systems on glycaemic control in patients with type 1 diabetes: a
systematic review and meta- analysis of outpatient randomised controlled
trials.</a><i> Lancet Diabetes Endocrinol</i>. 2017; 5(7): 501-512. doi: 10.1016/S2213-
8587(17)30167-5&nbsp;&nbsp;&nbsp;<a href="#ref37"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="38">Al Hayek AA, Robert AA, Al Dawish MA. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731614/" target="_blank">Evaluation of FreeStyle Libre Flash
Glucose Monitoring System on Glycemic Control, Health-Related Quality
of Life, and Fear of Hypoglycemia in Patients with Type 1 Diabetes. </a><i>Clin
Med Insights Endocrinol Diabetes</i>. 2017; 10: 1179551417746957. doi:
10.1177/1179551417746957&nbsp;&nbsp;&nbsp;<a href="#ref38"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="39">Leelarathna L, Wilmot EG. <a href="https://www.ncbi.nlm.nih.gov/pubmed/29356072" target="_blank">Flash forward: a review of flash glucose
monitoring.</a><i> Diabet Med</i>. 2018; 35(4): 472-482. doi: 10.1111/dme.13584&nbsp;&nbsp;&nbsp;<a href="#ref39"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="40">Oskarsson P, Antuna R, Geelhoed-Duijvestijn P, Krger J, Weitgasser R,
Bolinder J.<a href="https://www.ncbi.nlm.nih.gov/pubmed/29273897" target="_blank"> Impact of flash glucose monitoring on hypoglycaemia in adults
with type 1 diabetes managed with multiple daily injection therapy: a pre-specified subgroup analysis of the IMPACT randomised controlled trial.</a> <i>Diabetologia</i>. 2018; 61(3): 539-550. doi: 10.1007/s00125-017-4527-5&nbsp;&nbsp;&nbsp;<a href="#ref40"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="41">Fokkert MJ, van Dijk PR, Edens MA, et al. <a href="https://drc.bmj.com/content/5/1/e000320.citation-tools" target="_blank">Performance of the FreeStyle
Libre Flash glucose monitoring system in patients with type 1 and 2
diabetes mellitus. </a><i>BMJ Open Diabetes Res Care</i>. 2017; 5(1): 000320. doi:
10.1136/bmjdrc-2016-000320&nbsp;&nbsp;&nbsp;<a href="#ref41"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="42"> Dunn TC, Xu Y, Hayter G, Ajjan RA. <a href="https://www.ncbi.nlm.nih.gov/pubmed/29278709" target="_blank">Real-world flash glucose monitoring
patterns and associations between self-monitoring frequency and
glycaemic measures: A European analysis of over 60 million glucose tests.</a> <i>Diabetes Res Clin Pract</i>. 2018; 137: 37-46. doi: 10.1016/j.diabres.2017.12.015&nbsp;&nbsp;&nbsp;<a href="#ref42"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="43">Maahs DM, DeSalvo D, Pyle L, et al. <a href="http://care.diabetesjournals.org/content/38/10/e158" target="_blank">Effect of acetaminophen on CGM
glucose in an outpatient setting.</a> <i>Diabetes Care</i>. 2015; 38(10): 158-159.
doi: 10.2337/dc15-1096&nbsp;&nbsp;&nbsp;<a href="#ref43"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="44"> FreeStyle Libre. Frequently asked questions about the FreeStyle Libre 14
day System. 2018.&nbsp;&nbsp;&nbsp;<a href="#ref44"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="45">BusinessWire. Senseonics Announces CE Mark Approval for Eversense&reg;
XL CGM System. 2017.&nbsp;&nbsp;&nbsp;<a href="#ref45"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="46">FDA. FDA approves first continuous glucose monitoring system with a
fully implantable glucose sensor and compatible mobile app for adults
with diabetes. US Food and Drug Administration. 2018.&nbsp;&nbsp;&nbsp;<a href="#ref46"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="47">Kilov G, Januszewski AS, McGrath RT, et al. Comparable glucose related
self-care by adults with Type 1 diabetes in primary-care and specialist
diabetes clinics and need for patient education. <i>Diabetes & Primary Care
Aust</i>. 2018.&nbsp;&nbsp;&nbsp;<a href="#ref47"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="48">Larsson CR, Januszewski AS, McGrath RT, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/29573166" target="_blank"> Suboptimal behaviour and
knowledge regarding overnight glycaemia in adults with Type 1 diabetes
is common. </a><i>Intern Med J</i>. 2018; doi: 10.1111/imj.13798&nbsp;&nbsp;&nbsp;<a href="#ref48"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="49">Elliott J, Jacques RM, Kruger J, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24654672" target="_blank">Substantial reductions in the number
of diabetic ketoacidosis and severe hypoglycaemia episodes requiring
emergency treatment lead to reduced costs after structured education in
adults with Type 1 diabetes.</a> <i>Diabet Med</i>. 2014; 31(7): 847-853. doi:
10.1111/dme.12441&nbsp;&nbsp;&nbsp;<a href="#ref49"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="50"> Hopkins D, Lawrence I, Mansell P, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/22619082" target="_blank"> Improved biomedical and
psychological outcomes 1 year after structured education in flexible
insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience.</a>
<i>Diabetes Care</i>. 2012; 35(8): 1638-1642. doi: 10.2337/dc11-1579&nbsp;&nbsp;&nbsp;<a href="#ref50"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="51"> Muhlhauser I, Jorgens V, Berger M, et al. Bicentric evaluation of a teaching
and treatment programme for type 1 (insulin-dependent) diabetic
patients: improvement of metabolic control and other measures of
diabetes care for up to 22 months. <i>Diabetologia</i>. 1983; 25(6): 470-476&nbsp;&nbsp;&nbsp;<a href="#ref51"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="52"> Plank J, Kohler G, Rakovac I, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/15258736" target="_blank"> Long-term evaluation of a structured
outpatient education programme for intensified insulin therapy in patients
with Type 1 diabetes: a 12-year follow-up.</a> <i>Diabetologia</i>. 2004; 47(8): 1370-
1375. doi: 10.1007/s00125-004-1456-x&nbsp;&nbsp;&nbsp;<a href="#ref52"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="53">Unknown Author. Depression and its relationship to Type 1 diabetes
[Available from: https://beyondtype1.org/depression-and-its-relationship-totype-1/ ]. Accessed: 28 May 2018.&nbsp;&nbsp;&nbsp;<a href="#ref53"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="54">Dennick K, Sturt J, Speight J.<a href="https://www.ncbi.nlm.nih.gov/pubmed/28274681" target="_blank"> What is diabetes distress and how can we
measure it? Anarrative review and conceptual model.</a> <i>J Diabetes
Complications</i>. 2017; 31(5): 898-911. doi: 10.1016/j.jdiacomp.2016.12.018&nbsp;&nbsp;&nbsp;<a href="#ref54"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="55">Fenwick EK, Rees G, Holmes-Truscott E, Browne JL, Pouwer F, Speight J.
<a href="https://www.ncbi.nlm.nih.gov/pubmed/27106085" target="_blank">What is the best measure for assessing diabetes distress? A comparison
of the Problem Areas in Diabetes and Diabetes Distress Scale: results from
Diabetes MILES-Australia. </a><i>J Health Psychol</i>. 2018; 23(5): 667-680. doi:
10.1177/1359105316642006&nbsp;&nbsp;&nbsp;<a href="#ref55"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="56">Speight J, Holmes-Truscott E, Harvey DM, et al. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26688058" target="_blank">Structured type 1 diabetes
education delivered in routine care in Australia reduces diabetes-related
emergencies and severe diabetes-related distress: The OzDAFNE
program.</a> <i>Diabetes Res Clin Pract</i>. 2016; 112: 65-72. doi: 10.1016/j.
diabres.2015.11.002&nbsp;&nbsp;&nbsp;<a href="#ref56"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="57">Ogle GD, Kim H, Middlehurst AC, Silink M, Jenkins AJ.<a href="https://www.ncbi.nlm.nih.gov/pubmed/26482333" target="_blank"> Financial costs for
families of children with Type 1 diabetes in lower-income countries.</a>
<i>Diabet Med</i>. 2016; 33(6): 820-826. doi: 10.1111/dme.12997&nbsp;&nbsp;&nbsp;<a href="#ref57"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="58">Martyn-Nemeth P, Quinn L, Penckofer S, Park C, Hofer V, Burke L. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28143733" target="_blank">Fear of
hypoglycemia: Influence on glycemic variability and self-management
behavior in young adults with type 1 diabetes.</a><i> J Diabetes Complications</i>.
2017; 31(4): 735-741. doi: 10.1016/j.jdiacomp.2016.12.015&nbsp;&nbsp;&nbsp;<a href="#ref58"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="59"> Bailey SC, Brega AG, Crutchfield TM, et al.<a href="https://www.ncbi.nlm.nih.gov/pubmed/24947871" target="_blank"> Update on health literacy and
diabetes. </a><i>Diabetes Educ</i>. 2014; 40(5): 581-604. doi: 10.1177/0145721714540220&nbsp;&nbsp;&nbsp;<a href="#ref59"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="60">Boren SA. <a href="https://www.ncbi.nlm.nih.gov/pubmed/20046666" target="_blank">A review of health literacy and diabetes: opportunities for technology.</a> <i>J Diabetes Sci Technol</i>. 2009; 3(1): 202-209. doi: 10.1177/193229680900300124&nbsp;&nbsp;&nbsp;<a href="#ref60"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="61"> Kim SH, Lee A. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27104337" target="_blank">Health-Literacy-Sensitive Diabetes Self-Management
Interventions: A Systematic Review and Meta-Analysis.</a> <i>Worldviews Evid
Based Nurs</i>. 2016; 13(4): 324-333. doi: 10.1111/wvn.12157&nbsp;&nbsp;&nbsp;<a href="#ref61"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="62">Yee LM, Niznik CM, Simon MA. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27322666" target="_blank">Examining the Role of Health Literacy in
Optimizing the Care of Pregnant Women with Diabetes.</a><i> Am J Perinatol</i>.
2016; 33(13): 1242-1249. doi: 10.1055/s-0036-1584540&nbsp;&nbsp;&nbsp;<a href="#ref62"><i class="fa fa-level-up"></i></a></div></li>


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