Abbott, the Libre 2 App, and No Common Sense

For those familiar with continuous glucose monitors (CGM), you may be familiar with the Abbott FreeStyle Libre device. It is an extremely popular device that is based on Near-field communication (NFC) where the wearer uses their phone to poll the device attached to their body. NFC is convenient but very low range; it’s the same thing used for making payments at a gas pump or credit card terminal. This allows a diabetic to check their blood sugar without the annoying finger prick blood tests. You can check your blood sugar (aka blood glucose or BS for this article) as often as you want during a 14 day period before replacing the sensor. It makes checking BS cheaper than test strips and allows for much better control of your BS through those frequent checks.

Abbott created a new device, the Libre FreeStyle 2 that moves from NFC to Bluetooth which greatly expands the range. The biggest advantage is that the app can continuously poll your BS without you needing to scan the sensor yourself. Even better? If it detects an event such as low or high BS it can warn the user. For diabetics that check every two hours or more this becomes extremely helpful in heading off events that are life threatening or going for long periods with elevated glucose that impact the diabetic both short and long-term.

While this implementation and technology offer a new level of convenience that can significantly and positively impact a diabetic’s life, the mobile app that interfaces with the Libre 2 is sorely lacking. I have communicated with Abbott via Twitter before regarding issues and they have generally been polite, but have not improved the app. Like most companies they want to move you to DMs as fast as possible which doesn’t necessarily serve their customers. One of my consistent messages to them is that they don’t appear to have any diabetics that work on this app. They say otherwise but I simply don’t believe that.

If they do have diabetics on staff, specifically in the app design that focuses on the user interface (UI) and overall user experience (UX), it doesn’t show. Or, they are the same type of diabetic as a few of my past endocrinologists that seem to think every case of diabetes is identical to their own, which is just ignorant and dangerous. In this blog I am going to outline some serious deficiencies in the “FreeStyle Libre 2 – US” mobile app in an attempt to plead with Abbott to make enhancements, again.

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As noted above, the alarm functionality that allows the device to warn the user of high and low glucose events is the big difference in the Libre 2. Functionality around that is therefore important, making this helpful and safer for the diabetic. At least, it should be. This is where the app really comes up short and it is hard for me to believe this was designed for diabetics at large.

The app offers four new alarms related to glucose or the sensor:

Alarms from Hell

With mobile phones, everyone probably has apps that make sounds they aren’t fond of. Some apps let you change the various sounds just as the phone lets you set custom ringtones. The Abbott Libre 2 app however, does not. This is really unfortunate as a majority of the sounds it generates are piercing and horrible. Several of them play at twice the volume of any other sound on my phone and are simply piercing. In a work environment I would be told to silence my phone making the entire point of some of the alerts moot. A user could not keep their phone on during a movie, at church, a conference, school, a play, or even at a restaurant without risk of seriously angering everyone within 100 feet should an alarm go off. Worse, months after publishing this blog I had the alarm go off and scare a dog next to me who almost attacked me as a result.

The Libre 1 app started the trend. When a sensor has three days left, and again with one day left, it plays an extremely loud notification that makes no sense. It is not a critical alarm and should be a regular, more muted notification sound. For the Libre 2, they continued this trend with the low and high glucose alarms, but made it even louder. It is important that these be heard, yes. But it should be up to the user to decide what sounds are played and how loud. Abbot needs to make these configurable either via a selection of sounds and/or a volume control for the default sound.

Alarms That Aren’t Friendly

In the Libre 2, if you receive a high glucose alarm you hear the notification. Checking the phone you can see the icon in the notifications. Tapping on it opens the app to the “logbook” that shows the history of your glucose, but only when you scanned the sensor yourself. So it is telling you glucose is high but not telling you what the value is. Further, it doesn’t prompt you to scan so a quick look may make you think the last glucose reading is the current.

Instead, the logbook should show the high glucose reading that the app polled for and insert it into the logbook. It can be done in a different font or with an icon to show it was the automated poll rather than the user polling. This gives a more intuitive history and allows you to quickly see the glucose without having to clear notifications and poll the device yourself.

When an alarm goes off, even if your phone is in hand and you quickly swipe, unlock, drag the notification bar down, and swipe to quiet the alarm, it is already going off a second time. If left alone it will sound five times before it stops, waiting five more minutes to start sounding again. That means even racing to silence the alarm is difficult, further enraging the user.

Alarms That Hate the User

The most critical event for a diabetic is low glucose. At a certain point, if the body does not have enough glucose, it simply cannot function properly. If it drops low enough, you are at risk of going into a diabetic coma. While a Type 1 diabetic (T1D) can produce little or no insulin, we supplement using injected synthetic insulins. That stuff you hear about that is prohibitively expensive for many, even with health care. If we take too much that is when our glucose can drop and put us at risk. 

This is an important point, one seemingly lost on Abbott; not all diabetics have the same threshold. If my average glucose is very good (e.g. 90 – 100) my body acclimates to that and a swing down to 60 – 70 aren’t even noticeable. I function the same as any other day. There have been times where I have a blood sugar of 40 and feel like “my sugar is a little low” in fact. For some diabetics, a glucose level of 40 will have them en route to an emergency room. Now, most of the time I start to feel my sugar is low around 70 and if my average is running high, 40 will have my hands shaking, hard to focus, and only one desire to seek out sugar.

The ‘Urgent Low Glucose Alarm’ is designed to warn us of that glucose crash that is risky. Unfortunately, this alarm cannot be modified at all. I can’t set that glucose threshold, I can’t set the alarm tone, and I cannot change the fact it overrides Do Not Disturb. If I am a diabetic without this app, I live my life with that risk. I opted into using this sensor and associated app, I should be able to opt into this alert or at the very least, make it configurable. Want to force this alarm to stay on? Then let us change the sound at the very least. This alarm alone is making me debate going back to the Libre 1.

Alarms Not Created by Diabetics

In addition to the poor User Experience (UX) of the alarms, fundamentally the design is not mindful of how diabetes works. So on top of infuriating alarm volume, the frequency and pointless nature of some alarms is even more aggravating. If your blood glucose goes low and triggers an alarm it will sound; and then again in five minutes it will sound again. This goes on until your blood sugar is brought up into a satisfactory range. The problem is that if you receive the first alarm and immediately start eating hard candy such as SweeTARTS, Spree, or even pure sugar in Fun Dip, it takes more than five minutes for it to start acting.

Usually, blood sugar starts to rise 10-15 minutes after a meal and reaches its peak after an hour. However, these are just approximate guidelines as PPG (postprandial glucose) depends on several factors, such as the type of food consumed.

The Libre 2 app does not allow you to set the interval of these alarms almost guaranteeing you will get at least two alarms if you drop below the threshold. While this may sound moderately annoying, think about this when an alarm goes off at 4am. If you keep candy on the night stand and immediately eat some, you can’t really go back to sleep because that alarm will fire again in five more minutes, sometimes three times before your glucose is high.

Speaking of 4am alarms, the Libre 2 app designers apparently don’t understand how insulin works or what dawn phenomenon is. For Type 1 diabetics, we take two types of insulin. One is a fast-acting insulin used to counter large carbohydrate intake (e.g. meals, snacks) and the other is insulin glargine which is a long-lasting insulin designed to help avoid blood glucose spikes. Insulin glargine like Lantus or Toujeo also have the impact of slowly dropping your glucose over time. If your last food intake is at 10pm and you wake at 8am, that is 10 hours that the insulin is working and slowly dropping your glucose.

Going to bed with a blood glucose of even 130 puts some at risk of dropping into the 50s, which triggers several default alarms. Disabling all but the mandatory emergency low glucose alarm means that one may fire, but again, up to three times or more as you wait for the sugar to start absorbing into the body. To avoid that alarm you have to go into bed with a higher-than-recommended blood glucose which is not healthy. 

Further, even if you drop to the low or mid 50s, many diabetics experience dawn phenomenon. This happens at different times and to different degrees, if at all, for many diabetics. For me it can naturally raise my blood glucose between 10 to 100 points bringing me out of that ’emergency’ zone. That means I expect my glucose to drop considerably overnight and then raise to varying degrees in the morning, never putting me at risk. 

Being able to control that emergency low glucose alarm is vital for me to get good sleep. As is, I am awoken almost every night, sometimes several times, and long-term it is causing sleep deprivation. That is not healthy for a diabetic either. So this app basically forces diabetics to adopt or suffer several things that work against our health, all in the name of this app’s misguided notion of “health”.

When a diabetic is experiencing a low or high glucose event, it changes their demeanor. It can cause a wide variety of symptoms including irritability. Imagine the alarm firing four times in 10 minutes, the entire time eating candy to drive glucose up to shut the damn alarm up. By the time it silences you think you are in the clear only to have the high glucose alarm fire ten minutes later because you ate too much candy. The app literally drives the user to do unhealthy and ill-advised food intake just to silence the piercing alarms. That is dangerous behavior from the app that propagates to dangerous behavior by the diabetic. This happened again a week later with me eating a KFC combo through three alarms over 15 minutes, candy through two more sets of alarms, totalling 25 minutes of frequent alarms. The result? Spiked to 162 quickly after that and had a rollercoaster glucose the rest of the day.

Another night, the low glucose alarm went off at 5am and again five minutes later and again five more minutes after that. I tried turning Bluetooth off to shut it up only to have the phone vibrate a warning every five minutes about loss of connectivity. After that I disabled all alarm’s ability to override DND that I could and after losing almost two hours of sleep, the app is essentially worthless as far as emergency notifications.

Finally, you can’t set a custom alarm. Meaning the app comes with four default alarms, but you can’t create a fifth custom one with your own glucose threshold and name.

How Bad Are the Alarms?

It’s really easy to see that I am not alone in this opinion. Just take a look at the reviews on the Libre 2 app in the Google Play store. Countless reviews all share the same sentiment, that the alarms are obnoxious and they are upset they can’t change or disable them. Each time Abbott replies it is the same canned response, to call them, as if that will somehow alleviate the issue. It won’t. Despite over 600 reviews, a vast majority one star, they haven’t changed the app.

You may be thinking, “no really, are they that bad?” Well, let’s see what happens when I put the old decibel meter next to my phone when a low blood glucose alarm is going off:

Yes, 81.6 decibels. This alarm is technically illegal in the city of Denver according to Title 1, Chapter 36-6 of the Revised Municipal Code based on the table. Since my neighbors can hear it and if I am on the balcony it can be heard halfway down the block.

How Buggy are the Alarms?

Even if the alarms worked entirely as intended, which is bad enough, they don’t. Or in some cases they may work as intended, technically, but it goes back to my point that no diabetic worked on the app. No doctor was consulted. No link about Diabetes was read by Abbott developers either I don’t think. I’ll try to keep this brief simply due to the volume of issues I have experienced. Supporting screenshots at the end of this blog.

• I have received at least two high glucose alarms despite not being at the set threshold. One went off at 7:37am overriding DND before I realized that mistake.
• In addition to overriding DND, the app will actually set DND on when it should not be able to do it and no configuration option instructs the app to do that.
• App requiring privileges to override DND, but not showing in Android’s settings as having those permissions.
• App still has permissions to override notification settings and DND, despite all notification privileges being disabled.
• The app will not let you use it unless it has permissions to override DND, rather than suppressing that tiny bit of functionality.
• A notification icon that is permanently there, that cannot be dismissed, just as a shortcut to open the app. Despite being able to scan your sensor to open the app, or open it like any other app. [Fixed: An Android update ~ Dec, 2022 now allows you to dismiss!]
• When starting a new sensor, a notification icon that cannot be dismissed rather than throwing an error if you scan the sensor before it is ready.
• When a sensor is ending, that notification icon cannot be dismissed either.
• Disabling Bluetooth means you cannot use the app. There are times you may want to disable Bluetooth for various reasons, and rather than just suspend the syncing functionality with the sensor, the app refuses to work at all.
• There have also been times where the alarm has gone off six times in a 22 minute period despite my blood sugar being 158, two points below the 160 high glucose threshold set.
• [4/6 Update: Show the alarm and BS level in the log if an alarm fires!]
• [4/6 Update: A high glucose alarm will fire e.g. at 160, but the visible graph for that time period does not show glucose going above ~ 155.]
• [4/8 Update: Alarm fired at 178 despite threshold setting for 160.]
• [4/22 Update: Emergency low glucose alarm will fire in less than five minute intervals despite that stated limitation.]
• [4/24 Update: Design issue more than bug, but the ‘High Glucose Alarm’ is a single one and the user cannot add a secondary. If glucose rises past e.g. 160 and we take insulin, it may still keep rising and the alarm won’t sound. A secondary optional alarm to notify e.g. of 200 would be very helpful.]
• [4/24 Update: “Alarms are unavailable. Scan sensor.” That is the message received if something happens that interferes with the sensor and alarms. Scanning it is supposed to reset it and all is well. Often times scanning the sensor does nothing and the error persists.]
• [9/12 Update: If I scan and get 159 trending upwards, with a 160 alarm point, don’t sound the alarm 30 seconds later. I know it will hit 160 and I literally just saw that, I don’t need the obnoxious alarm to tell me.]
• [11/15 Update: If my phone volume is at 10%, the alarm will raise the volume to 100% before firing. This is absurd.]
• [12/29 Update: New sensor, 60m later obnoxious alarm indicating it is ready. Scan immediately, BS is 237, alarm barrier is 160. Seconds later, high glucose alarm sounds when I just saw the high glucose seconds prior.]
• [1/15/23 Update: It would be helpful to have a function to display BS every X mins for Y time. So during a workout when my BS drops considerably, I can see it dropping without having to scan every time.]
• [1/15/23 Update: If BS rises or drops too fast, the sensor will stop working and tell you to scan again in 10 minutes. Given it happens when it is the most critical to know your BS, this is a catastrophic failure. Abbott was not aware of this until I reported it months prior.]
• [1/15/23 Update: Implement a function to display BS on phone’s lock screen so you can quickly check it w/o unlocking the phone and scanning. This would better use the WiFi passive functionality.]

Abbott’s Response

When reaching out to Abbott via Twitter, their response is meaningless and a waste of time. Any public mention or criticism and they only try to steer you into direct messages, like so many companies do. Once in DMs, they try to steer you into calling them on the phone. Why? Do we really think they will listen to my feedback on the phone while ignoring it in writing? If so, then they are a horrible company with even worse customer service. Even in response to Google Play reviews you can see them replying that they want to follow-up via phone call. That is, when they aren’t deleting your review outright.

Additionally, once in Twitter DMs they will send you a random DM about their hours and availability, when they aren’t available, despite not messaging them. Below we see that they tried to set terms in DMs on Dec 30, 2021, so I set terms back to them. Months later in response to a public message, they sent me the DM at 11:17pm despite me telling them I don’t want to go to DMs and to quit asking me to go to DMs. They clearly owe me $1,000 and they can pay me in Libre1 sensors so I can quit using this shitty Libre 2 app.

A message for Abbott: I do not want to DM you. I do not want to call your customer service department. I have already spent a great amount of time telling you what is wrong with your app and now I have written this blog so you have a concise list of problems with it. Your team can read this and turn it into bug / feature requests and you have the opportunity to improve the app, making those 500+ people that took the time to review your app happy. This isn’t a difficult decision.

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