Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA)

Abstract

Physical exercise is an important component in the management of type 1 diabetes across the lifespan. Yet, acute exercise increases the risk of dysglycaemia, and the direction of glycaemic excursions depends, to some extent, on the intensity and duration of the type of exercise. Understandably, fear of hypoglycaemia is one of the strongest barriers to incorporating exercise into daily life. Risk of hypoglycaemia during and after exercise can be lowered when insulin-dose adjustments are made and/or additional carbohydrates are consumed. Glycaemic management during exercise has been made easier with continuous glucose monitoring (CGM) and intermittently scanned continuous glucose monitoring (isCGM) systems; however, because of the complexity of CGM and isCGM systems, both individuals with type 1 diabetes and their healthcare professionals may struggle with the interpretation of given information to maximise the technological potential for effective use around exercise (i.e. before, during and after). This position statement highlights the recent advancements in CGM and isCGM technology, with a focus on the evidence base for their efficacy to sense glucose around exercise and adaptations in the use of these emerging tools, and updates the guidance for exercise in adults, children and adolescents with type 1 diabetes.

Glucose management for exercise using continuous glucose monitoring: should sex and prandial state be additional considerations? Reply to Yardley JE and Sigal RJ [letter]

“…As Yardley and Sigal state [1], the role of fitness level and/or exercise experience on the risk for hypoglycaemia during or after exercise is unclear. To clarify, our position statement did not mention that 'inactive' people with type 1 diabetes have a higher risk of hypoglycaemia per se; however, it was discussed that 'individuals who do not routinely exercise may face an increased risk of hypoglycaemia', 'partially' in line with the study of Bohn et al [2,3]. Yardley and Sigal reference the article by Al Khalifah et al [4] as evidence that people who are more aerobically fit may have a higher likelihood of becoming hypoglycaemic during exercise compared with those less fit.…”

“…Based on the large cross-sectional study by Bohn et al [3] and in agreement with the present writing groups' clinical experience, we would still recommend higher glucose levels during exercise for those that are not routinely exercising to ensure safe exercise and a low risk of hypoglycaemia. Importantly, if a person exercises routinely and/or has a low risk of hypoglycaemia over a period of 3 months, then the glycaemic thresholds for carbohydrate consumption might be adjusted, as emphasised in our statement [2].…”

“…To the Editor: We thank Dr Yardley and Dr Sigal for their comments on the position statement pertaining to the use of continuous glucose monitoring (CGM) systems around exercise in type 1 diabetes [1,2]. The letter by Yardley and Sigal was centred on four points: (1) the potential difference in risk of hypoglycaemia in active vs inactive people; (2) possible sex differences in exercise-related hypoglycaemia risk; (3) the role of bolus insulin administration to prevent and/or correct exerciserelated hyperglycaemia that is sometimes associated with highintensity interval exercise (HIIE) and/or resistance exercise; and (4) the role of the prandial state on glucose responses during exercise.…”

“…Brockman et al [5] showed that it was male individuals, not females, who experienced the sharper decrease in glucose during resistance exercise and also higher rates of hypoglycaemia. Given the conflicting results, small differences between the groups and the limited studies in this area, we provided an initial focus on the overall population of people with type 1 diabetes, separating them into adults, adolescents and children, with subgroups based on risk of hypoglycaemia [2]. While we anticipate that future studies will provide a more complete picture on the role of sex in modulating exercise-induced changes in blood glucose levels, our position statement [2] is a first step towards evidence-based general recommendations about how to use CGM systems around exercise.…”

“…The authors mention in their letter that we recommend a bolus insulin correction in advance of HIIE and resistance exercise. While dosing insulin in advance of HIIE and resistance exercise may be dangerous in some situations, for the points raised in our position statement [2], we recommended a 50% reduced correction factor of the regular insulin dose at glucose levels >10 mmol/l, and not an insulin correction dose before HIIE and resistance exercise in general (see Table 1 in the position statement [2]). We also note that pre-exercise extreme hyperglycaemia (sensor glucose levels >15 mmol/l) can be treated with an insulin bolus (50% of a typical correction dose) [2].…”