CGM technology advantages -
A better understanding of your blood glucose and where it is headed can help you make informed decisions about insulin management and dosing. CGM systems have been shown to help users keep blood glucose levels stable, reduce both hypo and hyper episodes and decrease the risk of complications from diabetes.
But starting CGM is not a quick fix. It works best when you work with your healthcare team to come up with tailored strategies for you.
Get in touch with one of our experts today to discuss if CGM is right for you. If you are trying to decide if either CGM or Flash is right for you, you should consider the following factors when evaluating a glucose monitoring solution:. You should always speak to your doctor about what system will best help you achieve your blood sugar goals.
The biggest benefit of using CGM or Flash is gaining better insight into your blood glucose levels so you can adjust your strategies for better glucose management. For people living with diabetes, these solutions mean fewer finger-prick testing, more insight and more peace of mind.
However, it can feel overwhelming to determine which blood glucose monitoring system is best for you and if you are eligible for a system on the NHS.
At the London Diabetes Centre, we work with our patients to find the right glucose monitoring solution for them. Get in touch today to speak to a member of our expert team about continuous glucose monitoring.
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What is Continuous Glucose Monitoring and How Does it Work? What are the Special Features of a CGM? What are the Benefits of a CGM for Managing Diabetes? Are there any Disadvantages to CGMs?
Get Better Insight into your Blood Sugar Levels with a CGM. Which Glucose Monitoring System is Right for Me?
Flash vs CGM: A Summary. Need to speak to an expert about continuous glucose monitoring? Click here to chat to a member of our friendly team today. What is Continuous Glucose Monitoring CGM and How Does it Work? What are the Special features of a CGM?
Some special features might include: You can typically programme alarms for when your blood sugar goes too high or too low. You might be able to share your data with a family member or partner and programme alarms in case your blood sugar goes too high or too low this is especially helpful in the case of monitoring your child.
You can download the data onto a computer or tablet to easily see trends and patterns in your levels. You can use your smartphone instead of an additional reader. Insight CGM allows you to connect the dots between glucose readings and get a more complete picture of your blood sugar levels: Track your blood glucose levels any time of the day or night.
Use the provided software to see visual trends of your data over time. Share your data with your diabetes team remotely. Get insight into how factors from your daily life including food, exercise, stress, medications, hormones and illness affect you. Informed decision-making With access to more information about where your blood sugar levels are headed, you can make better decisions: Programme alarms to alert you if your blood sugar is too high or too low.
Take action sooner to prevent dangerous hypos. Tailor your insulin doses more carefully based on a better understanding of your blood sugar levels. Set up a safety net by sharing your data with a family member, partner or caregiver. Peace of mind Many CGM users report an increased peace of mind that comes from having easy access to their blood glucose levels as well as protection against sudden hypos: Overcome your fear of sudden hypos.
To mitigate post-exercise hypoglycemia, very few evidence-based data is available. We have reviewed the impact of bedtime snack on nocturnal hypoglycemic risk and highlighted the very low level of evidence of this widely recommended practice Taplin et al.
The available studies are generally of a small scale summarized in Table 1 and mostly conducted in laboratory settings, but could still help shaping some guidelines for glucose management around exercise for patients using insulin pumps. For anticipated exercise, if exercise occur during meal bolus action a reduction of this bolus proportional to exercise intensity and duration is a reasonably well-validated strategy; for exercise undertaken in the post-absorptive period in patients using CSII, the best timing and amount of insulin reduction prior to exercise onset is still a pending question.
In all situations post-meal vs. post absorptive as well as CSII vs. MDI different timings and percentages need to be tested in different types of exercise e. resistance vs. interval; duration; intensity; etc. In the case of unanticipated exercise, although insulin suspension at exercise onset seems the best solution for the time being, related studies have tackled mainly continuous moderate intensity exercise sessions.
An increased risk of hyperglycemia could be speculated for intense continuous or interval exercise with pump suspension and evidence-based data is lacking. In that situation, to correct post exercise hyperglycemia, a recent study validated the efficacy and safety of a correction bolus based on usual correction factor Finally to prevent late post-exercise hypoglycemic risk a nighttime basal rate reduction could be useful strategy.
Table 1. Main continuous subcutaneous insulin infusion studies with reported exercise related conclusions. Further studies are clearly warranted to guide insulin dose adjustments with CSII use.
Because of the large inter- and intra-individual variability in glycemic responses to exercise, recommendations can only serve as general starting points that will need to be individualized. With the difficulty of glucose management during and post exercise in patients with T1D due to rapidly changing levels and hypoglycemia risks, individuals must increase the frequency of glucose monitoring during exercise and the following recovery period.
This can be very cumbersome and undesired by many patients, especially when based on capillary glucose measurements. However, the introduction of continuous glucose monitoring in the early 2, has had a great impact on facilitating glucose profiling and helping with diabetes management.
With CGM, interstitial glucose is measured repeatedly e. CGM provides detailed glucose profiling in contrast to the readings that are possible with capillary measurements and has proved its efficacy in improving diabetes management and reducing hypoglycemia rates 36 — For physical activity, CGM has helped in gaining better understanding of changing glucose levels during and particularly in the hours following different types and conditions of exercise [an aspect reviewed recently by Houlder et al.
One of the first reports to demonstrate the utility of CGM during exercise was an observational study conducted in 25 adolescents 8—17 years old during a 2-week sports camp An algorithm of CHO consumption 8—20 g was followed according to CGM alerts, tendencies and rates of glucose change. Out of 22 uses of the CHO intake algorithm after CGM trend arrows indicated rapidly dropping glucose levels, only 2 hypoglycemia 3—3.
A recent study has also shed the light on the efficacy of combining CGM with a decision support system DSS in managing diabetes usual care The protocol included 2 sessions of 45 min three 15 min exercise with 5 min rest in between of mild to moderate aerobic exercise.
Interestingly, patients with T1D and health professionals who attended a boot camp that included real time CGM, in-class teaching and supervised exercise sessions have identified real time CGM as the best learning tool about glucose changes during exercise Patients reported that CGM helped improve glucose control by keeping it in target ranges during sports without needing extra capillary measurements e.
One possible limitation to CGM usage is a lower accuracy during exercise. This has been recognized in the literature and needs to be understood by patients and healthcare professionals. Among factors involved to explain this lower accuracy rapid blood glucose changes that accompany physical activity is probably a dominant factor.
Such situations increase the lag time between blood and interstitial glucose values due to delay to reach equilibration between compartments 5. This CGM delay has been estimated to reach up to 15 min during exercise and could result in either over- or most frequently underestimation of blood glucose.
For example, mean difference between CGM Medtronic Guardian Real-Time system and plasma glucose was 1. On the other hand, an underestimation of blood glucose by CGM has been reported with resistance type of exercise Most manufacturers and studies report CGM accuracy with median absolute relative difference MARD of CGM relative to blood glucose capillary or venous ; reflecting an average deviation from the reference in either direction.
MARD of two CGM devices Dexcom G4 Platinum and Enlite in reference to plasma glucose was evaluated at rest vs. exercise continuous and interval MARD was increased from In this cross-over trial design, no significant differences in MARD were observed between continuous vs.
interval exercise that were notably matched in total energy expenditure per patient 45 , this is in congruence with another study comparing continuous moderate intensity and high intensity interval exercise sessions On the other hand, significant differences in accuracy by MARD during continuous vs.
interval exercise was reported by another group despite comparing the two types of exercise at similar intensities Contrasting conclusions from these reports about CGM accuracy per distinct exercise types could be related to the respective studies design and small sample size.
For example, including a pre-exercise snack slower decline in blood glucose or hypoglycemia correction with CHO are all factors that could affect the interpretation and comparison of MARD across different studies. The overall accuracy of CGM devices during exercise is lower but still remains acceptable under exercising conditions.
Patients are encouraged to follow the arrow trends in their GCM devices and set their hypoglycemia alarms to higher values to anticipate events 5. Future research efforts should thus consider more comprehensive analysis of CGM biases over the course of different types of exercise and not only reporting average over the whole exercise session.
Studies should also report clear analysis of CGM accuracy during hypoglycemic episodes onset to reduce occurrence and following correction to reduce possible overcorrection preferably in comparison to capillary or venous reference values.
The results of such analyses could then be translated into clinical messages to help patients choose thresholds when setting their alarms to optimize the use of this option while concurrently following CGM arrow trends.
In summary, CGM technology eases the challenge of glucose management during and after physical activity in patients with T1D but patients need to be educated about the lower accuracy of these devices during exercise. Further technological progress has been achieved by linking CGM to insulin pumps 48 , 49 including sensor-augmented pumps SAP , low suspend and predictive-suspend pump systems.
In order to reduce hypoglycemia frequency, importance and length these technologies helps patients adjust their insulin treatment based on real-time feedback from the CGM function These systems are technological steps along the way to closing the loop of glucose control with the artificial pancreas systems targeting both hypo and hyperglycemia.
The artificial pancreas AP , equally referred to as closed-loop system, constitute to date the most advanced, and promising technology for insulin delivery in T1D Readings from CGM are communicated every few minutes to hormonal dosing algorithm which dynamically commands changes in hormonal basal rates or boluses administered by subcutaneous infusion pumps.
Clinical studies investigating artificial pancreas systems are increasing exponentially. These clinical trials mainly cover research on two AP versions; single-hormone AP SH-AP which delivers only insulin and dual-hormone AP DH-AP which delivers besides insulin mini-boluses of glucagon.
Two approaches govern the addition of glucagon to AP, either to allow more aggressive insulin delivery while avoiding hypoglycemia and generally aiming for lower glucoses targets or a more conservative approach which uses glucagon only after suspending insulin for low blood glucose in attempt to prevent pre-emptive hypoglycemia Around two-thirds to one-third is the proportion of SH-AP to DH-AP in the published literature with a lot of heterogeneity in terms of design, reported parameters, types of algorithms used and patient populations tested.
Two recent meta-analyses have clearly shown the clinical efficacy of AP systems in comparison to conventional or sensor-augmented insulin pumps 52 , Time spent with glucose levels in-target-range most used definition is 3. For this reason, we will limit the discussions in the following sections to the clinical trials that specifically reported exercise related outcomes.
Ideally, fully closed loop AP would be the easiest especially in the case of unplanned exercise. The algorithm would then be expected to adjust insulin delivery solely based on changing glucose readings. On the other end of the spectrum, hybrid systems involve exercise announcement by the patient to the algorithm to adjust glucose target ranges higher targets and adopt a more cautious insulin delivery.
In between the two ends, trials include addition of glucagon in DH-AP, use of exercise detectors such as heart rate or movement to guide the algorithm to self-adjust or combinations of these approaches.
The aim behind investigating these different strategies is to account for exercise-induced: 1-increases in insulin sensitivity and absorption from subcutaneous depot due to skin heat and movement, 2- delays in CGM due to rapid changes in blood glucose levels 5 , 6.
As discussed in the previous sections, the effect on glucose of different types, duration, intensity and timing of exercise need to be taken into consideration when examining AP studies around physical activity 6.
Good overall results were observed in a study conducted with unannounced 40 min exercise performed in a postprandial state as moderate and interval sessions in children and adolescents with T1D Median time of glucose-in-target 3.
standard insulin pump therapy; however, there were no differences in percentage of time in hypoglycemia ranges or in events requiring CHO replacement In another study, unannounced exercise to SH-AP algorithm was examined during prolonged skiing activity two sessions per day, 5 day camp in a group of adolescents and compared to another matched group under sensor augmented pump SAP control Although an overall benefit was seen with SH-AP vs.
SAP per 24 h and overnight for time spent with glucose-in-target, this was not maintained during the pooled skiing sessions and the hypoglycemia events requiring CHO correction Table 2 Table 2. Main artificial pancreas studies with reported exercise related outcomes.
These results support the use of a simple snacking strategy to avoid exercise-induced lowering of PG while on AP However, snack consumption may be undesired given the increased prevalence of the metabolic syndrome in patients with T1D who frequently practice exercise with in weight loss or maintenance objectives 3.
Other strategies to improve AP performance around physical activity consisted of examining the effect of glucagon addition through DH-AP systems and exercise announcement to the algorithm. Jacobs et al.
tested if announcing physical activity to their DH-AP algorithm by adjusting its insulin and glucagon dosing at the start of a 45 min aerobic moderate intensity exercise could improve glucose management in the following hours Less time was spent in hypoglycemia with adjustment to DH-AP by 2.
The authors observed a similar time spent with glucose-in-target between the three arms Another head-to-head SH-AP to DH-AP comparison in which insulin dosing algorithm is similar in order to specifically investigate the additional benefit of glucagon incorporation in AP during exercise Two types of exercise sessions consisting of 60 min of continuous and interval exercise were performed in the postprandial state under both SH-AP and DH-AP on 4 separate visits Exercise was announced 20 min prior to its start which resulted in changing the target glucose level from 5.
Overall, with DH-AP, median time spent with glucose-in-target was increased by The number of hypoglycemia events requiring CHO treatment were also reduced 3 in DH-AP vs.
An alternative to directly announcing exercise sessions to an AP algorithm was sought by some groups using exercise detectors such as heart rate monitors or accelerometers.
The idea behind exercise detection and indirect announcement is to relieve patients from active inputs especially during unplanned and unknown activity intensities. Such systems would be particularly interesting to investigate in youngsters whose activity level is often unpredictable making them at high risk for both hypo- and hyperglycemia.
Breton et al. were among the first to study the feasibility of adding heart rate monitoring to a SH-AP in 12 adults performing mild 30 min exercise sessions exhaustion at 9—10 on Borg scale Similar results were observed by Jacobs et al. This triggered a change in glucose target from 6.
A combination of different strategies was also tested. Recently, an interesting study was performed in adults comparing DH-AP and SH-AP that adapt to exercise using wearable sensors with predictive low glucose suspend and current care during and after exercise Both AP systems had an integrated algorithm for exercise detection that receives input from heart rate monitor and accelerometer the ZephyrLife BioPatch.
Once exercise was detected, the participant was asked by the algorithm to confirm it and the changes to insulin and glucagon were similar to what is described above for the study by Jacobs et al. Additionally the DH-AP was adaptive with adjustments to glucagon delivery at earlier timings and higher glucose levels on subsequent days 2—4 in comparison to day 1.
Number of hypoglycemia events requiring CHO consumption was also lowest with DH-AP over the whole study period with a mean of 0. The AP studies that specifically tackled glucose control in relation to exercise are still heterogeneous, small in size and do not cover all exercise scenarios Table 2 summarizes the discussed trials.
Most to date cover moderate intensity exercise performed in the post-absorptive state Table 2. Nevertheless, they highlight the positive impact of artificial pancreas systems around exercise.
AP is still an emerging technology and many future trials at large scale and in outpatient settings are needed in general and around exercise in particular.
Directly announcing exercise seems to still be needed for optimized results but the timing of the announcement from the start of exercise maybe an area to explore in future studies particularly for postprandial exercise when meal insulin boluses are active. Exercise detection by sensors is an interesting avenue particularly for children and adolescents living with T1D but adds the burden of wearing additional devices necessitating active research efforts in the future to develop small sensors integrated to the artificial pancreas itself.
Glucagon clearly shows an added benefit but the complexity of adding an additional chamber and material needs to be weighed against the additional hypoglycemia benefit. Therefore, future research trails should be designed to carefully identify patients who are most in need of glucagon and show high rates of exercise-induced hypoglycemia.
While SH-AP currently reach the market in various countries, DH-AP are not expected to be commercialized in the near future since stable glucagon formulations are not yet available for use but promising research is underway.
Clinical trials with DH-AP may still be conducted with the commercially available glucagon used for severe hypoglycemia treatment but needs to be reconstituted every 24 h Meanwhile, another pressing aspect is proving the safety profile of chronic glucagon use in its different formulations or analogs given its multisystemic effects in humans Technological advances have endowed individuals with T1D with important tools to help them better manage their blood glucose during exercise mainly allowing more secure conditions with reduced hypoglycemia risks.
Some limitations to the different technologies have been detailed in this review and future research areas that need to be explored have been highlighted as well.
The hope is that optimizing the use of these different technologies during exercise will encourage the majority of patients with T1D to regularly engage in physical activity.
ST, NT, and RR-L conceived the study design and content. ST and NT drafted the manuscript which was critically reviewed by RR-L. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
ST is supported by a fellowship grant from SFD Société Francophone du Diabète and FRM Fondation de Recherche Médicale. NT is recipient of scholarship of CIHR Canadian Institutes of Health Research and FRSQ Fonds de Recherche Santé Québec scholarships.
RR-L is holding the J-A DeSève diabetes research chair, a Diabetes Canada program grant DIRR and a NIH grant for artificial pancreas research that all supported this work.
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