Sensor glucose targets before exercise for children and adolescents with type 1 diabetes using continuous glucose monitoring

Target range for pre-exercise sensor glucose			Trend arrow on device	Action
Patients with habitual intensive exercise and/or low risk of hypoglycemia	Patients with habitual moderate-intensity exercise and/or moderate risk of hypoglycemia	Patients with low or minimal habitual exercise and/or high risk of hypoglycemia	Direction	If an increase in sensor glucose is expected*	If a decrease in sensor glucose is expected^¶
>270 mg/dL (15.0 mmol/L) and >1.5 mmol/L blood ketones			↑↗→↘↓	Do not exercise; give correction dose of insulin
>270 mg/dL (15.0 mmol/L) and ≤1.5 mmol/L blood ketones			↗↑	Consider insulin correction^Δ, can start mild-moderate aerobic exercise	Consider insulin correction^Δ, can start all exercise
			→	Consider insulin correction^Δ, can start mild-moderate aerobic exercise	Can start all exercise
			↘↓	Can start all exercise
181 to 270 mg/dL (10.1 to 15.0 mmol/L)	199 to 270 mg/dL (11.1 to 15.0 mmol/L)	217 to 270 mg/dL (12.1 to 15.0 mmol/L)	↗↑	Can start aerobic exercise	Can start all exercise
			→↘↓	Can start all exercise
126 to 180 mg/dL (7.0 to 10.0 mmol/L)	145 to 198 mg/dL (8.0 to 11.0 mmol/L)	162 to 216 mg/dL (9.0 to 12.0 mmol/L)	↗↑→	Can start all exercise
			↘↓	Take approximately 0.2 g/kg CHO^◊, then can start all exercise	Take approximately 0.3 g/kg CHO^◊, then can start all exercise
90 to 125 mg/dL (5.0 to 6.9 mmol/L)	90 to 144 mg/dL (5.0 to 7.9 mmol/L)	90 to 161 mg/dL (5.0 to 8.9 mmol/L)	↗↑	Can start all exercise	Can start all exercise; can take approximately 0.2 g/kg CHO^◊ if exercise will be prolonged and/or if high insulin on board
			→	Take approximately 0.2 g/kg CHO^◊, then can start all exercise	Take approximately 0.3 g/kg CHO^◊, then can start all exercise
			↘	Take approximately 0.3 g/kg CHO^◊; delay all exercise^§	Take approximately 0.5 g/kg CHO^◊; delay all exercise^§
			↓	Individual amount CHO ingestion, delay all exercise^§
<5.0 mmol/L (<90 mg/dL)			Individual amount CHO ingestion, delay all exercise^§

Color key:
No or minimal action required
Minimal or moderate action required
Moderate or urgent action required
Delay all exercise

This table provides information on actions that can be taken to start exercise safely when using CGM. Once the exercise is started, additional CHO may be needed to maintain the desired glycemic range. In general, additional CHO should be taken when the glucose level on the CGM falls below a user-defined threshold (eg, <125 mg/dL) or when a downward-trending arrow predicts that the glucose will reach a lower than desirable glucose concentration in the next 15 to 20 minutes (eg, <90 mg/dL). The threshold for taking additional CHO and glycemic targets for exercise should be predetermined by the user and health care provider; this table is a suggestion only. Of note, when glucose levels are trending down, actual blood glucose concentrations may be lower than the interstitial glucose concentrations measured by CGM. These recommendations are not applicable to people with diabetes who are using hybrid closed-loop systems.

CHO: carbohydrates; CGM: continuous glucose monitoring.

* An increase in sensor glucose is expected if the exercise will be brief (<30 minutes) and intense (ie, at a maximal or near-maximal aerobic intensity or with heavy resistance/anaerobic work).

¶ A decrease in sensor glucose is expected if the exercise is predominantly aerobic and prolonged (ie, >30 minutes).

Δ Use 50% of usual insulin correction factor when the sensor glucose reading is close to the upper threshold of the target range.

◊ For school-aged children, 0.2 g/kg CHO is approximately 5 g, 0.3 g/kg CHO is 7.5 g, and 0.4 g/kg CHO is 10 g. For mid-sized or large adolescents, 0.2 g/kg CHO is approximately 10 g, 0.3 g/kg CHO is 15 g, and 0.4 g/kg CHO is 20 g.

§ For patients with low or moderate risk of hypoglycemia, delay exercise until sensor glucose reaches ≥90 mg/dL (5.0 mmoL/L) accompanied by →, ↗, or ↑ trend. For patients with an increased risk of hypoglycemia, delay exercise until sensor glucose reaches ≥126 mg/dL (7.0 mmoL/L) accompanied by →, ↗, or ↑ trend.

From: Moser O, Riddell MC, Eckstein ML, et al. 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). Pediatr Diabetes 2020; 21:1375. Copyright © 2020 John Wiley & Sons Ltd. Modified with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: [email protected] or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/).

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Sensor glucose targets before exercise for children and adolescents with type 1 diabetes using continuous glucose monitoring