Living with type 1 diabetes (T1D) introduces unique challenges, particularly in managing blood glucose levels. Continuous Glucose Monitoring (CGM) systems have transformed this aspect of diabetes care, offering innovative ways to enhance your time in range (TIR). Here are the top 10 tips to optimise TIR with the help of an CGM system.
Should you follow them?
I don’t know, I do not know your circumstances or have skin in your game! Therefore, read for information and discuss with your healthcare team.
1. Food and insulin: 3 balanced meals with 10 minutes of activity after (supercharge that insulin)
2. High fat and protein meals: “Find out before you fiddle” then 25% extra insulin increments
3. After meal spikes: Insulin 15 minutes before in the abdomen or arm
4. 3 every 30: 3 minutes of movement every 30 minutes sitting
5. 10 by 2: 10 minutes of activity drops the glucose by 2 mmol/L (40 mg/dL) between meals (supercharge that insulin)
6. 50/50/20: The principles behind exercise insulin reductions for injections and standard pump therapy
7. T25/T25: Exercise insulin reductions for AID therapy
8. CGM: SLO ARSE, Slow and Low, Oil, Arm, Relax, Soft, Elevate
9. Site management: CAR, Change, Abdomen, Rotate
10. Ensure the CGM System and Blood Glucose System are targeting the same blood glucose (venous or capillary)
Here are the 10 tips summarised.
1. Food and Insulin:
- Strategy: Three balanced meals and engage in 10 minutes of physical activity after each meal to enhance insulin effectiveness.
- Quote: “Putting in that 10 minutes after walking after eating really makes a huge difference on the glucose levels.”
- Details: This activity helps match the timing of peak insulin action with glucose entry into the bloodstream, smoothing out potential spikes.
- Extra Tip: Consistency in meal timing and composition can also help stabilise blood glucose levels.
2. High Fat and Protein Meals – “Find out before you fiddle” – Francesca Annan RD
- Strategy: Adjust insulin dosages for meals high in fat and protein.
- Quote: “Find out before you fiddle,” and consider “25% extra insulin increments.”
- Details: Fats delay gastric emptying and can induce insulin resistance which may necessitate larger or more prolonged insulin dosing.
- Extra Tip: Monitor your blood glucose after these meals to learn how your body reacts and adjust future insulin dosing accordingly.
3. After Meal Spikes:
- Strategy: Administer insulin 15 minutes before eating to mitigate post-meal spikes.
- Quote: “The second part is where is the fastest place for absorption for your insulin? Well, the answer is in your belly… not far behind is the arm.”
- Details: Early insulin administration can synchronize insulin action with the rise in blood glucose post-meal.
- Extra Tip: Rotate injection sites between the abdomen and arm to maximize absorption efficiency.
4. 3 Every 30
- Strategy: Integrate short activity breaks into extended periods of sitting to enhance insulin sensitivity.
- Quote: “Just every 30 minutes they got up to walk around at the normal pace of three minutes… What percentage improvement in timing range do you think that they would have got? 14%.”
- Details: Regular movement helps decrease insulin resistance and improves blood glucose control.
- Extra Tip: Set reminders to stand or walk briefly; even light activity can have significant benefits, for everyone, not just those with T1D!
5. 10 by 2 mmol/L or 10 by 40 mg/dL
- Strategy: Use brief physical activity to quickly lower blood glucose levels.
- Quote: “10 minutes will drop the glucose level by two… or 10 will drop you by 40 milligrams per decilitre if you’re in those units.”
- Details: This strategy is effective in quickly reducing high blood glucose levels back into the target range.
- Extra Tip: Tailor the intensity of the activity to your current fitness level and overall health status.
6. 50/50/20 Exercise adjustments for injections and standard pump therapy
- Strategy: Apply a structured insulin reduction approach for pump therapy.
- Quote: “50/50/20… 50% insulin reductions for meals before (within 2 hours) and after, and 20% reductions of insulin overnight or 20 grams of carbs or 20 grams protein.”
- Details: Adjusting insulin around physical activity or overnight can prevent significant fluctuations in glucose levels.
- Extra Tip: With insulin on board from a bolus within 3 hours, the glucose will most likely drop
7. T25/T25 Exercise adjustments for AID therapy
- Strategy: Modify insulin dosages by 25% around exercise for users of AID systems.
- Quote: “T25/T25… The 1st T25 reduction speaks to the two hours before exercise. Ensure a 25% reduction in insulin for meals consumed within two hours of the exercise and start the exercise target 1-2 hours before. The second T25 speaks to stopping the exercise target as soon as finished and considering a 25% reduction of insulin for the meal after.”
- Details: Adapting insulin doses in response to physical activity helps maintain glucose control during and after exercise.
- Extra Tip: Monitor closely and adjust based on real-time feedback from your CGM.
8. CGM Management:
- Strategy: Follow the ‘SLO ARSE’ guidelines for optimal CGM care.
- Quote: “Slow and low is the key… Relax your arm, make sure it’s applied softly and elevate the skin off the muscle.”
- Details: Proper CGM maintenance ensures accuracy and extends the life of the sensor.
- Extra Tip: Insert a day before you use to get accurate 1st day readings
9. Site Management:
- Strategy: Rotate your insulin delivery sites regularly to maintain insulin absorption efficiency.
- Quote: “Change every two to three days and then obviously look after your skin as you go along and rotate where you do the sites.”
- Details: Site rotation prevents the formation of lipohypertrophy, which can interfere with insulin absorption.
- Extra Tip: Use a chart to track site rotation to ensure even usage over time.
10. Ensure CGM System and Blood Glucose System are targeting the same blood glucose (venous or capillary)
Calibration Alignment: Capillary vs. Venous Glucose
Capillary-aligned CGMs (e.g., Dexcom Options, Freestyle Libre Options, Acc-Check SmartGuide) give readings similar to standard fingerpick tests, making them ideal for everyday diabetes management and capturing high readings more effectively. Ideal for those prioritising preventing complications from high readings.
If you’re using a CGM system aligned with capillary glucose, it’s important to have a blood glucose meter that provides accurate capillary readings to avoid perceived inaccuracies. I’ve recently looked into this, and the most accurate and reliable blood glucose meters for CGMs aligned with capillary glucose from independent research are:
- Beat two by far: Contour Next One and Accu-Chek Guide
- The second best: Righttest GM700S
Venous-aligned CGMs (e.g., Medtronic Guardian 4 and Simplera) align more with venous glucose, which may be useful for those with hypoglycaemia unawareness, as they do not miss hypos. But highs will likely be underreported.
The most accurate and reliable blood glucose meters aligned to venous glucose from independent research are:
- Best, by far: Freestyle Libre Lite
- The second best: GlucoChek Gold
Conclusion
Implementing these detailed strategies can greatly improve glucose control for individuals using CGM systems. Each tip empowers users with practical, actionable advice tailored to managing type 1 diabetes more effectively.
Hope this helps
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John Pemberton – T1D since 2008