DIABETES TECHNOLOGY & THERAPEUTICS

Volume 21, Number 1, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/dia.2018.0292

BRIEF REPORT

Use of Continuous Glucose Monitoring Trends

to Facilitate Exercise in Children with Type 1 Diabetes
Marie-Anne Burckhardt, MD,1–3,* Tarini Chetty, MD,1,2,* Grant J. Smith, BSc,1 Peter Adolfsson, MD,4,5
Martin de Bock, PhD,1,2 Timothy W. Jones, MD,1–3 and Elizabeth A. Davis, PhD1–3
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Abstract
Diabetes care during exercise frequently requires interruptions to activity and adds extra challenges particularly for
young individuals with type 1 diabetes (T1D). This study investigated the use of a carbohydrate (CHO) intake
algorithm based on continuous glucose monitoring (CGM) trends during physical activity. Children with T1D
diagnosed for >1 year, ages 8–12 years, with a glycated hemoglobin of <10% were recruited into a randomized
crossover study. They attended two similar mornings of fun-based physical activity and adhered to either a CHO intake
algorithm based on CGM trends (intervention) or to standard exercise guidelines (consumption of 0.5 g CHO/kg/h
when glucose <8 mmol/L) (control). Outcome measures included events such as exercise interruptions, CHO intake,
and hypoglycemia events and percentage time spent in different sensor glucose ranges. Fourteen children completed
the study. No episodes of significant hypoglycemia (sensor glucose level <3.0 mmol/L) occurred in either arm. Mean
CHO intake was the same in both arms, 0.3 – 0.2 g/kg/h. However, the intervention algorithm resulted in fewer CHO
intake events per day: rate [95% confidence interval] 2.4 [1.6–2.3] versus 0.9 [0.4–1.5], P < 0.001, and exercise
interruptions: 7.2 [5.9–8.8] versus 1.4 [0.8–2.1], P < 0.001, compared with control. There was no evidence of a
difference in percentage time in range (3.9–10 mmol/L) and percentage time spent high between study arms. Both
control and intervention protocols prevented significant hypoglycemia. Using a CHO intake algorithm based on CGM
trends resulted in fewer CHO intake events and fewer interruptions to exercise. Use of this algorithm may reduce the
burden of diabetes management with potential to facilitate activity in young people with T1D.

Keywords: Type 1 diabetes, Continuous glucose monitoring, Exercise, Carbohydrate intake algorithm.

Introduction carbohydrate (CHO) intake.6,7 Such adjustments are gener-

ally required for prolonged (>30 min) moderate/intensity

A chieving and maintaining stable blood glucose levels

around exercise are challenging for individuals with
type 1 diabetes (T1D). In particular, exercise is associated
with an increased risk of hypoglycemia. This perceived risk
can prevent young people from engaging in a physically
active lifestyle,1 despite numerous well-established health
benefits of exercise.2–5
Strategies to prevent hypoglycemia during or after exer-
cise typically involve adjustment of insulin dosing and/or
exercise or hypoglycemia is likely to occur, especially when
insulin levels are above basal levels.8 The amount of CHO
required to prevent hypoglycemia will depend on the amount
of circulating insulin,9 duration and intensity of activity,10,11
and blood glucose level at the start of exercise,12 as well as
the nutritional status13 and fitness level14 of the individual.
These multifactorial effects lead to inter- and intraindividual
variability in glycemic response to exercise, which is chal-
lenging for the person with T1D.

1
Children’s Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.
2
Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Western Australia.
3
Division of Paediatrics, within the Medical School, The University of Western Australia, Perth, Australia.
4
Department of Paediatrics, The hospital of Halland, Kungsbacka, Sweden.
5
Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
*These authors contributed equally to this study.
Parts of this study were presented at the Advanced Technologies and Therapeutics in Diabetes (ATTD) Conference, February 14–17,
2018, Vienna, Austria.

51
 52
Continuous glucose monitoring (CGM) offers the oppor-
tunity to improve glucose levels during exercise by allowing
patients to respond not only to sensor glucose levels (SGLs)
but also to directional arrows that indicate rates of change in
glycemia in real time.
Advancement in CGM technology means that devices are
increasingly accurate15,16 and user friendly as reflected by in-
creased patient use. However, further evidence-based guidance
is needed to help children and their families use CGM effec-
tively to facilitate exercise.
An observational study in 25 adolescents using a CHO in-
take algorithm in response to CGM trend arrows showed low
rates of hypoglycemia, but did not have a control arm to the
study.17 The aim of our pilot study was to investigate whether
the use of a CHO intake algorithm based on rate of change of
real-time CGM data could impact on hypoglycemia events or
exercise interruptions and to produce estimates to inform the
design and power calculation for further research.
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Methods
Children diagnosed with T1D for >1 year, ages from 8 to
12 years, were recruited into the study. The inclusion criteria
were any insulin regimen and the latest glycated hemoglobin
(HbA1c) below 10.0% (86 mmol/mol).
The protocol was approved by the institutional ethics
committee.
The study used a two-condition, randomized crossover
design. Randomization to the sequence of intervention and
control was computer generated (www.sealedenvelope.com).
Participants came together for a camp-style, sports morn-
ing of fun-based activity organized by a professional sporting
organization, on two occasions, 2 weeks apart. Each sports
morning was sports/play based with a mix of aerobic and
skills-based activities consisting of two 90-min exercise
blocks with a 30-min break in between.
Participants were fitted with the Dexcom G5 Mobile
system (Dexcom, Inc., San Diego, CA) at least 24 h before
the sports mornings. The Dexcom G5 Mobile CGM system
allows transmission of SGLs via Bluetooth to a mobile device
that generates alerts. This information can be shared via
‘‘cloud’’ with up to five individuals, who are then able to
remotely monitor the CGM reading of the user in real time
along with the possibility to use individualized alerts. On the
sports morning, participants consumed a standardized
breakfast and were advised to reduce the breakfast bolus by
10%. Insulin pump users reduced their basal insulin delivery
by 20% and patients on intermediate insulin reduced their
intermediate acting insulin by 10%. During the physical ac-
tivity on the sports morning, participants adhered to either a
CHO intake algorithm based on CGM trends (intervention)
modified from Riddell and Milliken,17 shown in Figure 1, or
to a control protocol where blood glucose levels (BGL) were
checked every 30 min and CHO was given according to standard
exercise guidelines (0.5 g CHO/kg/h given as 0.25 g CHO/kg
every 30 min when the capillary glucose was <8 mmol/L).7,18
CHO was administered in the form of glucose tablets for both
groups.
During the intervention arm, participants were able to see
their SGL in real time and study personnel were following the
participants remotely. In the control arm, participants and
study personnel were blinded to the CGM.
BURCKHARDT ET AL.
Several outcome measures were explored: the number of
exercise interruption events (such as stopping to perform self-
monitored blood glucose [SMBG] tests or ingest CHO), the
frequency of CHO intake, as well as the CHO intake in grams
and the number of hypoglycemic events defined as SGL
<3.9 mmol/L and <3.0 mmol/L for >20 min. Percentage time
spent in different sensor glucose ranges during physical ac-
tivity (09:00 to 12:30 h on the sports morning) was calcu-
lated: percentage time in range (TIR), 3.9–10.0 mmol/L, and
in hyperglycemia >10 mmol/L.
The number of hypoglycemic events and the number of
participants experiencing events are presented for each arm.
Medians and interquartile ranges are presented for percentage
time spent in different SGL ranges for each arm; paired sign
tests were used to compare medians across arms. Event rates
with exact Poisson 95% confidence intervals (CIs) were
calculated for CHO intake events, exercise interruption, and
mild hypoglycemic events (<3.9 mmol/L for >20 min) in
each arm; mixed-effects Poisson models were used to com-
pare rates across arms.
All statistical analyses were performed using Stata/SE for
Windows, version 13.0 (StataCorp LP, College Station, TX).
All tests are two sided, and p values <0.05 were considered
statistically significant.
Results
The 14 children (5 boys, 9 girls) who completed the study
had a mean (–standard deviation [SD]) age of 10.5 (–1.4)
years, mean diabetes duration of 4.8 (–2.7) years, and mean
HbA1c of 7.7 (–0.6) %. The majority of the participants were
using an insulin pump (n = 9, 64%). Mean total daily insulin
dose was 0.72 (–0.16) U/(kg$d) and the children performed a
mean of 4.4 (–2.0) hours of exercise per week. None of the
study participants had self-reported impaired hypoglycemia
awareness. One participant had a history of severe hypogly-
cemia (hypoglycemic seizure) 4 months before the first sports
day morning. The hypoglycemia event rate (95% CI) in the
24 h before the sports mornings (SGL <3.9 mmmol/L) was
comparable in both groups: 1.36 events per person/day (0.79–
2.18) in the control and 1.62 (0.99–2.47) events per per-
son/day in the intervention group.
Table 1 shows the mean SGL (–SD) at the start of exercise,
the median percentage time spent in different SGL ranges,
and the rates of mild hypoglycemic events, exercise inter-
ruption events, and CHO intake events in the control and
intervention arm.
No hypoglycemic events with SGL <3.0 mmol/L for
‡20 min occurred in either arm. Mild hypoglycemic events
occurred on two occasions during the control arm and on five
occasions (three participants with one episode and one par-
ticipant with two episodes) during the intervention arm.
The distribution for percentage TIR was negatively
skewed and the distribution for percentage time high was
positively skewed; both had values at both upper (100%) and
lower bounds (0%). Median percentage TIR and median time
spent high were comparable across arms and there were no
statistically significant differences (Table 1).
Mean CHO intake during exercise was the same in both
arms, 0.3 – 0.2 g/kg/h. However, compared with the control
arm, the intervention algorithm was associated with fewer
 CGM DURING EXERCISE IN CHILDREN WITH T1D
< 6.1- 6.9 mmol/L
Sensor Glucose
< 7mmol/L < 5-6 mmol/L
during exercise and
dropping
< 5 mmol/L
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FIG. 1. CHO intake algorithm, modified from Riddell and Milliken.17 CHO, carbohydrate.
CHO intake events and fewer exercise interruption events, as
illustrated in Table 1.
Action according to the algorithm was taken 12 times
during the intervention arm. Five algorithm actions were
followed by mild hypoglycemia in a time frame of 60 min
after algorithm action. None of the algorithm actions resulted
in a glucose level >10 mmol/L in a time frame of 60 min after
algorithm action.
Discussion
This pilot study shows that both use of a CHO intake al-
gorithm based on CGM trends (intervention) and adhering to
standard exercise CHO intake guidelines (control) (0.5 g
CHO/kg/h) have the potential to minimize hypoglycemia
during a physical activity in children with T1D, as demon-
strated by no episodes of significant hypoglycemia (SGL
<3.0 mmol/L for ‡20 min) in both study arms. Moreover, the
rate of mild hypoglycemic events (SGL <3.9 mmol/L for
‡20 min) was low in both arms. Similarly, Riddell and Mil-
liken17 found that CGM use coupled with a CHO intake al-
gorithm largely maintained euglycemia during exercise.
Furthermore, this study demonstrates that use of CGM
with a CHO intake algorithm is associated with a reduction in
the number of interruptions to exercise for ‘‘events’’ such as
performing SMBG or stopping to ingest CHO intake, with a
similar time spent in defined glucose ranges compared with
using standard exercise CHO intake guidelines. These find-
ings are relevant to active young people with T1D who may
find it difficult or undesirable to stop and ‘‘test’’ during ex-
ercise. Moreover, performing SMBG may not be practical
during specific activities such as cycling, swimming, or ski-
ing. In particular, in very cold temperatures, blood glucose
meters may not work.
It should be noted that this study was a pilot study to generate
estimates of potential outcome measures and assesses the fea-
sibility of the study design to inform a larger trial and was not
powered to detect differences between the two arms. We gained
insight into the distributions of potential outcome measures and
their variability that will inform the design of future trials.
53
Directional arrows or :
Take 8g CHO
Directional arrows :
Take 24g CHO
Directional arrows :
Take 20g CHO
Take 24g CHO
The CHO intake algorithm used in this pilot study was
modified from Riddell and Milliken.17 Modifications to
Riddell’s algorithm encompassed giving larger amounts of
CHO at specific thresholds, as illustrated in Figure 1. Despite
increased CHO dosing, use of the modified algorithm did not
result in hyperglycemia (>10 mmol/L) within 60 min of CHO
ingestion. We found that the total amount of CHO ingested
during exercise was similar in both groups. However, par-
ticipants using the CHO intake algorithm ingested larger
amounts of CHO less frequently than the control group. It
remains to be determined if this pattern of CHO consumption
would have been feasible and effective in the control group.
The strength of this study is that it uses a randomized
crossover design to minimize interindividual confounding
factors that may influence glycemia during exercise, such as
fitness levels and nutritional status. In addition, exercise type
and duration, insulin adjustment, and consumption of breakfast
and snacks were kept constant between study days. However,
the study has several limitations. First, given that the risk of
hypoglycemia during exercise is known to be higher with
sustained moderate/intensity exercise compared with inter-
mittent high-intensity exercise,10 it is important to note that our
sports mornings comprised mixed activities, and consequently,
this may have attenuated the risk of hypoglycemia. However,
as type and duration of activity were standardized, the risk of
hypoglycemia was constant across both groups. Furthermore,
the program of activity performed was chosen to be relevant to
the types of fun-based activity children in this age group may
partake in, such as a school sports event. Second, it has to be
noted that the mean SGL at the start of the exercise was in the
hyperglycemic range, which also lowered the risk of hypo-
glycemia during exercise. It may have also been useful to have
performed this study without reducing basal insulin, to simu-
late spontaneous exercise that is common in children—and
may have been a stronger challenge to both the control and
intervention algorithm.
In summary, both CHO intake based on standard exercise
CHO intake guidelines (control) and use of a CHO intake
algorithm based on CGM trends (intervention) have the po-
tential to minimize hypoglycemia, and largely maintained
 54 BURCKHARDT ET AL.

derived from paired Sign tests. Events are expressed as rate of events per person per exercise morning with exact Poisson 95% CI; IRR with 95% CI comparing intervention to control and P-values are
SGL at exercise start is expressed as mean (mmol/L) and SD; the P-value is derived from a paired t-test. Percentage time spent in different SGL ranges is expressed as medians and IQR; P-values are
<0.001*
euglycemia during exercise in young children with T1D. In

0.001*
0.204

0.778
0.594
0.73
addition, use of a CHO intake algorithm resulted in fewer

P
CHO intake events and fewer interruptions to exercise. Use
of this algorithm may reduce the burden of diabetes man-
agement during exercise with the potential to facilitate ac-

[0.55 to 15.78]
tivity in young people with T1D.

[0.22 to 0.65]
[0.10 to 0.37]
[-3.6 to 2.6]
95% CI

—
—
95% CI

95% CI
Acknowledgments
We thank the patients and families who participated in the
study, and Sports Challenge Australia who provided the ex-
ercise program during the sports mornings. This study was
Table 1. Percentage Time Spent in Different Sensor Glucose Level Ranges and Event Rates

supported by a seeding grant from the Children’s Diabetes

Mean difference

CHO, carbohydrate; CI, confidence interval; IQR, interquartile ranges; IRR, incidence rate ratios; SD, standard deviation; SGL, sensor glucose level.
Centre in Perth, a JDRF/NHMRC funded Centre of Research
Excellence. M.A.B. was funded by a research fellowship of
2.96

0.38
0.19
IRR

IRR
—
—
0.5

the Ettore and Valeria Rossi Foundation, Switzerland, and

supported by an International Postgraduate Research Fel-
lowship from the University of Western Australia. Dexcom
provided the sensors and hardware through an unrestricted
Downloaded by Ghana Hinari Band 1 from www.liebertpub.com at 01/20/19. For personal use only.

grant.
[0.12 to 0.83]

[33.3 to 86.0]
[2.3 to 66.7]

[0.4 to 1.4]
[0.8 to 2.1]

Authors’ Contributions
4.5
SD

95% CI

95% CI
Intervention

IQR

M.A.B. and T.C. were responsible for the study design,

data collection, data analysis, and article preparation. G.S.
was responsible for data analysis and reviewed and edited the
article. P.A. contributed to the study design and reviewed and
Median
Mean

0.36
Rate

Rate

edited the article. M.D.B. contributed to the study design,

12.8

74.1
20.0

0.9
1.4

data collection, and reviewed and edited the article. T.W.J.

and E.A.D. contributed to the study design and reviewed and
edited the article. All authors approved the final version of
this article.
[0.02 to 0.52]

[48.7 to 85.7]
[11.9 to 42.9]

[1.6 to 3.3]
[5.9 to 8.8]
3.7
SD

95% CI

95% CI

Author Disclosure Statement

IQR
Control

No competing financial interests exist.

References
Median
Mean

0.14
Rate

Rate
12.3

66.7
25.9

2.4
7.2

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Address correspondence to:
Dr Marie-Anne Burckhardt, MD
Department of Endocrinology and Diabetes
Perth Children’s Hospital
15 Hospital Avenue
Nedlands, Perth 6009
Western Australia
E-mail: marie-anne.burckhardt@health.wa.gov.au