By Cindy King and Carley Rusch

As November is Diabetes Awareness Month, it’s crucial to highlight how technological advancements in diabetes care, including continuous glucose monitors (CGMs), can benefit active older adults. Nearly 50% of adults aged 65 and older have prediabetes, and approximately 25% have a diabetes diagnosis. In active older adults, it is important for them and their healthcare team to understand how their physical activity can impact their glucose. Physical activity may impact glucose levels for 24 hours or more after exercise. Lifestyle, including exercise and nutrition, should be foundational in the management of diabetes, and CGMs can further support glucose management and provide valuable information to decrease the risk of hypoglycemia.

Exercise and Glucose

Regular physical activity is an important part of managing diabetes. In most cases, exercise can help lower glucose as it improves insulin sensitivity and utilization during exercise. Some intensive exercises such as heavy weightlifting, sprinting, or other competitive sports may result in the body producing adrenaline, a stress hormone, which can increase release of stored glucose from the liver. A CGM may allow active older adults to identify these trends and implement adjustments in their exercise routines, nutrition, or initiation medication to minimize increases in glucose.

Recommendations for CGM use

CGMs are valuable tools for individuals and healthcare practitioners in the management of diabetes. These devices include a small sensor worn on the body with a thin filament inserted under the skin to continuously measure glucose levels. Glucose readings are visible on a mobile app or specific CGM reader. CGMs allow for frequent continuous monitoring of glucose levels which can allow older active adults to closely monitor their glucose to avoid hypoglycemia and understand how their body responds to exercise, nutrition, and medications.

The American Diabetes Association (ADA) and the American Association of Clinical Endocrinology (AACE) recommend CGMs for all adults with diabetes who need multiple daily injections (MDI), insulin pumps, or basal insulin. The AACE also recommends CGMs for people with Type 2 diabetes (T2D) at high risk for hypoglycemia or hypoglycemia unawareness. CGMs can benefit older adults by supporting medication, physical activity, and nutrition management. The devices provide current glucose values, trend arrows, and alerts through mobile apps, notifying individuals of hypo- or hyperglycemic events that may require action.

Understanding CGM data

Individuals utilizing glucometers are familiar with fasting blood glucose and 2-hour postprandial glucose goals which are often adjusted based on age or comorbidities. CGM users will notice their device provides a glucose value and accompanying arrow indicating the glucose trend (Figure 1). This combination empowers individuals to understand glucose changes and collaborate with their healthcare team to develop a medication, physical activity, and nutrition management plan.

Figure 1:   Examples of glucose values and symbols provided by a CGM

 
Additionally, healthcare practitioners can access reports to interpret CGM data. The International Consensus on Time in Range standardized the ambulatory glucose profile (AGP) report, which includes mean glucose, time in range (TIR), glucose variability, and other data. The target range for individuals with diabetes (not during pregnancy) is 70–180 mg/dL, but the recommended percentage of time in that range varies based on goal hemoglobin A1c (Figure 2). Small positive changes to an individual’s physical activity and diet can improve TIR as each 5% increase in TIR is considered clinically significant. A 10% increase in TIR is associated with a decrease in retinopathy, microalbuminuria, major adverse cardiovascular events, and hypoglycemia.

Figure 2:  Examples of targeted percentages for time in range (TIR) glucose based on hemoglobin A1c goals

Personalized nutrition interventions

There is no one-size-fits-all eating plan for people with diabetes, according to a consensus report from the American Diabetes Association. However, older adults with diabetes may shift food choices due to changes in appetite, taste, smell, and emotional well-being, often favoring high-glycemic carbohydrates and under-consuming nutrients like protein and fiber. Medical nutrition therapy (MNT) combined with CGM data can provide an individualized approach for older adults with diabetes. MNT includes lifestyle modifications through diet education and diabetes-specific oral nutrition supplements (ONS) to promote adherence and support healthful eating patterns and glycemia.

Here are examples of nutrition interventions to support optimal TIR and minimize hypoglycemia:

• Keep a food log to evaluate how choices impact glucose.
• Encourage patients to make changes to their food or beverage choices.
• Use the plate method: fill ½ of the plate with non-starchy vegetables, ¼ with protein, ¼ with carbohydrate foods, and pair with water or a low-calorie drink.
• Evaluate whether hyperglycemia peaks before or after eating.
• Hyperglycemia: balance the plate with non-starchy vegetables, whole grains, and lean proteins, consider reducing portion sizes, replace a meal or snack with diabetes-specific ONS, and/or increase exercise after meals.
• Daytime variability: review day-to-day activity levels, reinforce adherence to medication timing, and focus on foods that keep glucose between 70–180 mg/dL.
• For prevention of hypoglycemia prior to physical activity or treatment of hypoglycemia: use the 15/15 rule of 15 grams of fast-acting carbohydrates and recheck after 15 minutes.

For individualized meal planning, older adults with diabetes using CGMs should work with a registered dietitian (RDN) and/or certified diabetes care and education specialist (CDCES) to prioritize the right amounts of carbohydrates, fats, and proteins in their diet to support healthy aging and glucose control.

Cindy King, PharmD, BCACP, CDCES, is a Medical Science liaison for the Diabetes Care division of Abbott, in Alameda, Calif. Carley Rusch, PhD, RDN, LDN, is a Medical Science liaison for the Nutrition division of Abbott, in Columbus, Ohio.