Hypoglycemia is a serious complication for people with diabetes who are on medications such as sulfonylureas and insulin (1). Severe hypoglycemia can lead to seizures, declined cognitive function, cardiovascular events, and even death. Impaired awareness of hypoglycemia (IAH) makes matters much worse (2). Up to 25% of people with type 1 diabetes and up to 10% of people with type 2 diabetes who are on insulin have IAH (2). These individuals do not experience the typical symptoms of hypoglycemia because of autonomic failure; their glucagon or catecholamine levels may not increase to trigger hepatic glucose production in time.

Continuous glucose monitoring (CGM) systems are increasingly accessible and effective for hypoglycemia-prone people with type 1 or type 2 diabetes as a means of receiving real-time biofeedback and facilitating behavior change. CGM systems check glucose levels in interstitial fluid every 5 minutes. Alerts can be programmed to help prevent hypoglycemia, hyperglycemia, or both. Time in range (TIR) is an emerging CGM-based metric being used increasingly (3) to improve diabetes management. Although the traditional gold standard, A1C, can predict the development of diabetes complications (3), it does not show glucose excursions away from the normal range. Also, assessing glucose responses to lifestyle changes using A1C takes 2–3 months. In contrast, CGM can reveal people’s daily mean glucose, as well as many other details about their glycemic responses, including 24-hour glucose profile, extent of glycemic variability, fasting glucose levels, and TIR. CGM allows users to see their glucose responses to any lifestyle change in real-time basis, and TIR (3) and mean glucose are valuable parameters for assessing diabetes self-management.

Despite the benefits of CGM, however, Lin et al. (4) report that people with type 1 diabetes and IAH continue to experience more hypoglycemia events, even with dedicated CGM use. Many people with type 1 diabetes are so afraid of hypoglycemia that when they hear a hypoglycemia alert from their CGM system, they rush to eat and often end up eating more carbohydrates than needed to return to their glycemic target range. Then, about an hour later, they might get a high glucose alert and then take extra insulin, leading to another hypoglycemia alert later on. I have noticed this vicious cycle occurring in some patients. They cannot seem to break the cycle, and they may even become afraid to exercise because of the potential for additional hypoglycemia.

Research has shown that strict hypoglycemia prevention may restore hypoglycemia awareness (57). Nwokolo et al. (8) showed cerebral blood flow improving in a certain part of the brain, including the anterior cingulate cortex, as restoration of IAH occurs. Choudhary and Amiel (9) have recommended using technological and psychological means to prevent hypoglycemia. Lin et al. (10) reported beneficial effects of setting the CGM hyperglycemia alarm at <205 mg/dL and hypoglycemia alarm at >73 mg/dL (10).

Minimizing insulin doses and avoiding sulfonylureas are of utmost importance to preventing hypoglycemia. I had been managing my own type 2 diabetes for more than 22 years and have a history of IAH. My endocrinologist prescribed CGM in 2017 to deal with hypoglycemia. Before that, I had twice ended up in the Emergency Room with seizures. My blood glucose levels were 25 and 15 mg/dL, respectively, during those episodes. I had been taking 36 units of glargine insulin at the time. Guided by CGM, I was able to reduce my insulin to one-third of that dose by focusing on healthy meals and safe exercise. When the injectable glucagon-like peptide 1 receptor agonist semaglutide 1 mg weekly was added to my metformin 1,000 mg twice daily, I was able to taper off insulin completely.

Upon initiating CGM, I set my hyperglycemia alert at 250 mg/dL and the hypoglycemia alert at 70 mg/dL. However, after a while, I realized that these alerts did not help me regulate my glycemia. My TIR would go down, or my mean glucose would go up after the alerts. Then I started adjusting the high alert downward and the low alert upward and things started to improve.

Currently, my high alert is at 150 mg/dL, and low alert is at 90 mg/dL, which give me time to correct the glucose level. When I hear a high alert, I take a 20- to 30-minute walk, and when I hear a low alert, I eat a small snack. I have been successfully practicing a five-step program I will describe below for about 2 years, and my A1C has been in the range of 5.8–6.1% during that period. This account describes how healthy eating habits (11,12), safe exercise options (12), and smart use of CGM alerts can minimize hyperglycemia and hypoglycemia. The three meal-related steps (11,12) and the two exercise-related steps (12) are for all people with diabetes. The smart CGM alerts are specifically for people who use CGM.

People with type 1 or type 2 diabetes who have a glucose meter or CGM system are free to personalize their meals and exercise using evidence-based healthy practices. It is useful to check fasting blood glucose (FBG) every day and postprandial glucose (PPG) 1 hour after major meals, as needed. When starting the five-step program described here, initial FBG and PPG levels indicate the pre-intervention status of diabetes management. FBG influences PPG and A1C (13). PPG, in turn, influences FBG and A1C. Normal FBG indicates sound disease management. High and low FBG levels can be brought within the target range of 90–110 mg/dL, per American Diabetes Association guidelines (11). PPG levels >180 mg/dL (11) call for intervention in real time.

Individuals who are on insulin and have a FBG level <100 mg/dL may be encouraged to lower their basal insulin dose by 2 units. If their PPG is <150 mg/dL, lowering the mealtime insulin dose is preferred.

Step 1: Pay Attention to Meal Timing

Most people would benefit from eating a moderate breakfast, regular lunch, and light, early supper (all else being equal). This is because glucose tolerance is poor in the evening for most of us, and this type of eating pattern is in phase with the body’s circadian clock (12,1417). People with diabetes have poor glucose tolerance in the morning, as well (14). Adding a high-protein low-carbohydrate pre-breakfast snack 90–120 minutes before breakfast provides a second-meal effect (18), moderating the post-meal glucose surge. In practice, after having a morning snack, PPG levels for all meals throughout the day seem to be lower, as shown in Figure 1. The second meal effect may be less impressive in people with type 1 diabetes because they have exogenous insulin present in the body.

FIGURE 1

Effect of meal timing on glycemia. A: Delayed breakfast and late supper mean poor meal timing. Carb distribution is 2.5, 0.5, 2.5, 0.5, and 2, for a total of 8 carbs throughout the day. Breakfast PPG is 231 mg/dL, TIR 94%, and mean glucose 124 mg/dL. B: Morning snack and early eating mean better meal timing. Carb distribution is 0.5, 2, 2.5, 1, and 2, for a total of 8 carbs throughout the day. Breakfast PPG is 125 mg/dL, TIR 100%, and mean glucose 117 mg/dL.

FIGURE 1

Effect of meal timing on glycemia. A: Delayed breakfast and late supper mean poor meal timing. Carb distribution is 2.5, 0.5, 2.5, 0.5, and 2, for a total of 8 carbs throughout the day. Breakfast PPG is 231 mg/dL, TIR 94%, and mean glucose 124 mg/dL. B: Morning snack and early eating mean better meal timing. Carb distribution is 0.5, 2, 2.5, 1, and 2, for a total of 8 carbs throughout the day. Breakfast PPG is 125 mg/dL, TIR 100%, and mean glucose 117 mg/dL.

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Here is my preferred meal plan:

  • Morning snack (0.5 carbohydrate serving [carb; 15 g]); coffee with 1/2 cup milk plus an egg or a handful of nuts

  • Moderate breakfast 90–120 minutes after the snack (2–3 carbs)

  • Regular lunch 120–180 minutes later (3–4 carbs)

  • Light afternoon snack (0.5–1 carb, optional)

  • Early, light supper (0.5–1 carb)

Step 2: Meal Composition

It is well established that meal composition improves when fiber, lean protein, nonstarchy vegetables, and healthy fats are added to appropriate carbs (11,12). Carb intake should be lowered if post-meal glucose is >180 mg/dL (11). When meal composition improves, glucose is absorbed slowly, glucose surges are wider, and glucose variability is lower, leading to minimal hyperglycemia and hypoglycemia (Figure 2).

FIGURE 2

Effect of meal composition on glycemia. Meal timing on day 3 (A) is better than that on day 2 (B). Carb distribution is 0.5, 3, 3, 0.5, and 1, with 6.5 carbs consumed early in the day with light afternoon snack and supper. Meal timing, carb distribution, and all small meals are identical on days 3–6. A: On day 3, big meals have poor meal composition at breakfast (cornflakes, 1 g fiber, and 3 g protein/serving plus whole milk) and lunch (rice, 0 g fiber, and 3 g protein/serving plus yogurt). PPG after breakfast and lunch are 184 and 160 mg/dL, respectively; TIR is 99, and mean glucose is 127 mg/dL. B: On day 4, breakfast is granola with 9 g fiber and 9 g protein/serving plus whole milk, and lunch is barley with 7 g fiber and 5 g protein/serving plus yogurt. Better meal composition improves PPG after breakfast (from 184 to 159 mg/dL) and after lunch (from 160 to 141 mg/dL), TIR (from 99 to 100%), and mean glucose (from 127 to 117 mg/dL).

FIGURE 2

Effect of meal composition on glycemia. Meal timing on day 3 (A) is better than that on day 2 (B). Carb distribution is 0.5, 3, 3, 0.5, and 1, with 6.5 carbs consumed early in the day with light afternoon snack and supper. Meal timing, carb distribution, and all small meals are identical on days 3–6. A: On day 3, big meals have poor meal composition at breakfast (cornflakes, 1 g fiber, and 3 g protein/serving plus whole milk) and lunch (rice, 0 g fiber, and 3 g protein/serving plus yogurt). PPG after breakfast and lunch are 184 and 160 mg/dL, respectively; TIR is 99, and mean glucose is 127 mg/dL. B: On day 4, breakfast is granola with 9 g fiber and 9 g protein/serving plus whole milk, and lunch is barley with 7 g fiber and 5 g protein/serving plus yogurt. Better meal composition improves PPG after breakfast (from 184 to 159 mg/dL) and after lunch (from 160 to 141 mg/dL), TIR (from 99 to 100%), and mean glucose (from 127 to 117 mg/dL).

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Step 3: Nutrient Sequencing

In certain circumstances, nutrient sequencing can attenuate PPG: eat protein and vegetables first and then eat carbohydrates or dessert 10–30 minutes later (12).

Step 4: Pre-Meal Walk

High-intensity pre-breakfast exercise offers multiple benefits, including the absence of hypoglycemia during the activity, a delayed insulin sensitivity improvement that lasts for 24 hours or more, and better FBG (12,19,20). It also generates post-exertion hyperglycemia, leading to glucose dysregulation for 1–3 hours (12,19) and, in people who take insulin, delayed hypoglycemia (21). Because of this risk for hyperglycemia and hypoglycemia, the role and utility of pre-breakfast exercise in diabetes management remain unsettled (2224). According to my CGM data, a pre-breakfast walk of moderate intensity, followed by a morning snack every other day, has been especially valuable for metabolic control. This meal– exercise combination mitigates the negative effects of pre-meal exercise on glycemia.

Training during fasting is known to improve physical health, body composition, glucose tolerance, FBG, glycogen content, and GLUT-4 protein levels (19,20,25,26). Figure 3 shows the effect of pre-meal walks on glycemia.

FIGURE 3

Effects of different exercise options on glycemia. A: This is the same as Figure 2B (day 4), when meal timing and meal composition are optimal. B: On day 5, there was a 45-minute pre-breakfast walk, and 30 minutes of exercise was performed 40 minutes after lunch. PPG after breakfast and lunch did not seem to improve, but mean glucose decreased from 117 to 114 mg/dL, and TIR stayed at 100%. C: On day 6, no exercise was performed. The effect seen is from the pre-meal walk done on day 5. There were improvements in PPG after lunch (from 140 to 107 mg/dL) and mean glucose (from 114 to 104 mg/dL). TIR remained at 100%.

FIGURE 3

Effects of different exercise options on glycemia. A: This is the same as Figure 2B (day 4), when meal timing and meal composition are optimal. B: On day 5, there was a 45-minute pre-breakfast walk, and 30 minutes of exercise was performed 40 minutes after lunch. PPG after breakfast and lunch did not seem to improve, but mean glucose decreased from 117 to 114 mg/dL, and TIR stayed at 100%. C: On day 6, no exercise was performed. The effect seen is from the pre-meal walk done on day 5. There were improvements in PPG after lunch (from 140 to 107 mg/dL) and mean glucose (from 114 to 104 mg/dL). TIR remained at 100%.

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Step 5: Post-Meal Walk

Decades of studies in various populations have established that moderate, timely, post-meal exercise can lower the post-meal glucose surge after bigger meals through contraction-mediated glucose uptake (12,2731). If the goal is to blunt the post-meal glucose surge, an appropriate amount of glucose needs to be expended. Excessive energy expenditure through high-intensity or long-duration exercise may result in hyperglycemia or hypoglycemia, depending on the hepatic involvement (12). Because exogenous glucose is the main fuel for moderate post-meal activity, the resulting glucose tolerance is short-lived (32) and may not improve FBG (20). Post-meal exercise performed at the right time and of the right intensity is still quite valuable for day-to-day diabetes management (2731).

A 30-minute post-meal walk 30–45 minutes after any big meal would blunt the glucose surge in real time. (A short-duration, high-intensity exercise such as 12 minutes of resistance exercise would also work, but may increase the risk of hypoglycemia for people on insulin [12], whose glucose level should be monitored closely.) Patients may not need mealtime insulin when appropriate post-meal exercise is performed. Figure 3B shows the effects on glycemia of both pre-meal and post-lunch walks performed on the same day.

Smart CGM alerts is a good tool specifically for people who use CGM: I recommend setting the high alert at 150 mg/dL and the low alert at 90 mg/dL. After a high alert, they may take a 20- to 30-minute brisk walk. After a low alert, they may eat a small snack (e.g., three grapes or a mandarin orange). Smart alerts provide adequate time to take countermeasures to regulate glucose proactively.

Six days of CGM data are displayed in Figures 13, showing the benefits of healthy practices. Figure 1 shows the role of meal timing in glucose regulation. The nutritional components of the meals (e.g., 8 carbs/day) remain the same on both days. Breakfast is cold cereal (toasted oats, blueberries, and whole milk), and lunch is a smoothie (1 banana, 1 cup of whole milk, and 1 Tbsp peanut butter). Supper is chicken, vegetables, and a slice of avocado plus 2/3 cup of rice. On day 1 (Figure 1A), with a delayed breakfast and late supper, meal timing is poor. On day 2 (Figure 1B), with an early-morning snack and most carbohydrates (5 carbs) consumed early in the day, meal timing is better, leading to improved PPG after breakfast (from 231 to 125 mg/dL), TIR (from 94 to 100%), and mean glucose (from 124 to 117 mg/dL).

Figure 2 demonstrates the role of meal composition on glycemia. Meal timing on day 3 is further improved by making the afternoon snack and supper each smaller. Meal timing, carb intake (8 carbs/day distributed as 0.5, 3, 3, 0.5, and 1), a morning snack (egg and coffee with whole milk), an afternoon snack (two cherries and four blackberries), and supper (chicken, vegetables, and a slice of avocado plus one kiwi) are identical on days 3–6. On day 3 (Figure 2A), meal composition is poor for the two big meals; breakfast is corn flakes (1 g fiber and 3 g protein/serving) plus whole milk, and lunch is rice (0 g fiber and 3 g protein/serving) and yogurt. On day 4 (Figure 2B), meal composition is better because extra fiber and protein are included. Breakfast is granola with 9 g fiber and 9 g protein/serving plus whole milk, and lunch is barley with 7 g fiber and 5 g protein/serving and yogurt. PPG decreases after breakfast (from 184 to 159 mg/dL) and lunch (from 160 to 141 mg/dL) on day 4. Also, TIR increased from 99 to 100%, and mean glucose decreased from 127 to 117 mg/dL.

Figure 3 shows the effects of exercise on glycemia. Figure 3A is the same as Figure 2B (day 4). On days 4–6, meal timing and meal composition are optimal. On day 5, there is a 45-minute pre-breakfast walk. There is also a 30-minute walk taken 40 minutes after lunch (the third meal). On day 5, TIR remains 100%, and mean glucose decreases from 117 to 114 mg/dL. On day 6, no exercise is performed to illustrate the effect of the previous day’s pre-meal exercise. Mean glucose decreases to 104 mg/dL, and TIR remains at 100%.

My experience suggests that this five-step program can meaningfully change glucose levels and CGM data depending on how many habits are practiced. Better glucose regulation in the morning tends to help for the rest of the day. For example, if FBG is in the target range, PPG is likely to be better after meals as well. As shown on day 2 (Figure 1B), when the morning snack moderates breakfast PPG, that seems to help for the rest of the day. People who practice most of these healthy habits tend to stay on a virtuous cycle. As soon as they slip out of the healthy track, they may enter a vicious cycle, and some degree of vigilance may be needed to get back on track.

I will now present three real cases. One patient, a registered nurse, had difficulty keeping his FBG <120 mg/dL. As soon as he corrected his meal timing and started the pre-breakfast walk, his FBG normalized. Another patient was diagnosed with prediabetes in 2007. He started walking for 1 hour in the morning. Now, 13 years later, his A1C remains in the range of 5.2–6.1% despite stopping metformin. A third person, a psychologist, was introduced to the five healthy habits (12). His A1C decreased from 9.8 to 7.3% in 3 months, and his weight decreased from 85 to 76 kg. These three individuals are, of course, highly motivated.

Another observation concerns the mixed effects of pre-meal exercise. Initially, there is post-exertion glucose elevation, leading to glucose dysregulation for 1–3 hours after exercise (19). There is also delayed improvement in insulin sensitivity, which is usually better on the next day (12). The markedly improved glucose profile on day 6 (Figure 3C) is likely the effect of the pre-meal exercise done on day 5 (Figure 3B). In fact, overall glycemia is better when pre-meal exercise is done every other day. Post-meal exercises can be done after bigger meals on the remaining days.

The roles of meal timing, meal composition, and nutrient sequencing in improving glucose control are well documented. The positive and negative effects of pre-meal and post-meal exercise on glucose levels are also well studied. By practicing these five evidence-based habits and monitoring my progress via CGM, I found that the value of a morning snack was clear: Circadian-friendly eating and second-meal effects were helping PPG of both breakfast and lunch. Also, a pre-breakfast walk followed by the morning snack every other day turned out to be especially valuable; it mitigated the negative effects of pre-meal exercise and enhanced the positive effects. When I practiced what Lynn et al. reported about smart CGM alerts, I readily minimized hyperglycemia and hypoglycemia.

Both the existing scientific evidence and my own experience in self-managing type 2 diabetes with CGM for more than 2 years suggest that the five-step program described here is likely to yield good metabolic outcomes. The meal-time insulin dose at breakfast may be lowered or even eliminated with the help of the second-meal effect from the morning snack, and the timely post-meal walk after lunch can obviate mealtime insulin for lunch. The basal insulin dose can also be minimized as FBG improves.

This lifestyle is especially designed to prevent hypoglycemia and restore hypoglycemia awareness. The expected outcomes are normal FBG, moderate PPG, lower A1C, minimum insulin doses (basal and bolus), less hypoglycemia, lower risk of diabetes complications, and improved weight, blood pressure, cholesterol, and cardiometabolic health.

People with diabetes who have a glucose meter or CGM system should be encouraged to test these evidence-based healthy habits for themselves to improve diabetes management. Some may need close guidance and supervision. Randomized, controlled studies of this five-step program in different populations would be helpful.

Acknowledgments

The author thanks her endocrinologist, Dr. Christine Signore, of Middlesex Hospital in Middletown, CT, for her continued efforts to protect from hypoglycemia by ordering CGM and adjusting medications as needed.

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

Author Contributions

As the sole author, E.C., is the guarantor of this work and, as such, had full access to all the data included and takes responsibility for the integrity of the data and the accuracy of the article.

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