Contributor: Jami Klein, RN, BSN, CDCES, Clinical Education - Dexcom
What is all this talk about time-in-range (TIR) and what do people with diabetes need to know about it? TIR may be a new concept for you, or maybe you are looking for ways to use this information in discussions with your diabetes care team. Either way, let's take a closer look at what the chatter is all about.
So, let's break it down. First, what is TIR? TIR is a metric used in continuous glucose monitoring that denotes the percentage of time an individual's glucose level is within the target range of 70-180 mg/dL. For most people with diabetes, the goal is > 70% TIR while decreasing time below range (< 70 mg/dL) < 4% of the time. A TIR of 70% equates to an estimated A1C < 7%. As with anything related to diabetes, check with your healthcare team to know your individual recommended targets.
Using TIR to guide choices and healthy behavior can empower you to move towards more TIR and lower average glucose levels. Instead of evaluating A1C data from the previous 2-3 months, TIR provides us with data to take immediate action. Even small changes may increase our TIR today, next week or next month, getting us closer to our goal. An increase in TIR by 5% is considered clinically meaningful while a 10% increase may result in a 0.5% decrease in A1C over time.
Emotions can run high when people see the numbers on their glucose meter or continuous glucose monitor (CGM). As a nurse and diabetes care and education specialist who has lived with type 1 diabetes since 1988, I experience many emotions as both the person living with diabetes and the clinician educating others. Let's put guilt, judgment, and all the other (completely normal and understandable) emotions aside and talk about how we can use glucose numbers to learn and adapt. TIR can be applied to all choices we make in our management of a very complex condition. Diabetes management never stops. We can use TIR to discover ways to increase the time spent in target range, we may find that we feel better. This may also lead to uncovering "autopilot" strategies. For me, this means choices that generally produce the same expected result, such as when I walk in the morning after breakfast, it tends to not cause a spike in my glucose.
So, how do you begin to move towards more TIR? Here are some points to consider discussing with your healthcare professional.
- Personalize the approach - Each person living with diabetes is unique. While we have general guidelines to increase TIR, we each can discover what works best for our own body. This is best done collaboratively, with your healthcare team.
- Experimentation – This is what really helped me increase my TIR. I find it's best to start experimenting by looking at your CGM trend graph and focus on the areas where you want to spend more TIR. Start with times when glucose is less than 70mg/dL. Then look at days when your TIR is the highest, what did you do that day that worked for you? What foods were you choosing? Were you being physically active? When you focus on what is working well you can have a positive mindset. There are tons of experiments to try so be creative!
- Sleep - I like to ensure my glucose is in range overnight and that I'm waking up with glucose near 100 mg/dL. Then, during the day, I look for areas that tend to be patterns. If I have a random low or high glucose, I think back to the past few hours to see if there is a reason I can find that led to the glucose I'm seeing now.
- Real time data - For me, living life and doing what I enjoy, with minimal disruptions from diabetes, is the goal. One way I can do that is by using a CGM and time-in-range to make personal discoveries. When I learn something that works well for me, I add that to my "autopilot" list of ways to stay in range. As I learn how certain foods and activities will affect my glucose, I can plan better. There aren't many guarantees when it comes to diabetes so don't aim for perfection, shoot for continuous improvement. Look for hypoglycemia and work with your diabetes care team to decrease time below range. The goal is to spend as little time as possible in the low range while having more time spent in range (70-180 mg/dL).
A few final tips:
- Find areas where you are in range and do more of what is working. Look for and celebrate what is already keeping you in range!
- Is there a certain meal that keeps glucose in range?
- When you do more activity does that increase TIR?
- Does a good night's sleep increase your TIR?
- Then look at areas your glucose is above 180mg/dL. What is happening prior to these times? Are you exercising? Eating a certain food? Stressed?
- One way to frame this is “If ______, then_______.” For example, "If I walk during the day, then I tend to have more TIR."
- What are your “If______, then _______.” When it equals more TIR, do that more.
Diabetes management is tough. Stay positive and do your best. Even a 5% increase of time-in-range is significant. Celebrate the meals or activities that keep your glucose in range. Be curious. Ask questions. Work with your diabetes care team to discover what is best for you. Remember, this is an ongoing process, and you are awesome!
For more information about TIR and for a list of questions to help you speak with your care team about TIR check out The Global Movement for TIR at www.wheninrange.com. You can also view pdfs on Why Time in Range Matters and Metrics Beyond A1C.
Jami Klein is a nurse and certified diabetes care and education specialist who is passionate about education and technology to improve the lives of those living with diabetes. She has lived with type 1 diabetes since 1988 and had various roles in the diabetes field for most of her career. She volunteers at Camp Ho Mita Koda in Newbury, Ohio – the oldest operating camp for kids living with type 1 diabetes. Jami lives in Cleveland, Ohio with her husband and 2 sons.
Dexcom is a 2021 National Strategic Partner of DiabetesSisters. DiabetesSisters shares information they provide that is useful to our community; however, the relationship does not influence the decisions or opinions of DiabetesSisters, its governing board or staff.