Time in Range Should Be a Conversation
By Andrew Briskin
Having a consistent, meaningful dialogue with your healthcare team about Time in Range can help you adjust and improve your diabetes management. We sat down with Ellyn Grantham, who has been living with type 2 diabetes for 20 years, along with her healthcare provider, to better understand what type of communication works best.
Taking advantage of the vast amount of data that you receive from a continuous glucose monitor (CGM), including your Time in Range (TIR), can help you better manage your diabetes: from understanding patterns in your glucose levels to learning how your glucose responds to medications, diet, and exercise. Just as important, looking at your time spent above and below range helps to identify what methods work (or don’t work) to keep your glucose at a healthy level. However, the potential for better management is lost without the right dialogue with your healthcare provider.
“It’s not always the case where you simply put a CGM on someone, and they automatically do better,” said Dr. Diana Isaacs, a clinical pharmacist and diabetes care and education specialist at the Cleveland Clinic who regularly educates people about the benefits of TIR. “[Healthcare providers] need a plan to educate and train people to use their TIR data in a meaningful way, which comes from following up about the data and having a dialogue about the glucose profile.”
This dialogue is a two-way street between the provider and the people they treat.
“Before using a CGM, I had a lot of trouble logging my glucose, often estimating my values or overeating just to keep from going low,” said Ellyn Grantham, who has been living with type 2 diabetes for 20 years. She discusses her TIR with Isaacs on a monthly basis. “Now, when I go into the clinic, we go to my glucose report, look at some of my good and not so good days, and identify where my glucose may have been out of range; maybe I missed a meal, for example.”
Asking the right questions and matching your glucose trends with behaviors is key. And for healthcare providers, focusing on successes and identifying day-by-day glucose trends can help those with diabetes reinforce good habits. Isaacs took us through her typical process of discussing TIR with Grantham.
“TIR is the biggest thing when it comes to seeing progress week to week. I utilize the ambulatory glucose profile (AGP) report and look at the key metrics,” said Isaacs. “The AGP [report] also shows trends and patterns by time of day, which I use to guide the discussion. Beyond that, I like to focus on the things that are going well. With CGM, you can identify the best days to try to replicate what you did that day.”
Talking not just about TIR, but also Time above and below Range, drives the conversation around
“When I go down the AGP report, I talk about the coefficient of variation [a percentage that gives insight into how much your glucose levels vary over time], which if low, means that glucose levels do not have a lot of fluctuation and are relatively flat over time,” said Isaacs. Most experts encourage people to aim for a coefficient of variation of 33% or lower (though there are exceptions such as children and teens with type 1 and people with type 2 diabetes not on insulin).
“Even when the percent of Time below Range is small, I still like to identify each incidence of hypoglycemia. I then like to look at the best day, looking at post-meal spikes (or lack thereof) and identify what was eaten that day. For people on insulin pumps and pens, this can be really important for insulin adjustments throughout the day,” she said. Encouraging people to log their food, activity, and insulin each day can help illuminate these trends as they aim for a goal of 70% of their time spent between 70 and 180 mg/dL.
Grantham added that fingersticks simply don’t show her enough information about how, for example, certain foods affect her glucose levels. “With the CGM, I can actually see how my glucose levels change and bring that experience to the discussion of my highs and lows,” she said.
In addition, new data sharing capabilities are able to make these discussions possible virtually, without having to visit the clinic. Though Grantham prefers to visit the clinic roughly once a month, Isaacs explained that many people actually prefer virtual visits since all of their data is stored on the cloud.
Isaacs and Grantham said that they typically spend 30 minutes reviewing the AGP report together and talking about adjustments to Grantham’s diabetes management. Isaacs, an advocate for the expanding use of TIR and CGM access, recognizes that many people simply do not have this much time.
“A huge majority of people with diabetes, especially those with type 2, see a primary care provider (PCP) for their diabetes management. However, PCPs are often super busy, or not aware of TIR, and there isn’t anyone to follow up with people about their data,” she said. “There needs to be a member of the healthcare team who can train, educate, and support people in using CGM and TIR, which can often come in the form of a pharmacist or diabetes care and education specialist.”
To learn more about Time in Range, you can visit our resource page here.
This article is part of a series on Time in Range.
The diaTribe Foundation, in concert with the Time in Range Coalition, is committed to helping people with diabetes and their caregivers understand time in range to maximize patients' health. Learn more about the Time in Range Coalition here.
