FUDiabetes

ADA Issues Time-in-Range Targets for CGM Use

Nothing revolutionary but I find it helpful to read updated versions of these papers
Happy to see 3 of the pages of references and acknowledgements.

Press Release

Report (.pdf)

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Thanks for posting!

Page 4 of the report provides the following table of targets. Unfortunately I can only paste it in as a picture because the formatting gets all screwed up when I try to paste it in any other way. Hopefully those of you who are unable to read the picture can reference the link directly to view the table.

I’ve often wondered what the ideal % of time in range would be. I’ve never seen recommendations like this published anywhere.

The claim of benefits for every 5% increase is interesting. I might look into the references to see what benefits have been measured.

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Yep I like reading about that extra credit for beating the goals too! Especially since I fit in the “older” category.

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Gary Scheiner’s group told me to shoot for 80% in range, and less than 5% low if I recall correctly…or maybe less than 4% low…

But that was the ballpark.

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Looks like the benefits measured in the references are just less time spent hyperglycemic and a lower A1C. Which are obviously great, but I guess I was hoping they might’ve studied the risk of complications as well. It’s pretty redundant to say that more time in range is correlated with less time spent hyperglycemia…

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For the last 3 months, Samson basically almost hits these targets – he spends about 72% time in range and about 7% time low, so nearly double :frowning:. He spends 21% of his time high, but a little bit too much time very high (6% rather than 5%).

Another data point suggesting we need to figure out better settings for him!

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The thing I find interesting about these numbers is that, while it doesn’t have any explicit values for SD recommended, it does imply flatter blood sugar lines than we are able to attain, but at much higher average BG. For instance, Samson’s last A1C was 6.2% and he does not hit these targets. To hit these targets at an A1C of 7% I feel like you’d need to actually have more steady blood sugar readings than we typically see – which means you’d be steady and flat at a higher number. But if we were able to get Samson’s numbers pretty flat and steady at, say 140 mg/DL, I think we’d also be asking ourselves if we couldn’t do the same at, say 120 mg/DL or 100 mg/DL.

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I seem to hit their recommendations exactly based on my 14 day Dexcom data. Average BG of 7.9 mmol/L, standard deviation of 2.5 mmol/L, time in range (coincidentally using all the same ranges they suggest) of 79.6%, time low 3.6% (very low 0.4%), time high 17% (very high 2.1%). Estimated A1c of 6.6% (my last A1c was 6.8%).

I would ideally like to get the average BG and A1c down a little more. But my memories of when my A1c was 6.0-6.2% was that although I had far fewer highs, I also had more lows and it took a lot more effort. I’m not sure where the tradeoff is. My BG was definitely more stable, but with a lot more work. Unless more research of A1c <7% comes along, my current control seems pretty reasonable to me unless I find myself with extra time on my hands to work on tighter control.

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I honestly found this number impossible to keep below 4% when I had an A1c in the low 6% range. It was once 16% when my endocrinologist saw it, which he was not happy with (A1c at the time was 6.3%, I think). It’s only since letting my A1c rise to the high 6% range that I’ve managed to do it. I don’t really like my A1c at a higher level, but it’s hard to know whether higher and steadier (and less effort) is better than lower and, not necessarily more variable, but more prone to lows due to the lower average.

I think the reason so many people turn to low-carb as a way to get really tight control is that it’s virtually the only way to reduce both average blood sugar and standard deviation. Otherwise, the ups and down from food and insulin alone make it so that you’re almost guaranteed to have too many lows if you try to aim for a lower average. The alternative is sugar surfing and attending to your blood sugar every 15-30 minutes throughout the day to make dosing and eating decisions, but that’s very intense for most people (and of course can’t happen 24/7).

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Yeah, there’s no way I could obtain my current values without Afrezza. I spend 90% of the time in a range of 65-180 with no time above 250 in the last month. My average is around 110.

That wasn’t close to possible for me before Afrezza.

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@Jen, I agree with you maybe if you’re just sugar surfing. But Samson is looping and there are many, many people who are in the low 6s, to high 5s with a normal carb intake. The way you can think of it,just having the closed-loop at night shaves off, in my experience, 0.5 from the A1C, even if your control during the day is no better. So 6.5 on Loop is, effort-wise, the equivalent of 7 off Loop I think. We don’t really carb count much, our settings are all wrong, and we have teachers who do very little with respect to his diabetes care and often miss lows, and we’re able to achieve the 6.5 range pretty easily.

So in my case I think it’s very posslble we could both lower his A1C and lower his time spent low. But I agree that in general, for people on an ordinary pump or just doing normal shots, achieving a low 6 A1C without being low much requires superhuman effort, some residual beta cell function or a diet that takes away a lot of the variability.

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Oh, yeah, I forgot you guys were using a loop system. That changes everything. I think once I’m able to get my hands on a loop system that will enable me to finally break below the 6.0% A1c mark (just like it was CGM that enabled me to finally break below 7.0%).

My biggest challenge to control isn’t food (I eat basically the same things every day, so I could figure those out without too much effort) nor exercise, which I can also figure out with practice. It’s hormones. I’m really hoping that a loop system will help with that. I’m sitting here right now at 2.7 mmol/L, my third low of the day, (it’s only noon), despite the fact that I decreased my basal by 15% when I first woke up this morning because I knew lows were coming. I am sure a loop would be able to deal with all of this far better than I can.

I think Loop will only really help with those sharp hormone peaks once they approve microboluses – high temp basals just aren’t fast enough to deal with those peaks. It’s for that reason that openAPS did a better job with our son in controlling highs (he was less then 3% very high on openAPS, versus roughly double with Loop). Unfortunately, the hardware for openAPS is annoying and finicky, and the pump that works with androidAPS (which requires NO outside hardware other than the phone) is not approved in the US or Canada. Would LOVE if someone could work on getting androidAPS compatible with a Medtronic pump.

but yeah, I feel you. Samson’s average insulin usage is roughly 10 to 11 units a day. I looked at the last week, and he used 6.7 units one day, 13.6 the next, 8.5 the following day, and then 10.6. Loop smooths out the lows and highs that go with this variation but it’s not perfect. The high and low days had no correlation to pump site changes or age of the site; we were using the same reservoir. Ever since he was diagnosed with the autoimmune encephalitis and started taking the anti-seizure medication, I feel like his blood sugar has been much more erratic. Could be coincidence but it does make me wonder what else is going on in his body.

My blood sugar definitely became more erratic when I was diagnosed with Graves’ disease. So I sometimes think just having multiple autoimmune or health issues can impact that sort of thing. I’m sure some of the medications I take also affect my blood sugar.

I don’t think I’ll be using OpenAPS or Loop. I’m thinking of the Tandem as my next pump, or if I don’t go with that I may go with Ypsopump (but there’s no information on a timeline for CGM integration for them, though they’ve said it’s coming). So I probably won’t have access to this sort of thing for another few years.

Agree with pretty much everything Tia is saying and it’s applicable to Liam also. Here are Liam’s numbers over the past month. But he has many peaks and valleys - nowhere near a flat-liner. The Loop has helped his nighttime remain flat’ish, longer, and it’s helped us not go AS HIGH (which cuts down on overall SD), but SD still could still use a lot of work.

Update: I just noticed the INSANE number of carbs he eats per day for his age. :stuck_out_tongue: We don’t count…he just eats what he eats and we bolus. We don’t even have a feeding schedule although we’re going to start one to get him “ready for school”

Wow :flushed:. TDD of only 11.5U and he eats 143 grams of carbs?? That’s simply not fair :joy:

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But he’s 5. :stuck_out_tongue:

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Both you and @TiaG have amazing control considering age. I mean, I’m an adult and have about that level of control (fewer lows, but also a higher A1c, and also able to monitor my own symptoms and head off lows if I think or feel one is coming).

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It can be difficult to find up to date information. ISPAD is another great source for parenting T1D in my opinion. Most of the guidelines apply to kids&adults The full 2018 guidelines are at this link - https://www.ispad.org/page/ISPADGuidelines2018

The relevant section is Chapter 8 page 4. I use the targets as goals knowing that they are not easily achievable with a daughter who loves going to the pool and eating ice-cream

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