FUDiabetes

Help! Objective time-in-range data?

cgm

#1

I am a type 2 determined to get this blood sugar thing under control. I am using the Freestyle Libre CGM and would like to get some honest and objective information about ideal range. It seems to me that folks on this site are not afraid to tell it like it is.

I understand that setting a range is an individual decision based on many factors, especially the ability to avoid problematic lows. But so much of what I am reading talks about what people can “manage to do“ as opposed to what is healthiest/ideal.

This morning I read a article surveying doctors on time-in-range goals and here’s an example:

Giving someone a specific time-in-range target, in my view, may not be beneficial. At least some patients will become OCD trying to get to their target, and in general, putting too much attention into one’s diabetes adds more diabetes burden. The time-below-range of less than 5% is a safety parameter.

That seems crazy, right? I can’t imagine a doctor telling a patient with high blood pressure that the patient shouldn’t know what normal blood pressure is because it would be too much trouble to get their blood pressure below 160/120.

I have been proud of staying off insulin longer than anyone else in my family, but now I’m wondering if that is really a good goal.


#2

(I meant to add the following but accidentally posted!)

I’ve got pretty good control with Metformin and very low carb diet. But I am willing to lose more weight or start insulin if it matters.


#3

Great and interesting question! And welcome!

I’m sure there are lots of opinions and experiences on this. My personal thoughts have changed over time depending on what all I’m juggling at the moment in life or in Diabetes care.

I’ve been told by many doctors and CDEs not to test more than X times a day, or to not stress about getting lower bg bc it is what it is. But at the same time, if you can make adjustments that you can live with AND help your bg, why not?

My personal goals are tied to my tolerance for risk…and I have different risk factors than some other people.

SOOO…I don’t think there’s a perfect answer…but I try to balance good self-care without inducing burnout. And that leads to different results in different phases of life for me (pregnancy, young motherhood w little time to focus on me vs middle motherhood w more time to focus on me now).


#4

Thanks for the kind welcome!

And, to your comment, I say “Exactly!” Your way of approaching this is so sensible. Never let the perfect become the enemy of the good! I agree that our priorities and obligations change in different seasons of life. But that doesn’t mean we are too delicate to know the truth and to make our own cost/benefit decisions!

I know that I’m geeky about this and I choose to look at this an an interesting challenge. I find it less stressful to know more, not less. After all, if I can figure out how to have french fries from time to time, I’m more likely to stick with the program for the long run.


#5

:muscle::muscle:

You’ll fit in great here, then!! :grinning::grinning:


#6

Absolutely. You will see that if you read enough posts. People can become obsessive about anything. Certainly not most people nor even IMHO a significant percentage. I would consider it obsessive for a doctor to change their general patient instructions based on the possibility of a patient being obsessive.
:stuck_out_tongue:
Should doctor’s watch for obsessive behaviour and many other types of mental illness?
Absolutely.
Mental illness while perhaps not able to be cured can be managed. Ignoring mental illness does nobody any favors.
But a Doctor changing their entire approach based on the possibility of a patient having a (likely treatable) mental illness? Yeah - I would call that crazy.

Agreed.

Agreed.

@briopelle
Sounds like you are in the larger boat of people who enjoy balance.


#7

Thanks @Thomas. Honestly, it’s probably true that I’m a little OCD since I enjoyed law school. So I am trying to get some good data on the complications % at different ranges, how much spiky vs level graphs matter, and things like that. Then I can decide accordingly.

As a parent, I imagine there is not a lot you enjoy about managing this for your nugget. I have had a child with a serious case of POTS (not life threatening so no real comparison to your situation) who was basically bedridden for over 2 years and missed 3 years of high school. He’s now doing well in grad school. But we went through years of “child as science project” trying to find the right combo of meds and therapy to get him on his feet. His condition was literally affected by the weather, by his growth, and sometimes for no reason that we could discern. But keeping it “scientific” instead of emotional was all that kept us level sometimes.

I am sure you are an exceptional parent. So many just listen to a doctor for 10 minutes and think that is good enough!


#8

I went poking around online looking for this type of data, and I did find a paper discussing rates of diabetic retinopathy in type 2s based on differences in time-in-range. I haven’t delved too deeply into the paper (in truth I only read the abstract and looked to see if there was any handy graphs to describe their results, which there was not) but maybe it’ll be of interest to you.


#9

Nice find, @glitzabetes!

@briopelle, regarding your goal on Time-in-Range: we are not dealing with T2 diabetes, so I can give you data from a T1, and extrapolate a bit. I discussed this data recently on another thread. First, as a caveat, everyone’s D is widely different, so a good goal for one is a terrible goal for another! But I can give you some guesstimates that you will need to tune for yourself. Be careful to adjust them to your own physiology! And don’t stress about differences with other people: one can aim for 40% TIR and another for 90%, and these may be equally difficult to reach.

My son is a reasonably well controlled T1. He ranges between 5.3 and 6.6 A1c. We use a 70-120 range, fairly tight by most standards. After he got out of honeymoon but before we were proficient with sugar surfing, his TIR was about 65%. Then we became more skilled in sugar Surfing and small corrections, and his TIR went to 90-95%.

Then he got into puberty. Now we have to tackle on average 2 large hormone spikes a day, sometimes more. His TIR is now 50-55%.

You are a recent insulin user, I gather? So my guess is exogenous insulin is not the major part of your insulin, like a honeymooning T1. As a recent user, I would expect a good goal could be 60-70%. Needs to be tuned to your body, of course!

In the next year your BG management skills will become much better. If you start sugar surfing, it may not be unreasonable to aim for 85-90%.

As you grow much older, your body will make less and less endogenous insulin, and it will become less possible to exercise with same intensity. So lower TIR goals will become
more reasonable.

[EDIT] Just read your other thread. I now understand you have not started insulin yet, I thought you had started later than your family but were on insulin, sorry. So disregard this whole post.

@Richard157, after 73 years of T1 diabetes, can you share your average Time In Range?


#10

I enjoy being able to take this on myself rather than have my child forced to depend on somebody else whom I would feel is less competent.

Awesome on Grad school !!!


#11

Thanks everyone! You guys are awesome. I will read the study and focus on the posts asap and then reply. Day 2 of new puppy in the house, so a bit distracted from immediate responses. Appreciate all of you very much!

Here is Ollie:


#12

The question you are asking is interesting. i.e. how long can I stay in range without introducing insulin and a whole other bag of issues. I would say that right now, we don’t know, i.e. the tool hasn’t been studied enough to equate to TIR = increased or decreased risk of complications.

If you don’t mind sharing (and I totally get you might mind) what is your current A1c? If I had an A1c in the 5’s or 6’s I would use TIR to try to establish my baseline and make incremental improvements as well as grade my weeks efforts and results.

If i was in your position and my A1c was in the 8’s, I would be considering insulin therapy.

Super cute dog btw


#13

Hang in there Michel. I wish I could tell you it gets better, in fact for us it is has continued to be a tough struggle, and you add in that at age 16 your son naturally starts to pull away and has a whole host of other things to focus on i.e. friends, parties, girls, sports require more focus, etc etc. Control starts to take a back seat to life.


#14

Well, @Chris, now you are cheering me up :slight_smile:

But no worries. Both of our kids (yours and mine) are doing as well as can be expected. They will be fine. I can’t wait to see better control algorithms coming out though.

When is Cody going to college?


#15

He is a sophomore this year. So my oldest goes off in August, and Cody in two years.


#16

So…I think part of the issue is that doctors themselves don’t know exactly how much time in range is important. We have data on average A1C and mortality. For Type 1s and Type 2s, A1Cs below a certain level don’t add much benefit (say, 6.5 or 7.0) and that very tight control with drugs increases risk of hypoglycemia and is associated with higher mortality in patients with T2 for sure. But what we don’t know is whether a person who, say, never goes below 80 and never goes above 180 but has an average A1C of 7.0 is better off than a person who seesaws between 50 and 250 but who also has an A1C of 7.0. We also don’t know if the outcomes would be better for T2s if they were always in range with a lower A1C, versus having a lot of hypos and a lower A1C, because until recently all large, randomized trials have looked at people using multiple finger sticks a day. Those finger stick numbers do NOT tell the whole story, in my opinion.

Personally, I just aim to get in target as much as possible. On some days that’s 40% of time in range for my son (who is 4). Other days, I feel the wind at my back and things are going great so we aim for 100% time in range. Each 14-day period I reevaluate whether I’m doing a good or bad job and try to tighten my targets. Right now my son spends 70% of his time in range (80 to 140), 5% time below 80 and 0.5% time below 55. Those low ranges are okay with me so I’m trying to reduce how much time he spends above 180 and 250.


#17

I think the risks of mortality/complications are generally a “hockey stick” type shape and the curve starts to go up steeply around an A1C of 7.0 – but not sure if it’s exactly the same for T2s, and I think it depends on how old you are too.


#18

It all depends on who you are. After my stroke, the doctor suggested moving my A1c from 5.5-5.8 to 6.4. He told me to relax. Of course this affected my time in range big time.

But I’m 67 and have no complications, so a 6.4 is really not going to make a difference in the whole scheme of things. It just reduces the lows and increases time out of range.


#19

My general comment, not based on clinical studies but rather a “works for me” approach:
Basically when my TIR is lower than I want it to be, it causes me to look back at how active or inactive I was during that time. I have found that unless I get my heart rate up with some meaningful exertion at least every other day it becomes hard to stay in range. I look at Time in Range more as a symptom than a result. In other words, if I go through a patch when I am not hitting my personal TIR goal I tell myself to step it up, exercise more, get back on my routine, think harder about matching my pre-meal insulin to my carbs (and matching my corrections to my protein/fat), etc. When I know I am in my routine and doing everything I need to do to control TIR myself, my goal is 80% at 70-150. If work or travel comes up that prevents me from sticking to my routine, my TIR goal is “avoid highs and correct them when they happen”.

Feel free to take that with a YDMV dose of salt…it’s entirely possible that it only works for me and you may find something different.


#20

No, this works for me, too! You describe it perfectly! :sunny: