Diabetes Deep Dives: Time to Talk Time in Range

0:00 [Music]0:03 hello and welcome to diabetes deep Dives0:06 my name is Candace and I am from0:07 diabetes Canada if you are new to our0:10 video series thank you so much for0:11 joining us if you have been enjoying the0:13 series welcome back our diabetes deep0:16 Dives video series is designed to go0:18 beyond the surface of General diabetes0:20 education information we hope to spark0:23 continued interest and learning and0:25 leave you with practical tips and tools0:27 that you can easily use subscribe to our0:29 YouTube Channel and click on the0:30 notification Bell to be notified about0:32 new content you can also check us out on0:35 social media to find out when the next0:37 one will be posted to our YouTube0:39 channel thanks to those who have0:41 subscribed and supported our video0:43 series in this episode we will hear from0:45 Michelle crisp a registered nurse and0:48 community-based certified diabetes0:49 educator in Winnipeg Manitoba with over0:52 20 years of experience she provides0:54 support to people with type 1 type 2 and0:58 diabetes in pregnancy at the the winipeg1:00 clinic Michelle is also a certified pump1:03 trainer as well as a research nurse with1:05 the University of Manitoba where she is1:07 currently focusing on automated insulin1:09 delivery technology in1:11 pregnancy Michelle will walk us through1:13 what time and range is and what it means1:16 what the recommended goals for using1:18 time and range are and why time and1:20 range is useful and who would benefit1:22 from using it she'll also walk us1:24 through some strategies to work towards1:26 achieving the recommended goals for time1:28 and range we recognize that the content1:31 in this video may not be relevant for1:32 everyone and will depend on what your1:34 experience with diabetes is what and1:37 what devices are available to you where1:39 you live if you have specific questions1:41 about diabetes management please reach1:43 out to your Healthcare team these videos1:46 are for educational purposes only the1:48 content discussed in this video is not1:50 intended to be medical advice and to the1:53 extent that medical advice is required1:55 you should consult with a qualified1:56 medical professional the information1:58 discussed in this video cannot replace2:00 consultations with a qualified2:02 Healthcare professional to meet your2:04 individual medical2:05 needs the views and opinions expressed2:08 in this video are those of the speakers2:10 and do not necessarily reflect the views2:12 or positions of diabetes2:14 Canada as always we hope that this video2:16 Sparks your interest in learning more2:18 about diabetes management and now over2:20 to our guest speaker Michelle hi2:23 everyone and welcome to another diabetes2:26 Canada deep Dives today's topic is time2:29 and range2:30 my name is Michelle chrisp and I'm a2:33 diabetes nurse educator coming to you2:35 from Snowy Winnipeg2:38 Manitoba so what we're going to discuss2:40 today is time and range what is time and2:43 range recommended time and range goals2:47 the usefulness of time and range and who2:49 might benefit the most from it and steps2:52 to increasing time and2:55 range timing range is defined is the2:59 percentage of time time a person spends3:01 with their blood glucose levels in a set3:03 range it's commonly generated using 143:07 days of glucose data and it's a3:10 practical metric for showing where your3:12 blood glucose levels sit through the day3:14 and from dayto3:17 day if you're using a continuous glucose3:20 monitor that is probably the most3:22 accurate way to capture time and range3:24 however it can also be captured manually3:27 by using a blood glucose meter in that3:30 situation for about two weeks you would3:32 test your blood glucose before and after3:34 meals and occasionally through the night3:37 and then you take all those results and3:39 calculate how many of them or add up how3:41 many of them are in your time of your3:44 target range divided by how many of them3:46 you've done in total and Times by 1003:50 this is a lot of work and we know that3:52 when we test our blood glucose it's3:54 we're capturing a single point in time3:57 and we also know that uh our glucose can4:00 vary every five minutes and it's4:02 impossible to test your blood glucose4:03 that4:05 frequently time and range can also be4:07 calculated by blood glucose meters that4:10 Bluetooth over to different apps so the4:13 the Contour app or my sugar or one touch4:15 vario these are Bluetooth apps that can4:18 actually automatically generate your4:20 time and range every time a glucose4:21 level is put into there there are also4:25 tyool and other types of software and4:28 apps that can Auto aut atically generate4:30 time and range and again by far though4:33 the most accurate way to calculate time4:35 and range is by using a continuous4:37 glucose monitor a CGM and these devices4:41 have their own software apps that will4:43 automatically generate that4:47 data when we think about time and range4:50 it's most commonly shown as a bar graph4:54 and that bar graph you can see there is4:55 stratified into different color ranges4:58 with the red being the time below range5:02 the green area being the time you spend5:04 in your target range and the yellows5:06 being time above range depending on the5:09 device you use may you may also see your5:11 time and range as a pie chart like the5:14 one on the5:18 right in 2019 a pan experts got together5:23 and published recommendations about5:26 where time and range goals should be set5:29 not only the target ranges but also the5:31 amount of time or percent of your day5:33 that you should be spending in those5:35 Target ranges so you can see on the left5:38 that for most individuals healthy5:40 individuals with type one and type two5:42 diabetes the goal is to have a target5:45 range of about 3.9 to 10 and to spend5:49 about 70% of your time there no more5:52 than 4% of your data should be below5:55 range and about 25% acceptable to be5:58 above range6:00 for older high-risk type 1 and type two6:03 individuals they the time and range6:05 Target goes down a little bit to 50% we6:08 don't want these individuals having a6:10 lot of hypoglycemia it's more dangerous6:13 so less hypoglycemia the better less low6:16 blood glucose or time below range 50%6:19 within that target range of 3.9 to 106:23 and acceptable to have 50%6:25 above for pregnancy we know that6:28 outcomes for baby are improved when we6:30 have a tighter time in range and so for6:33 those individuals the target range is6:35 between 3.5 to 7.8 and to spend about6:38 70% of your time6:43 there when we talk about time and range6:46 it's good to talk about it I find in6:49 time itself sometimes the percentages6:51 are hard to to grasp and so putting it6:54 into that time frame of well 70% of your6:58 day is about 7 hours so you want to be7:00 spending about 17 hours of your day7:03 between 3.9 to 10 1% of every time and7:08 range percentage is 15 minutes so that's7:10 where we get those numbers from less7:13 hypoglycemia the better and the less7:16 hyper glycemia the higher higher over7:19 13.9 the less of that the better as7:22 well even though we have these7:24 recommendations it's really important to7:26 remember that they need to be7:28 individualized so not everyone may have7:32 time and range targets that fit these7:34 guidelines you may have an individual7:36 who's at more risk for hypoglycemia or a7:39 younger individual or a more frail7:41 individual or someone with really7:43 complex Health needs where their time7:45 and range targets need to be different7:48 and that's okay if you're starting off7:51 with higher blood glucose control and7:53 bringing your glucose control down you7:55 may also want to expend your time and7:57 range so that your Gent starting to8:00 bring things down closer to8:04 Target so how is time and range8:06 different from A1C you know we go to the8:10 lab every three to six months to take a8:12 look at that A1C and what is A1C it is8:16 the amount of glucose that's stuck on to8:18 the red blood cells in our blood it's a8:21 gold standard it has been a gold8:23 standard for many years and we have a8:26 lot of research to support that A1C can8:29 both prevent and predict8:32 complications A1C doesn't match average8:35 glucose in a on toone kind of way and so8:39 when you get your A1c to turn it into an8:42 average glucose you might look at a8:44 chart like we have on the right there8:46 where okay an A1C of seven is about an8:49 average glucose of8:53 8.3 but we know that there are8:56 limitations of A1C and this is a great8:59 great uh pictoral from di tribe that9:02 shows us the many faces of a 7% A1C so9:07 you can see that the individual on the9:09 left has 100% time and range and an A1C9:14 of 7% but they have very flat and narrow9:18 and inrange blood glucose control from9:20 day to day so they don't have a lot of9:22 Peaks and valleys and you can imagine9:24 that that individual probably feels less9:28 exhausted or maybe emotionally or9:31 physically less exhausted from all the9:33 Peaks and valleys that can happen when9:35 you live with type with with diabetes9:37 both type one and type two the person in9:39 the middle has also a 7% A1C but they9:43 are 70% in range with 25% of the results9:48 over their target range and 5% of the9:51 results below their target range and you9:53 can see more Peaks and valleys in that9:56 graph and the person on the right also9:59 has a 7% A1C but they're spending about10:02 40% of their time in their target range10:06 40% above their target range and 20% of10:10 their time low and 20% of time with10:13 every percent is one is you know it's 1510:15 minutes that's a lot of10:18 hypoglycemia so you can see how there10:20 are limitations in A1C in terms of10:22 showing us the daytoday variability that10:26 is living with diabetes the highs and10:28 the lows10:29 and those highs and lows can be10:31 exhausting so an A1C of s doesn't always10:35 reflect all of that and that is why time10:37 and range can be so much more useful as10:40 a10:41 metric we have research to support A1C10:46 and it for preventing and the risk of10:49 complications but now we're starting to10:51 see research for time and range as well10:54 so there are emerging studies for10:56 neuropathy as well as eye Dam damage10:59 retinopathy and kidney damage micro11:02 abumaria in terms of your time and range11:05 the more time you spend in range the11:08 lower your risk for these types of11:10 complications we also know in pregnancy11:13 that higher amounts of time and range11:16 also lead to better outcomes for11:22 baby when we're looking at time and11:24 range reports it can be really11:26 overwhelming so I think one of the first11:29 things we can do is take a look at that11:32 that bar graph and take a look at the11:34 percentages there every time we increase11:37 our time in range by 5% that's another11:40 hour that we're spending in our Target11:42 Zone and there's clinically meaningful11:45 significance with every 5%11:48 increase other metrics that we might11:50 want to look at other than that bar11:52 graph is something called the ambulatory11:54 glucose profile which takes 24 hours of11:57 data over two weeks11:59 and puts it into a nice line and then we12:02 can really see where on average our12:04 patterns might be this the software and12:08 apps will also sometimes highlight if12:10 they can find patterns of where your12:12 time above range is or where your time12:14 below ranges they'll also bring that out12:17 uh and highlight it for your attention12:19 which is useful when you're staring at a12:20 sea of12:22 data so another example of an ambulatory12:25 glucose profile you can see that green12:28 line that kind of goes through or that12:29 darker line that's your mean or average12:32 glucose and then the cloud around that12:34 that's a little bit darker is sort of12:36 your 25 to 75% of data and then the12:40 larger Cloud around that is encompasses12:42 more like your 10 to 90% of all your12:45 data when we're looking at an ambulatory12:47 glucose profile we're looking at what12:49 that mean line does does it go up does12:52 it go down at a specific time of day and12:54 how expansive is the data in other words12:58 how much vary ability does your glucose13:00 have from day to13:06 day daily reports is another nice way to13:09 look at data and this too can be13:11 overwhelming but if you're trying to13:13 tease out are my weekends different from13:16 my weekdays uh when I'm babysitting my13:19 grandchildren do I have more13:21 hypoglycemia these are really nice13:23 things to go in and take a look at okay13:26 well these are the things that happened13:27 those days and this is what happened to13:29 my blood13:34 glucose there are other really useful13:36 time and range metrics so some of the13:39 things that those abs and software will13:41 generate is an estimated A1C or what we13:44 call a glucose management indicator13:46 which is that if you have two weeks of13:50 data and you extrapolate it over three13:52 months your A1C may be estimated to be13:56 we also have something called a Coe ient13:59 of variation which shows us the14:01 variability of your glucose from day to14:04 day a larger coefficient of variation14:07 means that your risk for hypoglycemia is14:11 greater you can also see then so we talk14:14 about time in range but we also talk14:16 about time below range and the other14:18 important term to talk about is time14:20 above14:24 range in 2019 I watched a really good14:27 talk by Adam Brown from Di14:29 and I loved his analogy about time and14:32 range as a highway what keeps me on the14:35 road more so if you're time in range on14:38 the left side of the highway is that14:39 time below range and on the right side14:41 of the highway is that time above range14:44 and then staying on the highway that's14:46 your target zone so when you're looking14:48 at your data reflecting on what keeps me14:51 on the road what sorts of things that I14:53 do in my daily life that keeps me on the14:56 road and how can I do more of those14:58 those15:01 things what drives me off the road in15:03 either direction driving me low or15:06 driving me high and how can I recover15:09 quickly when those things start to15:12 happen and do I have guard rails to15:15 prevent extreme off-roading so guard15:18 rails might look like um more meal15:21 planning maybe when you go out to eat at15:24 restaurants looking those menu items up15:27 to find the ones that are15:29 uh maybe a better load of carbohydrate15:31 for your blood glucose um snacking15:34 before you exercise to prevent15:36 hypoglycemia or low blood sugar or um15:40 taking a snack before bed when your15:42 glucose is at a certain level to make15:43 sure that your glucose stay steady15:45 through the night those are the types of15:48 guardrails that when you're staring at15:49 your data you can start to formulate and15:52 have those conversations with your15:54 diabetes care15:57 providers and so so this is why time and15:59 range can be so useful it can help you16:02 recognize blood glucose patterns it can16:05 also be a springboard for really16:06 meaningful conversations with your16:08 diabetes Healthcare team and unlike A1C16:12 that looks at data over three months16:15 time and range can be generated on a16:17 daily weekly or U every 14-day level so16:21 you can really start to see quickly when16:24 you make changes to evaluate how those16:26 changes made a difference either16:28 lifestyle changes or medication16:33 changes so let's talk about how can I16:36 improve my time and16:38 range I think one of the first things is16:41 to look at your data we know that if we16:44 don't look at the data it is meaningless16:47 so looking at your data and sharing it16:49 with your Healthcare team a lot of the16:51 CGM devices can actually load data up to16:54 the cloud so your Diabetes Care team if16:57 you give them permission can go in and16:59 remotely look at data for virtual visits17:01 and things like that which is really17:03 useful and was very useful around covid17:06 when a lot of people weren't comfortable17:07 coming into the17:09 office the first thing when we look at17:11 data is always assessing for safety17:13 because hypoglycemia can be so17:15 problematic um it's really important for17:18 healthcare providers like myself and for17:21 individuals living with diabetes to17:22 focus on how much time below range are17:25 we17:26 spending then taking a look at how much17:28 time are we spending in our target range17:31 and one of the best questions you can do17:33 with your healthc care provider is talk17:34 about where my time and range Target17:37 should be it doesn't always have to17:39 reflect but those International17:40 consensus guidelines recommend certainly17:43 right away or even depending on the17:45 complexity of your17:46 health then we want to look at areas to17:49 improve so how much time did I spend17:51 above range and then discussing ways17:54 like those guard rails ways to reduce17:57 that time above range range and coming17:59 up with an action plan that's simple and18:02 achievable and something that you can18:04 take a look at and evaluate if it was18:07 effective so let's talk about improving18:10 time and range we know the first thing18:12 is that wearing CGM or checking your18:14 blood glucose more often is a way to get18:17 more in tune with your18:19 numbers talking to your diabetes18:21 Healthcare team about where your time18:23 and range Target should be is really18:26 important if you're going to sit down18:28 and look look at time and range I think18:29 that's a great question to start off18:31 with where should my time and range18:34 be observing the data first and then18:37 adding notes about what you did that day18:40 that's really useful was it a day that I18:42 looked after the grandkids was it a day18:45 that I went out for supper was it a day18:47 that I forgot my lunch dose of18:50 insulin watching and learning about your18:52 Trends and sometimes those apps and18:55 software can identify those trends for18:57 you but but am I more consistently high19:00 after dinner am I more consistently low19:03 before19:04 lunch making one change at a time and19:07 seeing if that impacts your time and19:09 range for that time of19:11 day focusing on habits versus the19:14 percentages we can get very number19:16 focused with diabetes it is a numbers19:19 game so much but focusing on when I did19:22 this this was the outcome I like that19:24 outcome maybe I'm going to do that more19:27 often and talking about what's going19:30 well we get really focused on what isn't19:33 going well that's human nature but19:35 talking about what's going well is so19:38 important especially from a preventing19:40 prevention of diabetes19:42 distress so remember to do that and19:45 oftentimes those apps will generate your19:47 best time and range day was and you can19:50 reflect on that sometimes it's good to19:52 take that print it and put it on the19:57 wall remember that you're not your19:59 numbers when our diet when we're testing20:02 blood sugars or when we're looking at20:04 our time and range you're just a number20:06 it's a fuel gauge and it's telling you20:09 how much of the time do you have the20:11 fuel in the right amount how much of the20:13 time is with too much fuel and how much20:15 of your time is spent with too little20:17 fuel high levels of emotional distress20:20 from trying to achieve that perfect time20:23 and range is also not healthy so it's20:26 really important to be real istic and20:29 kind to yourself when you're looking at20:31 your time and range and celebrating20:33 small gains again even 5% increases in20:37 time and range that's another hour of20:39 your day that you're spending in your20:41 target20:44 range also remember diabetes can happen20:48 this was taken by a good friend of mine20:50 who Liv with type 1 diabetes and she20:51 does a little bit of art on her um on20:55 her CGM uh screens so that we we can20:58 kind of like yep we can have our best21:00 intentions for the day or do the exact21:03 same thing we did yesterday and our21:05 results can be very21:07 different so sometimes just diabetes can21:12 happen and brown also talks about over21:15 42 factors that affect our blood glucose21:19 this is also very overwhelming and many21:22 of these things we can do very little21:26 about so it's important to focus on the21:29 things that we can change or that we do21:31 have control over some of the Practical21:34 tips for improving time and range might21:36 be exercise going for a walk even just21:39 10 to 15 minutes can help lower that21:42 blood glucose and bring those levels21:44 back21:45 down getting more sleep we know that too21:48 little sleep can increase insulin21:50 resistance and worsen our mood and all21:53 of those things can affect our blood21:55 glucose staying hydrated is really21:58 important your diet trying new foods or22:02 looking at carbohydrate amounts and22:04 speaking with the dietitian or choosing22:06 foods that trickle into the bloodstream22:09 vers versus gush those are foods that22:11 are lower on the glycemic index all of22:14 those things can help especially those22:16 after meal curves building strategies to22:20 reduce stress so we know that stress22:23 often raises blood glucose so how can we22:25 work things into our daily day that help22:28 us to manage stress better so there's22:30 less impact on our blood22:34 glucose if you're taking rapid insulin22:36 consider insulin timing I work with a22:39 lot of people who are on multiple daily22:41 injections or on insulin pumps and even22:44 not even changing the insulin dose but22:47 just the timing of that rapid insulin22:49 before you eat can make a huge22:51 difference in that postmeal22:53 curve being patient with your blood22:56 glucose levels a lot of times when22:58 people start to see data that they never23:00 saw before they panic and they start to23:03 take too much action to bring that blood23:06 glucose down if you're on insulin that23:08 can result in a lot of time below range23:11 so being patient just watching that data23:14 first and then starting to formulate a23:16 plan being aware of environmental23:19 factors that can affect your blood23:20 glucose level So Not Unusual to hear you23:23 know summer heat it increases or makes23:26 my insulin absorb faster or I'm more23:28 active and these are the reasons why I'm23:30 having more time below range so being23:32 aware of those kinds of things getting23:34 into a routine it's really difficult to23:38 establish patterns with blood glucose23:40 whether you're testing them or whether23:42 you're wearing a monitor continuous23:44 glucose monitor it's difficult to find23:46 patterns if your day-to-day routines are23:48 radically different so trying to develop23:51 some kind of routine helps us to better23:53 see the patterns the things that are23:56 working the things that we need need to23:58 work23:59 on and talking with your Diabetes Care24:02 team for continued strategies to improve24:04 your time and range so and remember that24:07 time and range is a moving Target in24:09 terms of you're G to have good days24:11 you're going to have good weeks um and24:14 you may have days that don't go so well24:16 days that aren't as good so time and24:18 range is going to be flexible we're24:20 looking for overall Trends towards24:23 increasing your time spending24:26 Target24:28 who would benefit most from looking at24:30 time and24:33 range we know that people with type one24:36 diabetes inclusing including those um24:38 who are on multiple daily injections and24:41 those with type two who are on multiple24:42 daily injections these people are at24:45 greater risk for both time above range24:47 as well as time below range and we so24:49 know we know that these individuals24:51 would benefit from from looking at time24:54 and range more and the data supports24:56 that I think really any person with24:59 diabetes who wants to take a more25:00 detailed look at what impacts their25:02 blood glucose levels with the goal of25:04 improving their time and range would25:06 also benefit from that but it does you25:10 know um rely on coverage in terms of25:13 your insurance coverage as well as your25:15 provincial coverage as to whether you25:17 can go on devices like CGM that would25:19 accurately capture time and25:21 range and remember that time and range25:24 data is meaningless unless people with25:27 diabetes and Diabetes Care team take the25:29 time to check25:33 it according to the clinical practice25:36 guidelines with the new update in 202125:38 those people who would benefit from CGM25:41 or people with type 1 diabetes using25:43 multiple daily injections people with25:46 diabetes who cannot feel their25:48 hypoglycemia or have had severe low25:50 blood glucose adults with type two25:53 diabetes using multiple daily injections25:55 and pregnant women with type 1 diabetes26:01 access to CGM varies across Canada26:04 widely and so if it's something you're26:06 interested in looking at it's important26:08 to talk to your Diabetes Care team as26:10 well as your insurance if you have and26:13 your provincial government to see what26:15 sorts of criteria and eligibility there26:17 are for you depending on your age and26:20 the type of Diabetes therapy you have26:22 and the type of Diabetes you26:26 have26:29 I hope that I've answered some of your26:30 questions about time and range today and26:33 I thank you for having me to talk about26:36 this really important topic thank you so26:38 much26:40 bye-bye thank you so much for tuning26:43 into this very informative episode of26:45 diabetes deep Dives and thank you to26:47 Michelle for a deeper look into time and26:49 range again this topic may not be26:51 relevant to everyone living with26:53 diabetes but we do hope that you found26:55 it interesting and learn something new26:57 please take the opportunity to keep the26:59 conversation going by posting a comment27:01 in the comment section on YouTube you27:04 can provide us feedback about the video27:06 by clicking on the link in the feedback27:07 survey in the description box if you27:10 have ideas for other topics you'd like27:11 to learn more about you can include that27:14 in the comments or feedback survey as27:16 well Michelle mentioned that access and27:19 financial coverage to medical devices27:21 for diabetes such as continuous glucose27:23 monitors varies by province in the27:26 YouTube description box below the video27:28 we have included a link to a diabetes27:30 Canada document that outlines the27:32 coverage for cgms by province as of27:34 March27:36 2022 for more information about diabetes27:38 management please visit our website at27:43 diabetes.com27:45 diabetes.com line at 1 800 Banting27:48 that's 127:50 18226 8464 and speak to one of our27:53 information and support Specialists who27:55 can address your needs thanks again for27:57 joining us and see you next28:03 time