Michelle Chrisp, a registered nurse and community-based Certified Diabetes Educator will explain what time in range is and what it means, what the recommended goals for using time in range are, why time in range is useful and who would benefit from using it. She’ll also walk through some strategies to work towards achieving the recommended goals for time in range.
Speaker: Michelle Chrisp, RN, CDE, CPT
Speaker: Michelle Chrisp, RN, CDE, CPT
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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
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survey in the description box if you27:10
have ideas for other topics you'd like27:11
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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
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time
[Music]0:03
hello and welcome to diabetes deep Dives0:06
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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
Category Tags: Blood Sugar & Insulin, Management;