10 Tips to Stay in Range With Type 1 Diabetes
By Michael Howerton
Dr. Steve Edelman, an endocrinologist living with type 1 diabetes, shares strategies for spending more time in range – and less time riding the blood sugar roller coaster.
There are several practical, everyday things that you can do to help keep your blood glucose levels between 70 and 180 mg/dl (time in range). Some may be things you already do, others might be good reminders, and a few might be new ideas.
Using stories from his practice and from his own experiences living with type 1 diabetes, Dr. Steve Edelman, director of the Endocrine Fellowship Training Program at UC San Diego and founder of Taking Control of Your Diabetes (TCOYD), outlined his top 10 recommendations for staying in range at the recent ATTD conference in Florence, Italy.
With these tips, people with insulin-dependent diabetes can spend more time in range and less time on the roller coaster of fluctuating highs and lows.
1. Wear a continuous glucose monitor
“I really believe it’s the most important advance since the discovery of insulin, no question,” Edelman said of continuous glucose monitors (CGM). Although the growth of continuous glucose monitoring technology use has been swift, more needs to be done to increase access and adoption. “I love the fact that everyone is getting on it, but there’s still a majority of people with type one in the world who do not have a CGM.”
Keeping your blood glucose levels within the range of 70 to 180 mg/dl for at least 70% of the day means, he said, the goal is to stay in range for a majority of the day, and avoid hypoglycemia as much as possible. TIR guidelines call for spending about 17 hours in this range and no longer than an hour either over 250 or below 70, and not more than 15 minutes below 54.
“Diabetes is hard,” Edelman said, adding that it’s important that people know that to stay in range, they “don’t have to be perfect all the time.”
2. Set up CGM alerts and alarms
“Alerts and alarms are your friends,” Edelman said, recommending people pick a tone that isn’t too annoying to them. (Don’t choose the crying baby alarm tone, he joked.) The settings are supposed to help you, not drive you crazy. He also suggested lowering the upper alert setting during the day.
“One method of improving time in range without changing anything with insulin is to lower the upper alert,” he said. “If your goal is 70-180 mg/dl, then why put your upper limit at 180? If it goes off, you’re already out of range.”
Edelman recommends lowering the upper alert setting to 150 or 160 mg/dl during the day. “At night, leaving it higher is sensible to avoid frequent wake-ups. This simple setting change,” he said, “Will improve time in range, decrease time above range, and improve A1C.”
3. Learn how to respond to trend arrows
“Most providers do not tell their patients how to respond to the trend arrows,” he said. “When it goes above your upper limit, you want to react to that.”
He recalled a study a few years ago in which he instructed those with diagonal arrows upwards to add 50 points to whatever their blood sugar was at that moment, and then correct for that increased number.
“This probably underestimates their true needs, but we wanted to make sure that they understood when the arrow’s going up, you need more,” Edelman said. “When the arrow is going down, you may not need [to do] anything at all, so wait until you stabilize.”
4. Make sure the basal rate is correct
The basal dose and rate settings are the foundation of all the other settings on a CGM. If these are not correct, nothing else can work properly. These settings are especially important for people who use multiple daily injections of insulin, for users of pumps that are not connected to a CGM, and for certain automated insulin delivery systems.
“Make sure you have training on how to test your basal,” Edelman cautioned. Most endocrinologists will suggest a starting basal rate, but to be certain, it’s also useful to conduct your own basal rate testing.
5. Inhaled insulin and pre-bolusing to prevent post-meal spikes
Edelman acknowledged that the biggest frustration of people with insulin-dependent diabetes is probably figuring out how to prevent post-meal spikes and then staying off the high-low roller coaster.
“We know that taking your insulin 20 to 30 minutes before eating makes a huge difference in the postprandial blood sugar,” he said. You can make a huge improvement in your time in range by taking insulin 20 minutes before eating rather than at mealtime or 20 minutes after.
“The problem,” he added, “is remembering.” Requesting a prescription for inhaled insulin, which acts quickly and then dissipates just as fast, can be a solution, he said.
6. Aim to reduce carbs in your diet
Eating is supposed to be a pleasure. If you try a diet full of foods you don’t like or meals that are so low in carbs that it’s not enjoyable, then it’s not going to work, Edelman cautioned.
For example, he said he makes what he calls “time in range tacos” using iceberg lettuce for the wrapping instead of a tortilla. “You have to pick what you like,” he told the room full of health care providers at ATTD. “You can’t force feed people food they’ve never eaten. They have to choose what they prefer.”
7. Don’t overtreat your lows
More about choosing the right foods. “I love peanut butter, ice cream, cupcakes, and cookies. Unfortunately, you can eat them pretty fast when you’re low,” Edelman said. “Then you rebound and have to give yourself a bolus, and you’re on the roller coaster again.”
Instead, he said, choose a small amount of candy or fruit juice. He said he likes to treat his lows with candy corn, but he warned the limit should be around 18 pieces – which is between 20 and 30 grams of carbs, depending on the brand – but it’s not always easy to stop eating.
8. Make sure you have up-to-date, easy-to-administer glucagon
There are easy-to-use glucagon options now on the market; Edelman emphasized that everyone should be carrying a form of it that is not expired. “We have nasal glucagon,” he said, referencing Baqsimi. “We have the Gvoke Hypopen, which is really easy to give, like an EpiPen.”
9. Find the right hybrid closed-loop system for you
Edelman strongly encouraged people with diabetes to consider automated insulin delivery systems, mentioning Tandem’s t:slim X2 with Control-IQ, the Omnipod 5, the Medtronic MiniMed 780G, the Omnipod DASH, and the iLet Bionic Pancreas as some of the automated insulin delivery systems available in the US right now.
“You have to find the system that fits your needs,” Edelman said, noting that he uses the Omnipod DASH himself. “I encourage people to look at each one and not to make a decision until they have seen all of them,” he said, noting that the one that they pick is usually going to be the right one for them.
Edelman praised the technology of automated insulin delivery systems for dramatically improving time in range. “Since when, before hybrid closed loop,” he asked, “could we get patients’ A1C less than 7 without hypos? It was just impossible.”
10. Exercise
“Exercise can make up for mistakes,” Edelman said.
Exercise with diabetes is essential, but it requires education and preparation since it can greatly affect glucose levels for those with type 1. “It’s important,” he said, “and I tell my patients you can exercise at any age.”
Final advice on staying in range with type 1 diabetes
Edelman ended with three extra reminders on how to maintain, as he termed it, “your mental time in range”:
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You are your best advocate
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Be smart and be persistent; knowledge is power
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Celebrate the victories no matter how small they seem, and find a dia-buddy!
Photo credit: TCOYD
