Time in Range – Communicating With Your Healthcare Team
By Julia Kenney
Time in Range (TIR) is more than just another diabetes metric; it is a tool that can be used to improve communication with your healthcare providers and empower you both in the doctor’s office and beyond. We sat down with two people with diabetes and their provider to discuss how TIR improves their patient-provider communication.
Conversations about A1C with your healthcare providers can often feel one-sided. It can be daunting to discuss A1C results that you are seeing for the first time, leaving your healthcare team to do most of the talking. Because A1C is only an average measure of your glucose management over a period of three months, it cannot provide information about how your day-to-day actions affect your glucose.
In contrast, Time in Range (TIR) fosters a more dynamic conversation because people with diabetes can discuss the TIR data they live with day-to-day. TIR can be measured using a continuous glucose monitor (CGM), which measures glucose levels automatically every five minutes. These numbers can be graphed to show the percentage of time spent within a healthy glucose range between 70-180mg/dL (or, Time in Range), giving the user much more information about their glucose patterns each day. A person with diabetes knows the most about their daily diabetes management, and TIR data gives them the tools to have an engaging and productive conversation with their providers.
To learn more about how discussing TIR might encourage a productive patient-provider dialogue, we spoke with Natalie Bellini, PhD, an endocrinology nurse practitioner in Buffalo, New York, and two of her patients with type 1 diabetes – Kristen O’Dell and Patrick Marks. O’Dell is a registered dietician and certified diabetes care and education specialist and has had diabetes for over 23 years. Marks is a mortgage banker, member of the JDRF board in Western New York, and has had diabetes for over 24 years.
Managing before TIR
Many people with diabetes do not have a personal CGM that they wear daily. Lack of a personal CGM makes it nearly impossible to use TIR in daily diabetes management. O’Dell was diagnosed with diabetes when she was 9, but she did not get a CGM until the end of college.
“Going through college as a freshman, you’re dealing with alcohol and all new foods and people around you that have no idea what diabetes is,” she explained, “I am very thankful to be alive.” When asked what it was like to manage diabetes before using a CGM, she said, “I wouldn’t consider it as thriving,” but “you just dealt with it.”
For Bellini’s patients who do not have a CGM, she works to collect similar data points through conversation. “I am trying to create a CGM [report] in my head,” she added, clarifying that she asks questions about their highs and lows and what factors impact their blood sugar.
O’Dell added that discussing TIR is difficult without CGM. Most people on blood glucose meters (BGM) don’t check their blood glucose levels often enough to calculate an accurate TIR.
Improving communication with your HCPs
Marks said he wonders how he ever lived without a CGM, recalling the stress of using finger sticks to check his blood sugar. The CGM helps ease those feelings of stress both at home and in the doctor’s office, he said. CGM metrics such as TIR can help people with diabetes set more personalized health goals with their healthcare providers. Outside of a medical appointment they are often able to access their CGM report to understand if they are meeting these goals.
In reference to his healthcare providers, Marks said, “As much as they tell you that you’re doing a good job, you can always look back to see what your time in range was and say, ‘Yeah, I am doing a good job.’” While he continues to monitor his A1C with his healthcare team, Marks says, “I know that if I’m in range, there won’t be any surprises; the A1C is going to fall in line.”
Bellini uses TIR as an opportunity to help her patients understand their day-to-day blood sugar management. She can use a person’s CGM report and their TIR data as a visual representation of their blood sugars to help identify positive trends and areas for improvement.
“We’re not looking for perfection, we’re looking for a way to improve their blood glucose levels and reduce their risk of complications,” she said, adding that compared to A1C, TIR fosters “better conversations” that focus on the everyday lives of her patients.
Building a Story Around Your Numbers
When describing her typical diabetes check-up, O’Dell said, “There is so much more of a conversation when talking about TIR as opposed to A1C,” and that means that for “half of my appointment we’re talking about my life, we’re not talking about diabetes.”
Bellini described this as “building a story around your numbers” where CGM metrics like TIR provide an outline of a person’s diabetes management, but the rest of the story is built out through conversation.
With CGM reports, your healthcare provider can identify areas where you are meeting or exceeding your health goals and understand what factors helped foster that success. Maybe your TIR was higher the day you took two walks instead of your usual one, or maybe you ate different foods that helped keep you in range. By discussing your TIR with your healthcare providers, you can celebrate positive moments in your diabetes management to help turn those moments into habits. The same approach can be used to identify and address any challenges you experience in your diabetes management.
From O’Dell’s experience as a healthcare provider, she said that TIR “creates a positive relationship with the patient that is more dynamic,” so that “you can meet them where they are with their life experiences…and you can see real feedback from their TIR.”
Bellini reinforced this idea by saying that her patients are “people first” and that “there’s a story behind their numbers; with A1C there’s no story.”
For those who are not already familiar with TIR, the metric could help you in your day-to-day diabetes management and foster conversations with your healthcare team. When asked what advice he has for those considering TIR, Marks encouraged them “be open to learning how TIR will help better manage your diabetes,” and that TIR “motivates you to be better each day.”
To best facilitate these conversations with your healthcare provider, you could write down notes before and during your appointment and keep track of your daily diet and exercise.
O’Dell explained that the constant feedback of TIR data helps her mental health: “You can have bad days and it’s not going to get the best of you.” She encouraged people with diabetes to use TIR because it’s a more “obtainable” and short-term goal than A1C, which is measured every three months. Remember that TIR is not a test or some sort of judgemental evaluation by a provider, but rather a progress report that can inform actionable next steps.
We encourage you to discuss TIR with your healthcare provider to help you with your day-to-day diabetes management. Learn more about TIR here.