The Benefits of Time-in-Range for Type 2 Diabetes with DCES Megan Muñoz
Continuous glucose monitors (CGM) are a valuable tool helping people with type 2 diabetes reach their blood glucose goals. Devices such as the FreeStyle Libre 14 day system allow a user to see what direction their blood sugar is trending, and gain more insight into their diabetes, revealing important measures like time in range.
Beyond Type 2 recently discussed the importance of time in range with Diabetes Care and Education Specialist and host of the Type2andYou podcast, Megan Muñoz, CDCES, CMSRN. We talked about how people with type 2 diabetes can use time in range to set expectations for their next A1C check-in, how to improve time in range, and how to calculate it without a CGM. Read our interview and watch the full discussion with Megan below!
BT2: We’re excited to chat with you about the importance of continuous glucose monitoring (CGM) and time in range, Megan. Please introduce yourself to our audience.
Megan Muñoz: I have a nursing background, but most of what I’ve done as a nurse has been working with people with diabetes—inpatient, outpatient, big hospital, smaller hospital, you name it. It has been a wonderful experience.
I’ve really liked learning about people, what they’re doing and how they’re managing their diabetes, as well as being their champion and helping support them. That’s why I started the Type2andYou with Meg Podcast to help really support people with type 2 diabetes and give them information about things they never had heard or thought about.
Can you explain what CGMs are and how they compare to blood glucose meters (BGMs)? How would you describe the difference between the two in terms of data that people with diabetes can get?
With a blood glucose meter, you check your blood sugar by pricking your finger, and you see what your blood sugar is at that moment in time. It’s like a snapshot, think of it as taking a picture versus making a movie with CGM.
It’s just one picture of your whole day, but you don’t know what happened before that and you don’t know where your blood sugar is headed. And that’s where a CGM is different because it provides the in-between the scenes [of your BGM] data. You get to see what happens before and after that blood sugar check.
CGM measures the blood glucose level in interstitial fluid, so a different part of your body than your blood. But it updates continuously, about every five minutes, or you can scan your CGM device, such as the Libre, on your arm and you can get all of your data on what your blood sugar is doing, and where it’s headed. I think it’s really helpful in providing more information.
It also comes with a lot of responsibility because you have more information [about your blood glucose] and need to know how to manage that info, but it definitely provides the in-between pieces [of what impacts your blood glucose levels].
Because of CGM, we talk a lot about “time in range” and “A1C.” What is time in range, and how is it connected with A1C?
That’s a good question. time in range is how long your blood sugars are spending between 3.9 mmol/L70 mg/dL and 10.0 mmol/L180 mg/dL. If your blood sugar is within that range about 70 percent of the time, then you’re going to be close to A1C of 7 percent.
With CGM, you can actually be a little more proactive, because you’re seeing what’s happening. You could change what you might be doing with your medicine, with your food, or your activity to maybe bring that blood sugar up or down so you’re staying in that healthy 3.9 mmol/L70 mg/dL to 10.0 mmol/L180 mg/dL range more often.
Is time in range more important than A1C? Why or why not?
So, I think it is more important than A1C for a couple of reasons. People still largely depend on A1C to help them make their healthcare decisions, and their providers do that as well. But CGM provides something completely different than A1C, and that we know what fluctuations are happening in blood sugars. So, somebody with an A1C of 7 percent could have a good portion of their blood sugars that are way too low.
They could be struggling with low blood sugars all the time, and a portion of their blood sugars that are way too high evens out [their average blood glucose] to look pretty great. I’ve had this happen to so many patients. They go see their doctor and their A1C is 6.5 percent or 7 percent, but they’re having so many low blood sugars. But their provider is not thinking about that or assessing for it. And this person is absolutely miserable and their health is at risk with so many lows.
But by looking just at that A1C, you can’t understand those pieces unless that person is communicating that with a doctor if they even feel lows. Whereas, with a CGM, there’s so much data beyond the time in range that tells you what the variability is in your blood sugars, how much your blood sugar is going up and down. That can affect your body just as much as you running constant high blood sugar levels. So, I think time in range is key.
How can people with type 2 diabetes use time in range to set expectations for the 90-day follow up?
I think the time in range has been a huge game changer and expectations. Even as educators, we’re always wondering if we should be pushing more for improved blood glucose. I think the time in range helps remove that perfection piece for a lot of people who feel they have to get more blood sugars within their healthy range and that none of them can be too high or too low.
Some have unrealistic expectations for themselves or their body, and it can be very stressful. So, I think that expectation piece is really huge as far as setting that expectation to that 90-day follow up. I think the other piece of that is connecting that time in range to what the A1C is going to be, as we just discussed, which is about about 10 percent. If you have about a 10 percent change in your time in range, that would equate to a .5 percent change in your A1C.
So, it sounds like just little baby steps, but little changes can make a big difference in the A1C level. I think that’s really helpful. You might aim for about 50 percent of time in range, or that’s close to an 8 percent A1C, where a 20 percent difference from that is going to be that 70 percent time in range, and a 7 percent A1C. So, I think that’s really helpful in understanding how that A1C connects to the time in range.
What are some everyday activities people can do to improve their time in range?
I love this question! It’s just good old-fashioned diabetes self-care. It’s being active. It’s looking at the food choices that you eat instead of demonizing what you eat, but just understanding what happens when you eat a combination of different types of food. Does it change the way your blood sugar responds?
Also, the timing of meds is important. It’s so amazing to see the difference in what people see when they time their medications correctly. I love for people to experiment because how else are you going to know? And now, you have this tool that gives you that feedback right away so you can understand, “Okay, how is this working for me? And if it’s not, what little thing can I change?” So, maybe if you’re struggling with activity, which is pretty common.
Maybe you look at your days that you are active versus days you aren’t. What is your time in range on those days? It reinforces the things that are working well, and you can build off of those.
For people who don’t have a CGM but are still interested in learning how often they’re in range. Is there a way for people who only have access to BGMs to do that?
The best way to do it if you are checking blood sugars is to take a 14-day span, and you try to check blood sugars as often as possible. Check two hours after your meal, before meals, overnight, bedtime. Dedicate your energy and time to checking as many blood sugars over that two-week period. And then, you take the number of blood sugars that fell between 3.9 mmol/L70 mg/dL and 10.0 mmol/L180 mg/dL, and you divide it by your total number of blood sugars.
So, let’s say you checked 100 blood sugars in that time period. And 75 of those blood sugars were in a healthy range, so between 3.9 mmol/L70 mg/dL and 10.0 mmol/L180 mg/dL. Take that 75 divided by 100, which is the total number of blood sugars, and times 100, times that by 100. That equals your time in range.
But I would add too, some of the meters now have apps that will go with them that will provide a lot of that information. So, that’s something you could check and see if the meter that you’re using, especially if it’s newer within the last three to five years. A lot of them have apps, where you wouldn’t have to go through the process of doing the math, but it would provide it for you.
Do you have patients who come to you and say, “Megan, I’m only in range for 40 percent of the time, how do I keep my perspective that I can actually manage my diabetes very well?” How do you help patients move through that?
That’s a really good question. That’s something that’s really hard to deal with when somebody has struggled with high blood sugars for so long. I actually find most people end up not using their CGM at a certain point and they take it off.
So, if somebody ever comes in to see me, and they’re not using it, I really want to know why because most people find success, and really enjoy it. Is it because they’ve really struggled with these high blood sugars, and they feel really hopeless?
I think the biggest piece is giving people that hope back. This is where they’re at right now, but that’s not where it has to be. It might take a month, it might take a month and a half and it might take three months, but we can get there, and I’m willing to partner and support you. And let’s start with a baby step. Let’s start with the first thing we can do to improve.
When you achieve little wins, you feel more successful. You don’t really do a great job when you feel like crap. Any change that goes in a positive direction, we celebrate it. I don’t care if it’s 1 percent, we celebrate because we’re moving in the right direction.
What else would you like our audience to know about CGM, time in range, A1C and how they all fit together? What are some key takeaways that you want them to take home?
I think the biggest takeaway about CGM is that it’s probably the wave of the future. It’s probably something that you will have access to in the next 10, 15 years more commonly than probably maybe even a blood glucose meter.
It sounds probably overwhelming if you’re not used to a device, but it is really intuitive and easy to understand once you dive into it. So, don’t let fear stop you. Don’t let a lack of knowledge or information by your medical team or yourself stop you from learning more about CGM.
Please tell everyone where they can get in touch with you, and how they can learn more about Type2andYou with Meg?
Oh, well, so you can go to type2andyou.org. My email is email@example.com. Type2andYou with Meg is the podcast. I really do like hearing back from people, or I like hearing people ask me questions sometimes on Instagram, or on the podcast. I really love learning more about you. I would love to hear from you if you have a question.
- Lowering Your A1C with the FreeStyle Libre 14 day System
- The Importance of CGM for Insulin-Dependent Type 2 Diabetes
- My First Time Wearing the FreeStyle Libre
This content was sponsored by Abbott, the makers of FreeStyle Libre 2,—a Founding Partner of Beyond Type 2.