10 tips to improve your time in range

Diabetes nurse educator, Christine Manga, shares 10 practical tips to improve your time in range.

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Time in range 101

Let’s start off by discussing time in range (TIR) and the importance of this concept.

  • Time in range is the amount of time spent in a specific target blood glucose range and is measured in %.
  • Target range is set at 3.9mmol/L – 10.0mmol/L for most people with diabetes.
  • Guidelines recommend that at least 70% of a day should be spent in range, which equates to just shy of 17 of 24 hours.
  • Less than 4% should be lower than 3.8mmol/L and less than 1% lower than 3mmol/L.
  • Time above range, higher than 10.1mmol/L should be kept to below 25%.
  • Pregnancy has a much narrower range of 3.5mmol/L – 7.8mmol/L. This is to mitigate the risks of pregnancy and birth complications including premature birth, high birth weight babies, miscarriage, or a stillborn baby.

Important to note: The guideline ranges may be too low for certain people. Factors that need to be considered for setting different target ranges in these certain populations would include age, duration of diabetes, life expectancy, physical or mental disabilities and work environment. These targets should be discussed with your health care provider for best long-term outcomes.

How is TIR calculated?

It’s calculated by taking a certain number of readings over a 24-hour period and dividing the number of readings in range by the total number of readings taken and multiplying by 100. This will give a percentage.

The easiest way to determine TIR is by wearing a continuous or flash glucose monitor. These systems measure glucose every five minutes, 288 times a day. An individual using these sensors can see TIR for a rolling 24hours. To get a true reflection of overall glucose control, a period of at least 14 days should be used.

TIR and Hba1c

Hba1c used to be the gold standard for measuring long-term glucose control. Unfortunately, there are shortfalls to using this method; it’s unable to expose glucose excursions and misses hypoglycaemia.

In the below image, all three patients have an Hba1c of 7%. The glucose readings of these patients are vastly different. Patient 3 has a TIR of 100% whereas patient 1 has huge variability. Glucose variability is considered an independent risk factor for developing long-term diabetes complications. TIR and Hba1c are closely correlated. Depending on baseline Hba1c, for every 10% change in TIR there is a 0.4 -1.0% change in Hba1c.

Ticking the TIR boxes

Maintaining a good TIR is possible and made easier by following some of these 10 simple tips:

  1. Medication

Take your diabetes medication as prescribed. Timing and dosage are imperative. Missing doses, taking too much or too little medication or insulin will reduce TIR. If necessary, set a reminder alarm on your phone to take medication timeously.

  1. Eating

Eating low-carb and low-GI foods prevent huge swings in glucose levels. Adding a protein to a meal assists in stabilising glucose levels. Eating vegetables with meals adds fibre, once again preventing spikes. If you are snacking, aim for less than 15g of carbs per snack. Be aware of portion sizes of meals, as the larger the meal, the greater the glucose fluctuation.

  1. Exercise

Regular exercise improves insulin sensitivity. It allows your body to better use the ingested glucose. Exercise can lower glucose levels for up to 24 hours post exercise. To remain in range, it’s important to make sure your glucose levels are not above 14mmol/L when starting exercise or below 5,5mmol/L. Exercise can assist in weight loss.

  1. Stress management

Stress releases hormones such as glucagon, adrenaline and cortisol. These increase insulin resistance causing an increase in blood glucose levels. Illness is a form of stress. Seek medical attention if you are ill.

To manage daily stress, meditation, breathing exercises and general exercise are excellent. If the stress is too great to manage alone, make an appointment to see a doctor or psychologist. During times of stress, try to increase glucose testing frequency.

  1. Monitor blood glucose levels

If you are fortunate enough to have access to sensor technology, use it. But, most importantly is to react to any alerts, high or low. It doesn’t help to know what your glucose level is if you’re not going to do anything about it.

Finger stick monitoring is most common in SA. The general rule is for every insulin injection given; you should be testing. Testing two hours post meal can assist you to increase your TIR by adjusting future meals or insulin doses. If a reading is out of range, think why that would be and see what changes you can make for next time. Advocacy is being done to enable more people with diabetes in SA have access to continuous glucose monitoring sensors.

  1. Sleep

Insufficient sleep can cause insulin resistance giving rise to elevated blood glucose levels in people with diabetes and increasing the risk of developing diabetes for those without.

Hormones released overnight also cause insulin resistance which result in elevated glucose readings in the hours before rising.

This overnight rise can be managed with diabetes medication. Sleep apnoea is another cause of insulin resistance, worsening TIR. If you snore or stop breathing overnight (often mentioned by your partner), it may be worth testing for sleep apnoea.

  1. Weight

Maintaining a healthy stable weight aids in keeping glucose levels stable. If you are overweight, losing just 5% of your body weight will improve insulin sensitivity and therefore glucose levels. If more weight is lost, medication doses may need to be reduced to prevent hypoglycaemia. Imagine having greater TIR with less medication.

  1. Sensor augmented insulin pump therapy

Having the privilege of wearing an insulin pump with a connected sensor is one of the easiest ways to maintain a high TIR. The insulin pump adjusts the insulin doses according to the sensor blood glucose levels. These systems enable you to reach a high TIR with a very low time below range.

Unfortunately, these systems are very expensive and not available to most people with diabetes. As mentioned earlier, there are wonderful advocacy groups putting pressure on the necessary bodies to get these pump systems to more individuals.

  1. Sick day/back up

When you are sick, glucose levels usually spike. It’s important to have a sick day protocol especially when using insulin. This will aid in keeping you in range. Your healthcare provider will be able to assist you with this.

Having backup stock for hypos is important, be prepared. Carry sugar or honey sachets, Super C’s or Jelly Babies. To remain within range don’t over correct a low blood glucose. Have 1 to 2 Super C sweets and wait twenty minutes, then retest your glucose level. If still below 3.9mmol/L, then have 1 more Super C.

10. Consistency

Try to remain consistent with all the above. Routine makes staying in range easier. There will be days that regardless of what you do your blood glucose will appear to have its own agenda. That happens. Accept it and move on. It’s the bigger picture that counts, long term, a less than good day here and there is not the end of the world.

Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.


Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.

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