Singer and actor Nick Jonas, who lives with type 1 diabetes and uses a continuous glucose monitor (CGM) himself, is throwing his celebrity status behind a new global effort promoting Time in Range as “a powerful metric for modern diabetes management.”

The big idea is to spread awareness among people with diabetes (PWDs) everywhere that focusing on Time in Range (TIR) can help them keep their glucose levels steadier and improve quality of life. It is fundamentally a more useful metric than the longstanding gold standard A1C, which only indicates a mathematical average.

This celebrity campaign kicked off June 24 just before the start of the American Diabetes Association’s annual meeting, with Jonas and diabetes orgs like Beyond Type 1, JDRF, and several others signing on with San Diego based CGM-maker Dexcom to lead the effort.

It’s all part of a growing push to make CGM technology a standard of care that healthcare professionals will use regularly to better monitor daily, weekly, and monthly glucose level patterns and make decisions based on that data.

“It’s time to kick-start the conversation here around the importance of Time in Range and how it makes people’s lives better,” Jonas said on a press call with diabetes advocates, announcing the new initiative.

Advocates have long been fighting to prioritize TIR because it gives people a sense of how often they are staying within the desired, healthy glucose range.

This is different than the traditional A1C lab test that only provides an average of glucose levels over the prior 3 months, but doesn’t reflect change or variability. So, two people with an A1C of 6.7 percent could have very different management profiles, where one has the coveted flatline, but the other person has highly variable glucose levels with frequent hypoglycemia. Or someone could have an “ideal” A1C level of 6 percent, but it only reflects a middle point between 3 months of severe high and low blood sugars.

TIR, on the other hand, uses continuous glucose monitor (CGM) results to show the amount of time a PWD stays within the desired range, expressed in an average of hours and minutes over any period of days, weeks, or months.

The “Beyond A1C” movement spearheaded by the diaTribe Foundation can now take a victory lap, with increasing recognition of TIR as a new established parameter for doctors to evaluate blood glucose control in PWDs.

A global consensus of diabetes experts define the target range as 70 to 180 mg/dL, and the new International Consensus on Time in Range recommends that patients should stay within that range at least 70 percent of the time.

Increasing research shows that glucose variability may play nearly as large a part in poor diabetes outcomes as do the glucose levels themselves. TIR helps PWDs and doctors identify variability far more efficiently than A1C.

It simply better reflects how people’s lives are being impacted by diabetes, including things like fear of hypoglycemia overnight, losing control and not being able to safely manage our own actions, or the stress and mental burdens we experience when eating foods that make our blood sugars rise dramatically and impact our moods.

Yet, most PWDs on insulin are not yet using TIR or don’t discuss it with their healthcare provider (HCP). In the press announcement, Dexcom published results of a survey based on their internal company data from November 2020, that found:

  • The vast majority (83 percent) of people with insulin-treated diabetes said they feel better when they spend more time in range.
  • But nearly half (47 percent) said they’re unaware of what time in range is and its advantages as a metric to gauge treatment success.
  • More than half (53 percent) said they’ve never discussed time in range with their HCP.
  • About two-thirds (68 percent) said they believe it is the responsibility of their HCP to bring new standards of care to their attention.
  • Three-quarters (75 percent) agree that when their glucose levels are out of range they feel unwell, and the majority (61 percent) report feeling stressed.
  • Half (51 percent) agreed that if they were able to spend more time in range, they’d feel more confident to pursue their dreams or passions.

Jonas, who co-founded the nonprofit Beyond Type 1, has openly talked about using the Dexcom CGM for years. He starred in a high-profile Superbowl ad for Dexcom in February 2021, and with that, has probably done more to raise the profile of diabetes among a younger generation than any celebrity ever.

DiabetesMine was fortunate to interview him a few times over the years following his diagnosis as a teenager in 2005 — especially once he teamed up with Dexcom.

Now, he’s using his platform to promote this TIR initiative to both promote the Dexcom CGM and further his mission to show people that it’s possible to live a healthy, active, productive life with diabetes.

The campaign site When In Range went live on June 24, with a variety of infographics, materials, and videos to explain TIR and help people achieve it through different technologies and treatments.

On the morning of this collaboration’s announcement, a group of diabetes advocates were invited to join a brief online call with Jonas to hear him discuss it. DiabetesMine posed a question about where A1C results fit into this new campaign. Many believe that A1C and TIR can complement each other, and that’s what Jonas responded with when asked the question.

“The more information the better,” he said.

Of course, a key question for all on the Jonas call was about access and affordability of CGM technology.

It’s no secret that pricing and accessibility are major barriers to CGM use — necessary to efficiently monitor TIR — and many who have a medical need for this technology can’t afford a CGM.

“I’m very aware, as all of us on this call are… of the need for access and that growing conversation is a priority for us all, in the U.S. and globally,” Jonas said. He recognized that his Super Bowl ad upset some people for that reason, but emphasized that raising awareness about diabetes on a mass scale helps lay the foundation for change. “I think that helps the bigger conversation about this need for access around the world,” he said.

While CGM is the most common tech used to track TIR, there are ways to monitor it using traditional fingerstick meters with a digital platform to analyze the data. That method certainly doesn’t generate as much glucose data on a continuous basis, but it can be helpful in showing broader patterns and management trends.

TIR is already included in the standards of care released by the American Diabetes Association (ADA), American Association of Clinical Endocrinologists (AACE), and other diabetes medical groups. That’s making it more of a focus for clinicians to talk with their patients about, whether for in-person or virtual visits. And it’s certainly a metric being integrated into many diabetes devices and mobile apps, for PWDs to view regularly.

TIR was a big topic at the ADA’s annual Scientific Sessions in late June 2021. Multiple diabetes experts in a variety of presentations highlighted the importance of TIR as they discussed latest research findings and management, complications that can materialize despite one’s A1C result, and even policy implications from looking at TIR rather than just A1C.

Natalie J. Bellini

One of those experts presenting on TIR at the conference was Natalie J. Bellini, a New York endocrine nurse practitioner and certified diabetes care and education specialist (CDCES), who is part of the Time in Range Coalition created by the diaTribe Foundation, aiming to make TIR the primary glucose metric for diabetes care going forward.

“I think the new global media movement will help propel the conversation between patients and providers,” she told DiabetesMine. “Patients who are referred to our practice using CGM do not all come in with medical records discussing TIR. I think we, as clinicians, need to use the tools we have to help patients reduce the risks of hyper and hypoglycemia by increasing awareness and analyzing data in a way that helps them address their personal time in range.”

She notes that therapy goals resulting from TIR data could include things like “urgency in reducing hypoglycemia” or “prebolusing to reduce postprandial spiking,” followed by changes to insulin pump settings or increased or decreased basal insulin, changes insulin to carb or sensitivity factors, etc. These are very fundamental and critical elements of managing diabetes on a daily basis.

“Time in range has given us a new tool to improve patient outcomes by opening discussions around insulin dosing, insulin timing, specific behaviors, other medications, stress, and all kinds of other factors we were not able to do before,” Bellini said. “Patients and clinicians alike need to adopt it into their vernacular. We also need more randomized controlled studies that help link time in range, time below range, and time above range to outcomes… [but] those are expensive and take a long time.”