First of all, clearly you have a ton of knowledge in this space, and I'm feeling very lucky I get to learn from your experience here. I have one more last question/challenge:
I totally get that we "treat the patient" -- that's sort of what I'm hinting at with the demographics. But, in my opinion this thing you said:
> we don't have actual data about how much an extra X% outside of target ranges matters in terms of clinical outcomes and complication rates. We only really started getting this data with CGM and complications in these mild states would require very large cohorts and long (10-20 year) follow-ups to detect differences as they're likely to also be mild.
... is not the same as saying "we know that 70% TIR is safe to live with no complications". I don't think any of the guidelines are that confident, because there's not enough evidence yet. Consider this study (discussed at [1]):
> Overall, increasing time spent with glucose levels in the target range of 70–180 mg/dL (3.9–9.9 mmol/L) was associated with decreasing risk for microvascular complications. For instance, 50.0% of the 10 individuals in the lowest category for TIR (<40%) had at least one microvascular complication, compared with just 27.3% of the 99 people in the highest category for TIR (≥70%).
> Moreover, El Malahi said that the 180 people with microvascular complications had significantly lower average TIR than the 324 individuals without, at 60.4% versus 63.9%.
This suggests to me that a difference of 4% of TIR can seriously affect long-term outcomes. And, by the way, even those with the highest TIR still had microvascular complications higher than the normal population. On top of that, we know that genetic and environmental factors may be at play.
Therefore, my monkey math is that 75%+ as a TIR goal may mean that even if the patient is an order of magnitude more vulnerable to complications, microvascular or otherwise, they have a much better shot.
And, unfortunately, the typical western diet with 3 meals a day and snacks, you have to be "good at managing diabetes" to get to 75%+ TIR. Thanks for reading my ramble.
I totally get that we "treat the patient" -- that's sort of what I'm hinting at with the demographics. But, in my opinion this thing you said:
> we don't have actual data about how much an extra X% outside of target ranges matters in terms of clinical outcomes and complication rates. We only really started getting this data with CGM and complications in these mild states would require very large cohorts and long (10-20 year) follow-ups to detect differences as they're likely to also be mild.
... is not the same as saying "we know that 70% TIR is safe to live with no complications". I don't think any of the guidelines are that confident, because there's not enough evidence yet. Consider this study (discussed at [1]):
> Overall, increasing time spent with glucose levels in the target range of 70–180 mg/dL (3.9–9.9 mmol/L) was associated with decreasing risk for microvascular complications. For instance, 50.0% of the 10 individuals in the lowest category for TIR (<40%) had at least one microvascular complication, compared with just 27.3% of the 99 people in the highest category for TIR (≥70%).
> Moreover, El Malahi said that the 180 people with microvascular complications had significantly lower average TIR than the 324 individuals without, at 60.4% versus 63.9%.
This suggests to me that a difference of 4% of TIR can seriously affect long-term outcomes. And, by the way, even those with the highest TIR still had microvascular complications higher than the normal population. On top of that, we know that genetic and environmental factors may be at play.
Therefore, my monkey math is that 75%+ as a TIR goal may mean that even if the patient is an order of magnitude more vulnerable to complications, microvascular or otherwise, they have a much better shot.
And, unfortunately, the typical western diet with 3 meals a day and snacks, you have to be "good at managing diabetes" to get to 75%+ TIR. Thanks for reading my ramble.
[1] https://diabetes.medicinematters.com/easd-2020/glycemic-cont...