A Wrinkle in Time (in Range)

April 30, 2025
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Now that many people with diabetes are using time in range (TIR) versus HbA1C as a benchmark for risk of complications, diabetes researchers and clinicians are starting to ask whether pushing further to “Time in Tight Range” (TITR) will be the next indicator used for diabetes care. As discussions continue, there are debates on the use and impact of such a metric.

Defining Time in Tight Range (TITR)

The metrics for time in range currently are 70-180 mg/dL (3.9-10 mmol/L), and time in tight range would be 70-140 mg/dL (3.9-7.8 mmol/L). Researchers who argue that utilizing TITR is beneficial tout that TITR is closer to “normal glycemia” and, therefore, an indicator of risk reduction.1,2 As this is a new metric, more studies are being conducted to determine if TITR is more beneficial than TIR.

What is a goal TITR for someone with T1D?

There is no international consensus yet for the goal of TITR. Still, the most recent 2024 International Society for Pediatric and Adolescent Diabetes (ISPAD) Guidelines state that a possible target is >50% TITR.3 The guidelines state that this is still an emerging area of research, needing more data to provide a widespread consensus on the target. Additionally, there may be different phases of life in which the TITR goal may be higher, such as during pregnancy.

Is TITR a realistic goal?

Real-world data in children and adolescents has shown that the target of >50% is challenging. In one study in Italy, 854 youth had an average TITR of 36.4%, with participants using AID systems having higher percentages of TITR.4 Other data from Sweden and people using the MiniMed 780G system show that the goal of >50% is possible for pediatric patients.5,6 These studies show that it is more likely to be a realistic goal for PWD using an AID system. Given that many people with diabetes around the world do not have access to AID systems, CGMs, and insulin pumps, it is not going to be a realistic goal for everyone.

Concerns about the added burden

Many PWDs cannot achieve the targets for TIR (>70%) with their current treatment methods. For those struggling to reach the first target with a broader range, being asked to meet the new, more aggressive target may be incredibly defeating. Diabetes psychologist Dr. Molly Tanenbaum and her team from Stanford University conducted focus groups with 30 adolescents and parents of children with diabetes about TIR and TITR, in which many expressed concerns about the added burden, risk of low glucose, and increased family conflict.7 Dr. David Maahs and colleagues also raised the issue of an increase in alarm fatigue with TITR.8

As a person living with diabetes, I can attest that with a lot of work, TITR of >50% is achievable for some time. Even without AID systems, I achieved very high TIR and TITR during my pregnancy. However, this was a temporary time frame with an end goal in sight, and I relaxed my goals after delivery. Balancing the ability to spend most of the day in the target range with adequate quality of life will be the key to this metric. Diabetes is a marathon, not a sprint, and resilience is key. Time will tell whether this becomes our new goal for diabetes management. Until then, I’ll keep doing my best as we all do.

  1. Is It Time to Move Beyond TIR to TITR? Real-World Data from Over 20,000 Users of Continuous Glucose Monitoring in Patients with Type 1 and Type 2 Diabetes
  2. The association of chronic complications with time in tight range and time in range in people with type 1 diabetes: a retrospective cross-sectional real-world study
  3. International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Glycemic Targets
  4. Aiming for the Best Glycemic Control Beyond Time in Range: Time in Tight Range as a New Continuous Glucose Monitoring Metric in Children and Adolescents with Type 1 Diabetes Using Different Treatment Modalities
  5. Using Time in Tight Glucose Range as a Health-Promoting Strategy in Preschoolers With Type 1 Diabetes
  6. Time in Tight Glucose Range in Type 1 Diabetes: Predictive Factors and Achievable Targets in Real-World Users of the MiniMed 780G System
  7. ‘We’re taught green is good’: Perspectives on time in range and time in tight range from youth with type 1 diabetes, and parents of youth with type 1 diabetes
  8. Time in Tight Range for Patients With Type 1 Diabetes: Examining the Potential for Increased Alarm Fatigue

Written and clinically reviewed by Marissa Town, RN, BSN, CDCES

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