A1C Recomendations

[solox316]

Out of curiosity, and not to start a heated debate...

If AADE and AACE have evidence to support a 6.5% A1C being the optimal range for lowest risk of complications, why are so many people concerned with staying in low 5s, or even 4s?

My doc, who is involved with many research studies, including ACCORD, and was involved with DCCT, cited many studies supporting the 6.5% target.

I know many people follow Bernstein's treatment philosophy, and I am curious to know the research behind other modes of thought.

[BlueSky]

... If AADE and AACE have evidence to support a 6.5% A1C being the optimal range for lowest risk of complications, why are so many people concerned with staying in low 5s, or even 4s? ....
The HBA1c, IMO, is not an end in itself. It is a reflection of the level of control that has been achieved. By control I mean stability in blood glucose levels. The more stable blood glucose is, the easier life becomes. Achieving stability in blood glucose becomes easier as blood glucose levels approach normal. This is the most compelling reason to aspire to a low HBA1c. The fact that the risk of complications declines as blood glucose approaches normal levels, is an added bonus.

I agree with Bernstein's view that diabetics deserve normal blood sugars. An HBA1c of 6.5% corresponds to an adequate level of control, but I really want the control that goes with an HBA1c of less than 6%. In addition to making me feel good, it optimises my performance at work. When you are self-employed, this is important. ;)

[xMenace]

I believe these values have a built in judgment: perfect control for the diabetic is not practical. It takes too much effort and it is too risky due to increased hypoglycemia.

Many people are proving these assumptions wrong. Many of us IDDs are getting 6.0% or better with LESS hypoglycemia. Many type 2's and type 1's are getting there with radical, in the minds of the medical establishment, diets. Tangent: Does anyone else think it odd that surgery to make you eat less is now being promoted, but a diet containing less food is not? *wobble-head*

For me complications are all too real. That's motivation enough. Screw anyone who says these targets are too aggressive, and the horse they rode in on. :ridinghor

[Funnygrl]

My doctor wants <6.5% if it can be done without serious swings. I think that's reasonable.

[Funnygrl]

Does anyone else think it odd that surgery to make you eat less is now being promoted, but a diet containing less food is not?

I'm not sure what you're getting at here, but I'll take a stab at it anyways, while going on a wide tangent (my apologies). The gastric bypass surgery promotes eating less to lose weight, while still allowing a wide variety of foods. Bernstein's method cuts out almost every nutritionally sound food out there in favor of pork rinds and "bread" made out of microwaved American cheese.

Further, I'm convinced the effects of gastric bypass aren't simply due to eating less. When you have gastric bypass, your stomach has a Billroth II. This causes food to rapidly transit through your system- dumping syndrome. A side effect of this is hypoglycemia. If your base line is high, this can return you to normal.

[solox316]

By control I mean stability in blood glucose levels. The more stable blood glucose is, the easier life becomes.

This was the main topic of our conversation... Yesterday my A1C was 6.2, which I was very happy with, my second lowest ever. However, I have averaged 5-7 hypos per week (<65).

So my next goal would be to maintain the 6.2, or even get to 6.0, without the hypos all the time. It has been so hard because we have changed out diet significantly, we have resumed normal exercise, and I have started on Symlin again... It almost feels like starting over at times...

[shabbie]

Out of curiosity, and not to start a heated debate...

If AADE and AACE have evidence to support a 6.5% A1C being the optimal range for lowest risk of complications, why are so many people concerned with staying in low 5s, or even 4s?

My doc, who is involved with many research studies, including ACCORD, and was involved with DCCT, cited many studies supporting the 6.5% target.

I know many people follow Bernstein's treatment philosophy, and I am curious to know the research behind other modes of thought.

my uk specialist must be of the same school of thought! he wants me to maintain an A1c of 6.8%.
he will go ape when i produce my last one of 5.7%!!! lol
i'm not sure i will manage such a good one again. i just cant stick to low carb at all, so my Bg's are a little unstable as a result!

[DarthDiabetes]

I would be happy with anything below 6 I guess, since I am still so new who knows. I dug up my med files from the years past and on two occasions had an A1C done, both came back at 5.6 one 5 years back and one 10 years back. Course I still run hypos all the freaking time even taking so little insulin :(

[fgummett]

From experience I feel that less than 6% should be readily achievable for myself... a Type 2 on a pump

But it is interesting to note that an arm of the ACCORD Test was canceled earlier this year :

February 12, 2008 — The blood-glucose-lowering part of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial in patients with type 2 diabetes at especially high risk of heart disease has been stopped prematurely because of a higher rate of mortality in the patients in the intensive arm vs that in the standard arm.

Patients in the standard-treatment group will continue treatment without changes, but patients in the intensive-treatment group will now be transitioned to the standard treatment.

The trial was a study of strategy rather than specific drug therapy, and many diabetes agents were used to reach glycemic targets. The higher death rate in the intensive group was not due to episodes of hypoglycemia or to any single drug, including rosiglitazone, or to a combination of drugs, ACCORD investigators said.

ACCORD is an National Heart, Lung, and Blood Institute (NHLBI) study of approximately 10,000 patients with type 2 diabetes and either heart disease or two risk factors for heart disease. The trial has a double 2X2 factorial design. All patients were participating in the glycemic-control part of the trial, which was testing whether an intensive strategy that targets a hemoglobin A1c (HbA1c) level of <6.0% reduces the rate of cardiovascular events more than a standard strategy that targets an HbA1c of 7.0% to 7.9%.

Then, depending on their blood-pressure and cholesterol levels, patients are assigned to two other parts of the trial. These are testing the combination of a fibrate (to raise high-density lipoprotein [HDL] and lower triglycerides) and a statin (to lower low-density lipoprotein [LDL]) vs a statin alone, and lowering systolic blood pressure to a target of below 120 mm Hg vs a target of 140 mm Hg. These blood-pressure and lipid arms of the study will continue until the study ends as planned, in June 2009.

In the glycemic-control part of the study, the median A1c level achieved in the intensive-treatment group was 6.4%, vs 7.5% in the standard group. The trial was stopped because of an excess of three deaths per 1000 participants per year in the intensive group vs the standard group, over an average of four years of treatment.

[davef]

Don't know if my Doctor is more or less enlightened. At my last review (3 months after DX) I was asking what he felt my target A1c should (I had views of my own but wanted his) and his response was that the standard answer would be 6.5% but he would be happier for me to aim/beat 6.0%. He went on to say that I need to keep my eye in the meter as much, if not more, than the A1c, his think was that if I can keep BG down around (preferably below) 108-110 that my A1c would fall in line. I keeping my 14 & 30 day average to 97.2, and I working on my Standard Deviation.

Personally I would love to get my A1c down to about 5.5%.

[fgummett]

Canadian Diabetes Association, Clinical Practice Guidelines for 2003 (to be revised in 2008) recommends:

http://www.diabetessupport.ns.ca/images/bg_targets2004.gif

I'm sure most folks know this but I have encountered confusion in the past so... remember that an A1c of 5% does not equate to an average BG of 5mmol/l

[kgm0612]

My endo recommends an A1c under 6.5, but says this is individually based. I've been as low as 5.8 and as high as 7.3. MY goal is to be between 6.0 & 6.3 come June.

Karen

[princesslinda]

My doctor says anything under 6 should be my goal. I'm happy in the 5's and don't have problems with lows.

If you think about, for those of us with HTN or cholesterol problems, we are given medications to keep our levels within "normal" range. Seems that diabetes is one of the few conditions where the medical community doesn't feel the need to encourage us to reach "normal" (ie: non-diabetic) levels...and i'm not really sure why this is, esp. for we T2s who aren't on meds that could cause us a hypo risk.

When I mentioned this to my doctor, he says most diabetics can't ever achieve normal levels, even with meds...I really think he'd never thought of it that way until I mentioned it.

[REDLAN]

In the UK, the current A1c Target for people with type 2 is between 6.5% and 7.5%, depending on risk of microvascular complications, and risk of iatrogenic hypoglycemia (i.e. caused by the drug treatments).

It may surprise you to know that this target is a level D recommendation. This means that it is either based directly on the evidence/opinions of expert committees, or clinical experience of respected authorities. OR it is based on the extrapolation of clinical studies.

It is the weakest recommendation under NICE.

On A1c recommendations for type 2, it has long been demonstrated that lowering A1c much below 7.5% has no clinical benefit - it does not lower risk of complications, nor will it lower mortality. This was the result of the UKPDS trial - pretty much the largest and best trial investigating treatment for people with type 2. ACCORD is the first and only study that showed that harm could result from trying to lower the A1c below 6% (not that other studies have shown that there isn't harm, I just think that it is the first one to try)

The DCCT relates soley to type 1 and compared intensive therapy to standard therapy. It showed that there were significant benefits to intensive therapy. The mean hba1c achieved by intensive therapy was 7.2% compared to 9.0% by conventional therapy. The DCCT then recommended HbA1c below 6.5%, although the average was much higher than this.

Although some individuals are able to achieve extremely low HbA1c values (i.e. normal or near normal), there is NO evidence that this has any benefit - potentially there may actually be harm if it is achieved with multiple drug therapies as in ACCORD

the biggest proponent of near normal hba1c is bernstein, and there is not one single study demonstrating that his treatment is effective. Not one. I know because I have searched for them. The only thing bernstein publishes are articles, and books.

So if want actual evidence derived from large clinical studies, then...

having an Hba1c of 9.0% will result in far more complications than if you have an hba1c of 7.0% for type 1 and 7.5% for type 2. Particularly for type 2 there is no evidence that hba1c levels lower than this are of benefit, and may actually be harmful. For type 1 there is no known benefit for an hba1c level much below 6.5%, there is potentially a theoretical benefit - the man with all the data and patients hasn't even done an observational trial.

(If I want to read testimonials I can go to any quack medical site for those - they aren't reliable evidence.)

[fgummett]

Very interesting REDLAN: I agree with Linda's observation that for just about every other blood level we aim for a "normal" reading but this recent ACCORD finding has me second guessing my struggle for a "normal" BG. It's really counter-intuitive that a normal BG could be harmful but the evidence seems real enough... what the heck is going on in our bodies?!

I had not read the UKPDS trial finding that below 7.5% had no clinical benefit for type 2... time for me to do some more reading I guess ;-)

It'll be interesting to see if the 2008 CDA Clinical Practice Guidelines actually raise the limits

[princesslinda]

Keeping A1C at near 7.5 would certainly allow me (and probably many other T2s) much more laxity with diet...actually, if these were the acceptable guidelines, many of us might be able to go off medications we're currently on and still get A1Cs at this level.

However, I've heard it mentioned several times that damage occurs with prolonged readings of 140 or greater (which according to my A1C conversion chart 140 equal an A1C of 6.1) that i've always worried when i've been above this level.

I know that I physically feel much better, more energized and alert with readings in the 80's and 90's than I do when I have a reading that's higher (say 150-160). Call me simple, but I just don't understand how having these readings could be harmful to us.

[REDLAN]

You won't find that info very easily on UKPDS. they trumpeted all the others - i.e. the importance of BP control in reducing retinopathy.

It was from a comment on a Blog about ACCORD by this guy.

Hooked: Ethics, Medicine, and Pharma: Science by Press Release? More Evidence of Commercial Control of Research (http://brodyhooked.blogspot.com/2008/02/science-by-press-release-more-evidence.html)

it's by Howard Brody who is director of the institute for medical humanities. There's a link to his bio on his blog.

[Lloyd]

As my glucose went lower and lower, my standard deviation also went lower. Standard Deviation is a measure of how closely packed or widely scattered your readings are compared with the average.

My lipid results also improved, as did my blood pressure and weight.

The ACCORD results have not been matched by other studies, they stopped the trial because they really had no clue as to what was going on.

I personally feel you should strive for as low an A1c as you can get, consistent with the lifestyle you wish to lead and the risks you are willing to take.

I am NOT willing to take the risks of hypoglycemia, that is not a problem for me at my current level, it might well be at my A1c for others who might be brittle, especially T1's. Personally, I am lucky in that if I do the right thing to control my glucose, at least 99% of the time I will get a good result.

-Lloyd

[REDLAN]

Call me simple, but I just don't understand how having these readings could be harmful to us.

my suspicion would be that the increased mortality would be due to the multiple drug therapies required to achieve an a1c below 6.0% rather then the lower BG's per se.

analysis of ACCORD showed that the excess deaths were not caused by hypoglycemia, nor were they caused by avandia.

There is this interesting article in the new york times that describes the intensive style treatment in more detail, and also speculates on the possible causes for the excess deaths



it's quite an interesting read :)

[REDLAN]

link doesn't work, and neither did the last one which is why I deleted it rather then fill up the thread.

this one should work <fingers crossed>

http://www.nytimes.com/2008/02/07/health/07diabetes.html?_r=2&ref=health&pagewanted=print&oref=slogin&oref=slogin

[Lloyd]

my suspicion would be that the increased mortality would be due to the multiple drug therapies required to achieve an a1c below 6.0% rather then the lower BG's per se.

analysis of ACCORD showed that the excess deaths were not caused by hypoglycemia, nor were they caused by avandia.

There is this interesting article in the new york times that describes the intensive style treatment in more detail, and also speculates on the possible causes for the excess deaths



it's quite an interesting read :)

Everyone is different, I take metformin and insulin only.

-Lloyd

[fgummett]

I checked on the Canadian Diabetes Association site and found this in regards the UKPDS trial:

The UKPDS has now simplified the approach to diabetes management. Taken together with the DCCT, it is clear that regardless of the type of diabetes, a policy of intensive glycemic control is beneficial. Concerns that a policy of intensified glucose control may do more harm than good in patients with type 2 diabetes, or may increase their risk of cardiovascular disease were not supported by this study.

CDA - UKPDS Position Statement... (http://www.diabetes.ca/Section_Professionals/cpg_ukpdsposition.asp)

---

I'm confused, but my gut (hah!) tells me that better control for me at least must be better in the long term

---

Thanks for the links REDLAN... interesting NY Times article... not really conclusive as to the reason.

BTW I didn't realise that ACCORD was just a US study ;)

[princesslinda]

My way of looking at it is fairly simple: I keep my numbers under the tightest control that I can, using whatever means necessary so that if/when any complications do develop, I can honestly say i've done all that's possible to prevent or delay them.

In the case of my mom, a very non-compliant diabetic who suffered just about every complication you can read about, I will ALWAYS wonder if perhaps she'd eaten fewer candy bars and actually took her meds as instructed, would she still be here today for her children, husband and grandchildren?

I don't want my husband or family to have to wonder the same about me someday.

[xMenace]

my suspicion would be that the increased mortality would be due to the multiple drug therapies required to achieve an a1c below 6.0% rather then the lower BG's per se.

analysis of ACCORD showed that the excess deaths were not caused by hypoglycemia, nor were they caused by avandia.

There is this interesting article in the new york times that describes the intensive style treatment in more detail, and also speculates on the possible causes for the excess deaths



it's quite an interesting read :)

My intuition points to

Or it may be that participants reduced their blood sugar too fast, Dr. Hirsch said. Years ago, researchers discovered that lowering blood sugar very quickly in diabetes could actually worsen blood vessel disease in the eyes, he said. But reducing levels more slowly protected those blood vessels.

This is the first reference I've ever seen to eye conditions, something many of us suspect.

What happens when someone with plaque buildup and stiff arteries suddenly drops their A1C? My layman's understanding says the blood becomes less sticky and flows better and the veins become more supple. It sounds like a recipe for sudden plaque break-offs which are not what we want.

[princesslinda]

What happens when someone with plaque buildup and stiff arteries suddenly drops their A1C? My layman's understanding says the blood becomes less sticky and flows better and the veins become more supple. It sounds like a recipe for sudden plaque break-offs which are not what we want.


I've never thought about it from that standpoint, but it certainly stands to reason that quick shifts from the norm might cause problems that could be diverted by more gradual change. That's certainly something to think about.

So many of us are so "freaked out" by the diagnosis that we immediately start the lifestyle we should have been implementing all along...and who knows at that point what problems we may have but be unaware of.

What an interesting thread!

[fgummett]

Be that as it may... I think we (on the forum) are already past that initial step and it should no longer be an issue for us.

I'll certainly be keeping a weather eye on developments and any future trials, but meantime I'm going to keep working for the best BG I can get.

[princesslinda]

I'll certainly be keeping a weather eye on developments and any future trials, but meantime I'm going to keep working for the best BG I can get.

Ditto I'm with you Frank!

[REDLAN]

it is clear that regardless of the type of diabetes, a policy of intensive glycemic control is beneficial. Concerns that a policy of intensified glucose control may do more harm than good in patients with type 2 diabetes, or may increase their risk of cardiovascular disease were not supported by this study.

I read the report - What the CDA report highlights is that good BP control reduces the risk of complications. However it shows a much lower benefit for good glucose control.

the UKPDS did not find that good glucose control was harmful, but then it's threshold for good glucose control was much higher than ACCORD ie. 7.0% as opposed to <6.0%

there is a critique by Ewart, with a response by the study authors

The case against aggressive treatment of type 2 diabetes: critique of the UK prospective diabetes study (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1121393#B1-7)

essentially the critique is on the changing end-points, and the lack of randomisation. Changing the end-points whilst a study is in progress is bad because it can seriously introduce bias - i.e. the authors can change the end-points to create a favourable result. However the study was scrutinised by the ethics committee. Lack of randomisation is an issue as it tends to introduce bias into a study, but would be very hard to achieve in a study of this type.

on the actual results....

the best and most unequivocal end-point is all cause mortality

do people live longer in the treatment arm?

and the answer to this is NO

does better glucose control lower diabetes related deaths?

the answer is NO

Does better glucose lower myocardial infarction

possibly but it's right on the edge of statistical significance the result could easily be a fluke. The authors did not claim this result as significant.

so what does better glucose control improve...

microvascular complications. (retinopathy and renal failure)

on retinopathy good BP control was more significant than good glucose control.

The study reduced the risk of any Diabetes related end-point by 12%. However Ewart claims that the authors state that a clinically significant reduction should be at least 15%. So this result may not even be clinically significant - i.e. you wouldn't notice the difference.

so does this study demonstrate a clear benefit for good glucose control?

[Lloyd]

Macro vascular complications involve more than just glucose control, you also need to control lipids, weight, and blood pressure, and generics and history play a role too.

Do the best you can and have no regrets.

-Lloyd

[davef]

Seems that diabetes is one of the few conditions where the medical community doesn't feel the need to encourage us to reach "normal" (ie: non-diabetic) levels...and i'm not really sure why this is, esp. for we T2s who aren't on meds that could cause us a hypo risk.

That is an excellent point, I think would help a great if doctor's treating diabetics could stop and ponder that and every now and then try to put themselves into a diabetics shoes or mind!

[MarcS]

I get frustrated when I go in for my A1C. My readings for the last month have averaged 117, for the last 2 weeks 114. Yet I take the test again and am at 7.1. I attribute it to my weight which is going down very slowly (was 240, now at 235). I am exercising 3 times a day for 1 hour or longer in total. I admit I have on rare occasion taken a high reading of 200 after eating something I didn't realize spiked me, but that is all part of the average since I also get lows of 65. I think that since I have to lose about 40-50 more pounds until I do so my A1C will suffer (ok it might break 6.5, but I my goal is to lose this weight this summer).

[princesslinda]

Marc, you say your blood sugar averages have been in the
114-117 averages...which is great by the way, but to have an
A1C of 7.1 correlates to an average of 175. How often do you test each day? You're going higher than you realize at some point.

I don't think your weight is affecting the A1Cs as much as some of your spikes that you may or may not be aware of. I'm overweight as well, but find that my A1Cs have remained about the same through nearly 80 lbs of weight loss.

I'd encourage you to test often (esp. in the 2 hr post-meal period), avoid food that's causing you to spike, and continue with all the great things you're doing. Hang in there!

[MarcS]

It's weird. In the morning I am 65-94 generally each morning with few exceptions. I test again at around 3pm usually around 100-120 usually snack around then, another reading at 6pm before or after I exercise (usually around 80-115). Then 2 hours after dinner which varies from 100-135, rarely have seen 175, and once or twice 200. I look at the sheets (I save them), and at my meter showing the averages. Perhaps more testing in the late morning, but I am testing now like 5 times a day already. I test before and after exercising just for fear of being too low (and eat something if I am low). Thanks for the encouragement. I am actually noticing that there is a washboard stomach trying to reemmerge again...lol.

[princesslinda]

With your improved readings lately, your next A1C should be much lower. Don't get discouraged, we're in this for the long haul and will have ups and downs.

For your own information, you might want to start testing 2 hrs after your first bite of food (you can choose a different meal each day to check) just to see how your foods are affecting you. I was amazed at how much green grapes caused me to spike...now, I opt for an apple instead.

And congrats on that "washboard stomach." As a 44 year old woman, gravity is not always my friend...:o ;)

[rzrbks]

Bernstein's method cuts out almost every nutritionally sound food out there in favor of pork rinds and "bread" made out of microwaved American cheese.

:rofl: :rofl: :rofl:

Trrrouble with Osama bin Bernstein too, I have.

[BlueSky]

... Although some individuals are able to achieve extremely low HbA1c values (i.e. normal or near normal), there is NO evidence that this has any benefit - potentially there may actually be harm if it is achieved with multiple drug therapies as in ACCORD...
Complication risks decline all the way down the HBA1c curve to normal levels. The graph here [/url] (I cant insert it for some reason) is based on DCCT data. It shows retinopathy risks rising from an HBA1c of 6%. The graph probably ends there because of lack of data. I read somewhere that, based on these big studies, retinopathy risk increases by 40% for each 1% that the HBA1c exceeds 5%. Similar relationships no doubt exist for other high blood glucose complications, like neuropathy and kidney disease.

The ACCORD study simply shows that there is no use in treating the symptom if the cause is not dealt with. With T2 diabetes, elevated blood glucose is just the symptom. The cause is insulin resistance. The ACCORD study found that intensive treatment of poorly controlled Type 2s increased the risk of heart disease. It didn't say that reducing blood sugar levels is a bad thing. The finding was that doing whatever it takes to reduce HBA1c from 8%+ to 6% could cause problems. We really shouldn't be surprised by this. Treating the symptom and ignoring the cause is bad medicine.

People with poorly controlled Type 2 diabetes were intensively treated using injected insulin and oral drugs to bring their HBA1c below 6.5%. They clearly had pretty intense insulin resistance to start with, especially in view of their poor control. Injecting large amounts of insulin and taking drugs to stimulate beta cell production would have substantially increased those insulin levels. This would have made insulin resistance go up, not down.

The association between high insulin levels (insulin resistance) and heart disease is well known. It is a defining characteristic of the Metabolic Syndrome. And the findings of the ACCORD study are in line with this principle. Increasing insulin levels increases heart disease risk. So what is new?

All this is of little significance to T1 diabetics, as DCCT demonstrates, because T1s are typically insulin sensitive. The results of this poll [url]http://www.diabetesforums.com/forum/type-1-diabetes/27847-type-1-daily-insulin.html (http://diabetes.bio-rad.com/images/graph.gif) shows this. Because insulin levels are low, improving glycemic control does not have the same adverse effect. T1s are fortunate in that doing what it takes to improve glycemic control makes them feel better and reduces (microvascular) complication risk. Hypoglycemia, as always, is an issue. But the notion that tight control increases hypoglycemia is a myth.

Once again, a lot of the commentary on the ACCORD study is confusing correlation with causality. The fact that tighter control in T2s is associated with heart disease does not mean that near normal blood sugars are bad.

[fgummett]

Thanks BlueSky, I think that perspective make sense to me.

I also read on the Dr. Ian Blumer site... (http://www.ianblumer.com/) that,
the UKPDS study showed that - a one percent drop in A1C reduced the likelihood of microvascular (that is; eye, kidney and nerve) damage by THIRTY SEVEN PERCENT

---

What you say has me wondering if I should be on medication to reduce my insulin resistance, as I am using around 100u of insulin a day to keep my sugars in check..?

[solox316]

the biggest proponent of near normal hba1c is bernstein, and there is not one single study demonstrating that his treatment is effective. Not one. I know because I have searched for them. The only thing bernstein publishes are articles, and books.

(If I want to read testimonials I can go to any quack medical site for those - they aren't reliable evidence.)

I was hoping to find someone with some study to clinically prove Bernstein's conservative views, glad to hear you have tried.

Your last statement really sums it up, to me.

[solox316]

However, I've heard it mentioned several times that damage occurs with prolonged readings of 140 or greater (which according to my A1C conversion chart 140 equal an A1C of 6.1) that i've always worried when i've been above this level.

According to my endo's explanation of the biology of A1C, it takes nearly 3-4 hours of a reading to affect one's A1C. So... that being said, a post meal spike over desirable range will have little to no effect on A1C, as long as it doesn't remain constant... His biological explanation was above my comprehension, but it is similar to other explanations I have heard/read.

[solox316]

It shows retinopathy risks rising from an HBA1c of 6%. The graph probably ends there because of lack of data.

Exactly the reason I started the thread...

http://diabetes.bio-rad.com/images/graph.gif

BTW- Sorry for the three posts in a row... just got home to read em, and replying as I go...

[RobiJo]

My intuition points to

Or it may be that participants reduced their blood sugar too fast, Dr. Hirsch said. Years ago, researchers discovered that lowering blood sugar very quickly in diabetes could actually worsen blood vessel disease in the eyes, he said. But reducing levels more slowly protected those blood vessels.

This is the first reference I've ever seen to eye conditions, something many of us suspect.



My eye doctor told me the same thing last year when I was going through all the laser. He said the situation could get worse before it got better if there was a drastic change for the better in my control. I've been on the slow in steady plan--not necessarily on purpose but that's how its been going. My A1c goes down about .2 every 3 months. Most recent was up .2.

In response to the original question. I think the A1c<7 campaign is a good one. Once you reach that goal then you can fine tune and aim for the lower 6's. Goals must be achievable in order to reach them or people give up. The exact goal is very particular for the individual.

[BlueSky]

I was hoping to find someone with some study to clinically prove Bernstein's conservative views, glad to hear you have tried. ...
Bernstein is a clinician, not a researcher. He really doesn't have anything to prove. All he is saying is that near-normal blood sugar is more healthy than abnormally high blood sugar. And no-one disagrees with that. A lot of people question whether it is worth the effort, though. And that is a personal call. If you want to see examples of Bernstein's clinical experience, go here Read It Online! (http://diabetes-book.com/book/beforeafter.shtml). These people tell their personal stories about achieving success they were unable to achieve in any other way.

[solox316]

All he is saying is that near-normal blood sugar is more healthy than abnormally high blood sugar. And no-one disagrees with that.

I beg to differ. It sounds like many replies on here have doctors who shoot for between 6 and 6.5, which the research supports.

[CrazyGramma]

. Hypoglycemia, as always, is an issue. But the notion that tight control increases hypoglycemia is a myth.


The reason I went looking for info and found this forum has a lot to do with my last AIC discussion with my endo. His strategy, I believe, was to try to convince me that an a1c of 8-9 is okay, in order to reduce the amount of hypos. I have been working hard on improving my control for the last month and have been actively avoiding hypos. It is very doable. I have been with this endo for 2 decades and although his advice seems crazy he achieved his goal of sending me off to prove him wrong.

Here are the questions related to AIC - is it possible to have a wide standard deviation ie. lots of hypo and some hi and end up with a decent aic? If that is possible, my second question would be what is the long term effect of many incidents of hypo (I dont mean the obvious danger, I mean dipping below the norm regualarly)

[BlueSky]

... is it possible to have a wide standard deviation ie. lots of hypo and some hi and end up with a decent aic? If that is possible, my second question would be what is the long term effect of many incidents of hypo ...
While it might be possible to have a good HBA1c with excessive standard deviation, it isn't feasible. It would mean having lots of severe lows. The only sustainable way to achieve a good HBA1c is to reduce the standard deviation. This is what improving control is all about. And you do it by minimising carbohydrate consumption, together with reduced insulin bolus dosages. It is also important that you optimise insulin sensitivity through muscle building exercise.

In answer to your second question, hypos are never good. But they are particularly hazardous when blood sugar drops fast. This is heightens the stress response, which causes all those distressing symptoms. Once again the rate of decline in BG is reduced by minimising bolus dosages. The gradual falling of blood glucose can mean that you don't feel it happening so, as always, it is important to test often.

Having said all that, I think the harmful effects of low blood sugar are often overstated. This happens because hypo distress is confused with physiological effect of low blood sugar. The most sensitive part of the body to low blood sugar is the brain. I have had difficulty finding info on this, but it seems that blood glucose needs to fall below 10mg/dl before brain damage occurs. This is way below the blood glucose level experienced in most hypos. So I don't worry about it.

Congratulations on improving your control, and keep up the good work ...

[CrazyGramma]

Thank you very much for that...I have never been even remotly afraid of low bg's but my recent experience with major fatique and just plain feeling aweful, which I understand has to do with the body's response to lows has caused me to smarten up.

[solox316]

Here are the questions related to AIC - is it possible to have a wide standard deviation ie. lots of hypo and some hi and end up with a decent aic?

Possible yes, good for you, no, like BlueSky said. My Dr. cited some research which constant peaks and valleys can be worse on your body than maintaining a steady higher reading.

That being said, getting to that point is the challenge, otherwise we wouldn't all be here... My current challenge is lessening my quantity of hypos, as I have done much better at lessening huge peaks and sustained higher readings...

[Real4]

If AADE and AACE have evidence to support a 6.5% A1C being the optimal range for lowest risk of complications, why are so many people concerned with staying in low 5s, or even 4s?

I can't imagine anyone actually saying that 6.5% is optimal. If you look at the studies, all that 6.5% is a data analysis breakpoint. The results from below and above are compared and Lo and Behold those below 6.5 (or whatever the breakpoint choosen) do better in every way. With one exception, I've never seen a study that says 6.5% is BETTER than 5.0%, for example, (if one can get 5.0% without lows).
The one recent study that suggests that a higher number is better because of potential heart problems, makes me very suspicious.

[REDLAN]

The one recent study that suggests that a higher number is better because of potential heart problems, makes me very suspicious.

This refers to ACCORD, in which aiming for an A1c below 6.0% caused excess deaths. Note that this is for people with type 2. Nobody knows if it applies to similar aged people with type 1.

Bluesky mentioned heart disease, however there is no mention as to the cause of the excess deaths in the original press release. They specifically eliminated hypoglycemia, and avandia as contributary factors.

The speculation is that the excess deaths were caused by the demands of maintaining an a1c below 6.0%, or that the rapid decline in blood sugars may be responsible. The fact is that nobody knows what caused the excess deaths.

http://www.diabetesforums.com/forum/attachment.php?attachmentid=3091&stc=1&d=1209106766

nice graph :)

retinopathy appears from DCCT and UKPDS to be the most sensitive condition to high blood glucose levels. UKPDS showed a 25% reduction in RR for retinopathy. DCCT did much much better with a 76% reduction (this is really big - most drug therapies rarely lower risks by more than a 33%)

back to the graph - what you will notice is that the graph isn't flat. It has a flattened S shape - it's nice to see, because this is the classic shape for any biological response. Notice at the top and bottom the graph starts to flatten out.

In conclusion - you won't do much additional damage to your eyes with an A1c much above 12%, and although there is no data, extrapolation of the graph would suggest that an A1c much below 6.0% confers very little additional benefit.

Hypoglycemia, as always, is an issue. But the notion that tight control increases hypoglycemia is a myth.

where did this come from? It is clear from the DCCT that tight control does INCREASE the risk of hypoglycemia. The quote below is from the DCCT page from the NDIC

In the DCCT, the most significant side effect of intensive treatment was an increase in the risk for hypoglycemia (low blood sugar) episodes severe enough to require assistance from another person. Because of this risk, DCCT researchers do not recommend intensive therapy for children under age 13, people with heart disease or advanced complications, older adults, and people with a history of frequent severe hypoglycemia.

DCCT increased the risk of severe hypoglycemia (i.e. needing someone to help you because you are unable to do it yourself) by 3 times. This is a large increase in risk. I remember reading that on average patients in the treatment arm experienced 3 hypos a week. The fact that a small number of individuals can maintain very tight control with few hypos, does not mean that everybody can - in fact the data shows that most people can't.

What this discussion has highlighted mostly for me is the differences between type 1 and type 2. Research from DCCT (solely looking at type 1's) is then used to make recommendations for type 2. The research results for UKPDS are used to inform treatment for type 1's (my doctor presented a very strong case for me going onto ACE inhibitors because of the results from UKPDS)

the fact is they are 2 completely different diseases

type 1 is an auto-immune disease, where there is partial or complete destruction of the beta cells of the pancreas.

type 2 is a metabolic disorder of unknown cause. Type 2 leads to multiple metabolic disturbances, one of which is inflexibility of insulin resistance by the tissues. There are also disturbances in lipid, and cholesterol metabolism. Blood pressure maintenance systems are also adversely affected, possibly through metabolic disturbance of the kidneys. As the disease progresses pancreatic function declines (nobody knows why), and glycemic control worsens.

which leads me to a question. why does the treatment of type 2 almost exclusively focus on glycemic control, when it is clear that the metabolic disturbance affects many systems throughout the body.

In NICE the A1c recommendations for type 2 are DCCT aligned i.e. from data about type 1's

UKPDS actually showed that good BP control was more important than good glycemic control in preventing complications - but they trumpeted the glycemic results instead. What UKPDS actually showed that there was very little difference between an a1c of 7.0% and an a1c of 8.0%, and what differences there were, were probably not clinically significant. After 10 years there was no difference in the most important outcome of them all - mortality.

Seems to me that the poor results of ACCORD were from assuming that the results of DCCT applied to a completely different group of people.

wouldn't it makes more sense to set A1c targets at levels that have been experimentally verified to improve complications and outcomes for patients, and to focus on correcting the metabolic disturbances that cause the greatest damage - such as blood pressure?

[BlueSky]

Hypoglycemia, as always, is an issue. But the notion that tight control increases hypoglycemia is a myth.
... where did this come from? It is clear from the DCCT that tight control does INCREASE the risk of hypoglycemia. The quote below is from the DCCT page from the NDIC



DCCT increased the risk of severe hypoglycemia (i.e. needing someone to help you because you are unable to do it yourself) by 3 times. This is a large increase in risk. I remember reading that on average patients in the treatment arm experienced 3 hypos a week. The fact that a small number of individuals can maintain very tight control with few hypos, does not mean that everybody can - in fact the data shows that most people can't....
My assertion comes from personal experience and the realisation that the results of the DCCT and similar trials only tell half the story as far as hypo risk is concerned. Let me explain ...

Intensive therapy, as investigated by DCCT, involved injecting a long acting basal insulin daily and a fast acting insulin before meals and for corrections. This was in contrast to conventional therapy, which involved a fixed schedule of regular/NPH or mixed insulin. Intensive therapy therefore involved more intensive and aggressive use of insulin. I agree, doing this increases hypo risk. No doubt about it. But more intensive use of insulin is not the only way to achieve tighter control. HBA1c can also be substantially reduced by reducing carbohydrate intake and reducing insulin dosages at the same time. The difference is that hypo risk is reduced by doing this. The less insulin you use, the smaller the risk of hypo's becomes. It is Bernstein's "Law of Small Numbers". Control can also be improved and hypos reduced by improving insulin sensitivity through muscle building exercise.

DCCT did not consider these options. This is why the generalisation that reducing HBA1c increases hypo risk is simply not valid. Partial information is being used to reach a generalised conclusion. It is a conclusion that unfortunately leads both doctors and patients astray.

......which leads me to a question. why does the treatment of type 2 almost exclusively focus on glycemic control, when it is clear that the metabolic disturbance affects many systems throughout the body.
...
Good question. The answer is that glycemic control is the only thing medical science has developed the tools to manipulate. Doctors don't even bother to measure insulin levels because they can't do anything to change the level of insulin resistance. Metformin is a safe drug, but its insulin sensitising effect is limited. The benefits of other insulin sensitising drugs (Actos and Avandia) are questionable. And sticking to glycemic control is the safest bet. Blood glucose is easy to measure and improvements in it are easy to achieve. The fact that it amounts to treating the symptom rather than the cause is indeed an inconvenient truth ....

[REDLAN]

The less insulin you use, the smaller the risk of hypo's becomes. It is Bernstein's "Law of Small Numbers"

you might be interested in what Bernstein himself actually has to say on this matter. When I commented on the lack of research by Bernstein, I did another search and found this on pubmed - he's not the lead author mind.

The effects of a low-carbohydrate regimen on glyce...[Metab Syndr Relat Disord. 2003] - PubMed Result (http://www.ncbi.nlm.nih.gov/pubmed/18370654?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)

it's a chart study - in other words they have published the test results of a group of selected patients. We won't go into validity and bias and all those other things that make this a poor quality study. Anyway...

Additionally, the reduction of insulin afforded by this diet could theoretically lead to a reduction in hypoglycemic events.

so it would appear that Bernstein himself doesn't know for sure. ;)

[solox316]

I can't imagine anyone actually saying that 6.5% is optimal.

Some people's replies tell otherwise.

I've never seen a study that says 6.5% is BETTER than 5.0%, for example, (if one can get 5.0% without lows).

And the same goes the other way. There aren't published large scales studies that show running a 5.0 is overly superior in terms of chances of complications, to say a 6.0, or 6.5.

One can INFER, or ASSUME, this, but the data isn't there.

Personally, I won't shoot for a low 5 number, because of the risk of hypos, it isn't worth it, to me. I wouldn't fault someone who disagrees though. If you can do it without hypos, then I applaud that, but I think those people are a small number. I just read the US Median is 7.3... not sure if that is accurate though...

[HelenM]

I have grave doubts about Dr Bernsteins methods but it does seem intuitive that sustaining normal or near normal average blood glucose (without large/frequent peaks and troughs) is less likely to lead to complications. Unfortunately it isn't easy for many people to do this and the risks, such as for some dangerous hypos or effect on quality of life may be too great.

I found a 1996 paper using the DCCT data: ( from the DCCT team? no author cited )
Although the magnitude of the absolute risk reduction declines with continuing proportional reductions in HbA1c, there are still meaningful further reductions in risk as the HbA1c is reduced toward the normal range. When the instantaneous risks for different complications associated with different HbA1c values are compounded over time, there are substantial differences in the cumulative incidence of patients experiencing a complication for patients with HbA1c values of 6 vs. 7 vs. 8% or higher. In fact, no HbA1c threshold could be identified, short of normal glycemia, below which there was no risk of the development or progression of these complications.

also

In contrast, although the absolute risk of severe hypoglycemia in the intensive treatment group increased as the HbA1c decreased, the relative risk gradients were significantly less for HbA1c levels < or = 8.0% than for levels > 8%.
the conclusion:

Therefore, the DCCT continues to recommend implementation of intensive therapy with the goal of achieving normal glycemia as early as possible in as many IDDM patients as is safely possible.

The absence of a glycemic threshold for the develo...[Diabetes. 1996] - PubMed Result (http://www.ncbi.nlm.nih.gov/pubmed/8826962?ordinalpos=51&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)

[Alice]

This was mentioned earlier, I think...but I wanted to point out that the term "intensive insulin therapy" is an older term used in the original early 90's study...back when many people were only taking one injection of an intermediate acting insulin such as Lente added with R, Humalin R and such. There were severe gaps and peaks in such an older regime.

The "intensive" was more of a move to MDI (Multiple Daily Injections) with newer insulins coming onto the market. I believe it was prior to Lantus/Humalog...but about the same time. Therefore, "intensive" is only in relation to the older form of insulin injections.

I don't consider it "intensive" in that I'm forcing more into my body than I can utilize...or at least try not to!

Intensive A1C goals is a different topic than "intensive insulin" use...or multiple injections.

[RobiJo]

I just read the US Median is 7.3... not sure if that is accurate though...

That seems very low for the average. Maybe the average for those who get it done all the time, or those considered more compliant or something. With the number of poorly treated or non compliant...the average HAS to be higher.

[Doug]

My experience and research shows that a1c is an average.

Which means that to have an a1c of 5 you need to spend as much time under 70 as you do over 100. Ive never been able to use insulin well enough or reduce carbs enough to keep my BG from going over 130 during or after meals

The risk of hypoglycemia is too great for me.

Keep in mind that while we are discussing patient feedback that, patients tell the Drs what they want to hear. a1c is after all, largely a lie detector test... At a recent JDRF event I was talking to a fellow type 1 who told me that my a1c was dangerously high ( 6.6 ) and that I should work harder to get it lower like his, he then proceeded to tell me about the number of times he has passed out from lows and had to be revived by his wife or taken to the ER. Including 3 times while behind the wheel. In my opinion one easy way to avoid complications is to kill yourself from repeated lows. Lows can kill you quick, my goal is to keep a consistent reasonable a1c with ZERO lows that I cant treat myself. That assures me the best chance to live long enough to see what complications are in store for me.

I congratulate any type 1 that can consistently achieve a1c under 6 with zero lows that they need help treating