Where should ones comfort level be in readings.

[Larry H.]

Hello friends,

I am going on over two years in and out of here now. My initial readings that got me here were a blood test that showed a reading of 128 and my doctor at the time pointed me to the net to bone up on what steps I could take to help myself. Once I purchased a meter I got a few readings of over that point by a bit, but only at the beginning. I restricted my diet and began walking daily. My after meal readings which at first fell often above 150 and on one occasion as high 198. But it began to fall as I walked and lost weight and ate to ADA guidelines most of the time.
For some time now I have seen Fasting levels from low 90s to 110 on the higher, more rare end. After meal levels have generally stayed under 140 and often much lower. I have also chosen so far to do this without medications.
Frankly I was feeling pretty good about my progress using the guide lines I thought were reasonable of staying under 140 post meals, and better when possible. Now and then of course as all of us I have seen some higher readings, but much more rarely.
So when recently I was challenged here that my eating habits and comfort level with numbers was faulty, I have become somewhat confused as to my status. Personally I choose the Pre diabetic tag because my numbers usually were not the kind I see in advanced type II cases. But that is something that isn't a big deal, were all diabetic in some way and mine is no doubt like everyone else's.
What is bothering me now is that the bar seems to keep being lowered on what to strive for. I don't mind cutting back to a point that gives me the results I thought I should see. But now I was pointed to the fact that my fasting really ought to be in the 80 to 90 range or less and anything over 100 can be a major issue health wise.
Needless to say my comfort level is now challenged. The problem for me is that the recommended levels by most major diabetic groups is more in line with what I was doing. I know some of you are getting those incredible low reading and are able to stay there. Some with medication and some without. Are those levels really where everyone has to or should be considering we have diabetes, or are all the mainline opinions such as the ADA that far off? I recently attended a hospital diabetes meeting where it was announced the ADA is lowering the Type II AC1 to 6.5 from a 7 reading as the type II levels. I did feel they were a bit too high to start and needed lowering, but how much is really necessary?

[MCS]

I would be comfortable with 140 or even 150 1hr PP, as long as I would return to 100 or less in 2 hrs and have a FBG of 100 or less. After battling this icky sicky thing I am hoping things will get back to normal for me.

I personnel feel its the duration of the high spike that causes problems, I would rather be at 140 for 15 minutes or so, than to be at 110-120 all day long. Just me, no data to back this up. My thinking is when your BG is elevated you are creating a situation of stress on your body. Now your body can over some of this stress thru its own antioxid controls. When you are elevated for long periods of time you body can not keep up with the stress your BG is putting on it. You loose the ability to self repair. Thats my take on things.

[princesslinda]

Larry, I think we all have to find our individual comfort level in the way we manage our diabetes.

I was just thinking recently as I read over the thread about "what was your morning blood sugar reading" that if I compared myself to the majority who post on that thread, i'd feel like I was a failure as a diabetic, as I don't think in the entire 3 years that i've been diagnosed that i've had a fasting blood sugar in the 80's..EVER, even when doing the Bernstein way of eating.

For me personally, i'm okay with being 140 or less at the 2 hr post meal reading. I have plenty of food choices I can eat and stay within this parameter so it works for me. I'd like my fasting to be 110 or less, however it seems to stay a little higher than that most days (other than the weekends, not sure why).

Blood sugar readings are going to vary, based on length of time having diabetes, the meds we take, the exercise we get, the food we eat, sometimes it even seems to change with the planetary alignments;) . We just have to find a way of managing that we can live and be at peace with. It will vary for all of us, and the readings we see may indeed change (for better or worse) as we continue our lifetime of diabetes management.

[fgummett]

My opinion is that we strive for normalcy (which is hard to get clearly defined) but we have to be realistic about what we can achieve safely and reasonably without letting D rule our lives.

Is it worth the potential complications and/or side-effects of medication to lower your Fasting BG by 10 points? I guess that is ultimately up to you, with advice from your Health care Team.

Looking back on my history: my A1c was 5.4% last November, and my most recent was 6.1% BUT I have lost an additional 65lbs of excess fat mass and come right off any injected insulin during that time... yes I could very likely have an A1c of 5.4% today but it might be at the cost of extra fat mass... not to mention extra work and focus on D on a daily basis.

I'm hopeful, given time, that I will have an A1c of 5.4% again but if I can get it with less fat mass and less of my day spent stressing over D, then so much the better. But if I can't get there, then a 6.1% will do just fine... much better than where I would be had I not taken charge of myself that's for sure.

What is the best compromise of all factors for you?

[Josselyn]

I was diagnosed a Type 2 (probably very early stage) while my FBGs at the MDs office were still under 100 (87, 96, 99). I was in denial big time. I fought for the "pre", but my doc does not believe in the pre-diabetic label. Failed the OGTT (have you had one yet?) with a 288 at two hours, and that was the end of discussing my being Type 2 or Pre-Diabetic. I later got my A1c back and it was 6.6.

You're doing a great job of controlling your BG, and should be commended. You also had a good doc who didn't ignore the signs.

Yes, the powers that be ARE lowering the bar for a T2 diagnosis, as well as for the goal numbers one should strive for. These "major diabetic groups" are now realizing that 7.0 is uncomfortably close to the level causing later diabetic complications and studies have found that earlier intervention helps provide for a healthier outcome. When I read this stuff at first, I was resentful and saw it as a way for them to make money from people like us. Now I recognize that it gave me a "head's up" on pulling it all together...as it did you.

No need to be uncomfortable with your numbers and methodology...but if the trend creeps upward, please don't be complacent about it. Many of us are just aiming for numbers that are "normal", not "normal for a diabetic."

I think we're going to see a lot of changes in near future regarding the criteria for diagnosing Type 2 diabetes. It's long overdue.

[jps]

I believe the ADA's guidelines are way too loose. The ACE's are much better, but I believe that they are too loose too.

The ADA does seem to be the authority and I think that's a big part of the problem. Full compliance to ADA guidelines still offers a good chance of complications at some point in my opinion.

I aim for normal, non-diabetic numbers. Because I think that is the absolute most I can do to avoid diabetic associated complications. I don't think those numbers are possible for everyone. We are all on a different point along the type 2 diabetic continuum. The closer you are to the beginning, I think the more realistic it is to live up to lofty goals.

But in the end, it comes down to what you are trying to accomplish. There are different priorities for different people. In my case, cutting out a bunch of carbs is too extreme for some people, they still want to enjoy lifes pleasures. I completely understand it. We just value things differently, I don't think one is right or one is wrong. It comes down to personal preference.

[Larry H.]

Thanks for the kind replies, I am breathing a bit easier now. I have tried very hard to reduce my levels but have not perhaps gone to what I would consider extremes to get it down. I rather agree with the idea that as long as your after meal readings do not go too high and do not last for extended periods most likely you doing fairly well. Sure I would maybe like to see those near normal readings, but I am not normal so its pretty hard to do even though I know some here manage it.

[plattb1]

Target goals for blood glucose set by the American Diabetes Association (ADA) are 70–130 mg/dl before a meal and less than 180 mg/dl two hours after the start of a meal. The American Association of Clinical Endocrinologists (AACE) has defined stricter blood glucose targets of less than 110 mg/dl before a meal and less than 140 mg/dl two hours after the start of a meal. The differences in those targets are at the heart of the controversy.

The AACE says: "The most common error that leads to preventable complications is delayed diagnostic screening, which is most often a system-derived problem because of the pressures to limit screening, even in high-risk populations. More than 50% of patients diagnosed with T2DM have at least one complication at the time of diagnosis, which would probably have been preventable with earlier diagnosis." For that reason, I err on the side of caution & use the AACE's guidelines as my targets.

As always, it's a personal choice. What is more personal than one's own body?

[Larry H.]

I was reacting somewhat to a mutual friend here who as suggesting that a after meal reading of 112 & 119 were type II numbers and should be reduced. Frankly I didn't agree with that but after some of the posters who say they don't go over 100 after meals just made me wonder where I really was and if I was within a set of goals that would work for me.

I do agree that those ADA numbers are too high and have often said so at the hospital meetings. I really don't know how the ADA selects representatives, but often when someone speaks who tend to reflect their views I find that they are not well versed in reality.

[Josselyn]

I was reacting somewhat to a mutual friend here who as suggesting that a after meal reading of 112 & 119 were type II numbers and should be reduced. Frankly I didn't agree with that but after some of the posters who say they don't go over 100 after meals just made me wonder where I really was and if I was within a set of goals that would work for me.

I do agree that those ADA numbers are too high and have often said so at the hospital meetings. I really don't know how the ADA selects representatives, but often when someone speaks who tend to reflect their views I find that they are not well versed in reality.


Hi Larry,
I would be thrilled to have your postprandial numbers of 112 & 119. I cannot imagine ever getting to the point of having my numbers under 100 pp...though that would be impressive, indeed.

If you go to bloodsugar101.com, you'll find much in the way of information there, including the following topic which addresses your initial query:

Misdiagnosis By Design - The Story Behind the ADA Diagnostic Criteria

Keep up the good work!

[ShottleBop]

I'm with jps. Dr. Bernstein hosts monthly teleconferences (there's one tonight). During last month's teleconference, he said that most of his patients coming in with an A1c of 5.3 or 5.4 have complications already: 24. At what blood sugar level do diabetic complications start occurring?

Answer: That’s an excellent question. I have seen a number of patients who come to my office just for weight loss, people who have not been diagnosed with diabetes. Every person who walks in here gets an A1c test. We get a result in six minutes. With one exception, all of these obese people had A1cs between 5.2 and 5.6. I examine every new patient for diabetic complications, and lo and behold, every one of these people had a host of diabetic complications. Typical complications are what’s called the Intrinsic Minus Foot, which is a foot shape that includes a forefoot that’s rotated upward relative to the hind foot, hammertoes, high arch, and so on. They tend to have bounding oscillometric readings. Oscillometry is a way of measuring circulation. Diabetics, early on, have calcification of the muscular walls of the large arteries in their legs that give them bounding pulses that far exceed what you see in non-diabetics. I see these changes, and many other minor changes in these obese people who have no diagnosis of diabetes, but have A1cs between 5.2 and 5.6. 5.6 corresponds to a moving average three month blood sugar of about 124. That will certainly cause diabetic complications, as will a 5.2, which is about 108. The ADA would disagree with me, but, they’ve not really studied this. They have never published a study showing that lowest mortality risk occurs at Hgb A1c values between 4 and 5%.

He may be engaging in hyperbole, to a certain degree--and, in the report put out by the ADA recommending that diabetes be diagnosed on the basis of an A1c of 6.5, they state that the risk of complications, such as retinopathy, doesn't really start ramping up until 6.0. Nevertheless, I think it prudent to aim for BGs as "normal" as I can. Personally, that means that I try to keep my average BG below 100, and my highs below 110--goals that, for me, are currently within reach by way of diet and exercise.*

______________
* I received my wake-up call at an A1c of 6.5, and my FBGs straddled the borderline between "pre-diabetes" and "diabetes"; I seem to produce enough endogenous insulin to do this without meds. I would hope, however, that I would not be shy about starting metformin and/or insulin, should they become necessary to keep me at my target levels.

[fgummett]

As I recall there is a whole area devoted to this subject on the Blood Sugar 101 site... why the ADA set their levels where they did. (ETA: as mentioned by Josselyn above)

If I recall they did have some well meaning rationale; such as not wanting to incorrectly label someone as having D, with all the possible insurance repercussions, for example. So playing the numbers game, they consciously set the criteria high to avoid false positives BUT as we all know the sooner this beast is diagnosed and tamed, the more likely are healthy outcomes.

[ShottleBop]

And the ADA doesn't say that anything under the threshold for diagnosis should be ignored--it's just that our health system tends to be binary in its approach to the maintenance of health.

[fgummett]

The other failing in the system that I seem hear too often is that: maybe it is reasonable for the ADA set the diagnosis criteria at higher BGs (I don't think it is...) BUT when a diagnosis does finally come along lets get busy with it... urgently... none of this "oh lets wait and see how you are in 6 months... then we'll maybe try some Metformin.." and so on... I call this the "let's wait to see how bad it can get" approach, and it fails to recognise that the D did not start on the day of diagnosis but instead has been building for many years prior.

This is why I applaud Larry's proactive approach to Pre-D rather than sitting back and saying "we'll it's not really so bad that I need to do anything about it yet."

[jer.lawrence]

I cannot imagine ever getting to the point of having my numbers under 100 pp...though that would be impressive, indeed.

I agree that consistently under 100 pp seems difficult, yet impressive. I'm at 101 after lunch today (fried chicken and a salad) but usually I see 110s or 120s after meals.

I try to stay under 130 (just because it gives me a little wiggle room) after meals, and I like seeing fasting numbers under 100, or around 100.

[davef]

I do think it's a personal thing.

I aim to be at (preferably below) 6.1/110 for my FBG and to be at (preferably below) 7.5/135 two hours after first bite of a meal.

I don't always achieve my targets but it doesn't stop me trying, as some times I beat my targets.

[bunbury]

I try keep as close to normal as possible and will, over time, use whatever means I have to reasonably do that. 'Reasonably' is the key word. The method and the number will change as my circumstances change.

At the moment my target is under 110 at all times. I miss most often in the morning after breakfast. I can usually come in under 100 @ 2 hrs PP dinner.

[sumi]

It is completely individual, Larry. I, too saw the references to staying under 100 at all times with dismay and disbelief. Although higher numbers may damage beta cells, I assume -without any research- that beta cells , like most cells in the body are constantly being renewed. I do not believe that other damage has been shown. It seems to me that if such numbers were indicative of a problem, the majority of the population would have it. My own numbers are usually in the 110-120 range when I wake, but are also often under 100 two hours after lunch and supper. This is not from any extraordinary measures on my part, it is just my own particular brand of D. I think that the only way that I could get my morning level into line with normal is to take more meds. Even if I wanted to do that, my Dr. still seems uncomfortable with how much I have lowered my A1C and would probably be 'non-compliant'.

[bunbury]

Although higher numbers may damage beta cells, I assume -without any research- that beta cells , like most cells in the body are constantly being renewed. I do not believe that other damage has been shown.

Sadly, higher BG numbers kill beta cells which are not 'constantly being renewed'. Once they're dead they're lost for ever. Other damage from high BG levels include multiple neuropathies, loss of limb and CHD, blindness and a wide variety of premature deaths. The higher your BGs, the faster you loose your beta cells, the higher your BGs go... and the sooner the complications set in.

[sumi]

[Sadly, higher BG numbers kill beta cells which are not 'constantly being renewed'. Once they're dead they're lost for ever. Other damage from high BG levels include multiple neuropathies, loss of limb and CHD, blindness and a wide variety of premature deaths. The higher your BGs, the faster you loose your beta cells, the higher your BGs go... and the sooner the complications set in.)
Bunbury, I was specifically speaking of any level over 100 (not the more common 140) Have you seen studies showing this to be harmful?

[ShottleBop]

The studies posted at Blood Sugar 101 show damage to beta cells at a two-hour measurement on the OGTT of 100, and at fasting blood sugar levels of 110.

[sumi]

Sorry, I once again was not clear. Yes, I have seen the study on beta cells being damaged at lower levels, what I meant was organ or neurological damage at this level (100-110). I did look up some information on beta cells and apparently they do regenerate, although very slowly.

[Larry H.]

Yes and that very study seemed odd to me. Like they also say that normal people often peak to 120 after a meal, so does that mean they are killing off cells too? I think this study is flawed in some way and slanted to absolute perfection.
To talk about the total destruction of cells with readings over 100 flies in the face of reality. There are also a number of studies out there that show when caught soon enough that cells can recover much of their ability to function properly. If it were only a one way street would that happen? Also if readings over 100 caused irreversible damage many here one be on insulin in no time which is not the case.
Well I admit I haven't a clue, but I think there are extreme views in everything and this theory is one.

[bunbury]

Bunbury, I was specifically speaking of any level over 100 (not the more common 140) Have you seen studies showing this to be harmful?

Hi sumi, sorry I was baffled by the statement and my apologies, I miss-read you.

Shottlebop has pointed you to Blood Sugar 101 Beta Cell impacts. The same site has information on rising risks of CHD as A1c climbs above 5%

[ShottleBop]

One more opinion (this one from Dr. Bill Quick, over at Diabetes Health, from his sharepost for October 17):

. . . where should the BG levels for someone with type 2 diabetes be? Well, ideally, you might think that all people with diabetes should be aiming for normal levels. But there's plenty of evidence that normalizing all BG levels is extremely difficult, and carries a risk of accidental hypoglycemia. That has to be balanced against the reverse observation: that elevated BG levels mean elevated risk of diabetes complications, including eye, kidney, and nervous system damage. So any pronouncement about where BG levels should be must be tempered with caution.

It's my feeling that all patients with diabetes should be treated to avoid numbers higher than 400, and to avoid numbers lower than 60: there's an increased risk of acute complications of nausea and vomiting, dehydration, and subsequent nasty things if BG levels are in the 400's -- and clearly the risk of hypoglycemia is dramatically elevated if BG levels are below 60. So there's a starting point for where to aim.

And the ultimate in BG control would probably be to keep almost all (maybe 90%) of before-meal BG levels between 70 and 100, and after-meal BG levels below 150. That's a goal that's pretty close to what non-diabetic patients might have. Is it possible? Sure, even if you have type 1 diabetes: if you are on an insulin pump or multiple insulin doses, testing 4-10 times a day, and motivated to continue doing so for a prolonged period of time. (The best example of motivators might be pregnancy: young women with type 1 diabetes who are planning pregnancy, or are pregnant, would be potential candidates for an ultra-tight diabetes control program aiming at numbers like these.)

Dr. Bernstein would not agree.

[ShottleBop]

Yes and that very study seemed odd to me. Like they also say that normal people often peak to 120 after a meal, so does that mean they are killing off cells too? I think this study is flawed in some way and slanted to absolute perfection.
To talk about the total destruction of cells with readings over 100 flies in the face of reality. There are also a number of studies out there that show when caught soon enough that cells can recover much of their ability to function properly. If it were only a one way street would that happen? Also if readings over 100 caused irreversible damage many here one be on insulin in no time which is not the case.
Well I admit I haven't a clue, but I think there are extreme views in everything and this theory is one.

Again--the study does not say that ANY reading over 100 indicates that beta cells are being destroyed; it says that decline in beta cell function can be detected in people whose two-hour results on an OGTT exceed 100: Abstract

Aims/hypothesis. Both insulin resistance and beta-cell dysfunction play a role in the transition from normal glucose tolerance (NGT) to Type 2 diabetes (T2DM) through impaired glucose tolerance (IGT). The aim of the study was to define the level of glycaemia at which beta-cell dysfunction becomes evident in the context of existing insulin resistance.

Methods. Insulin response (OGTT) and insulin sensitivity (euglycaemic insulin clamp) were evaluated in
388 subjects in the San Antonio Metabolism (SAM) study (138 NGT, 49 IGT and 201 T2DM). In all subjects the insulin secretion/insulin resistance index (ΔI/ΔG÷IR) was calculated as the ratio of the increment in plasma insulin to the increment in plasma glucose during the OGTT divided by insulin resistance, as measured during the clamp.

Results. In lean NGTs with a 2-h plasma glucose concentration (2-h PG) between 5.6 and 6.6 and between
6.7 and 7.7 mmol/l, there was a progressive decline in ΔI/ΔG÷IR compared with NGTs with a 2-h PG less than 5.6 mmol/l. There was a further decline in ΔI/ΔG÷IR in IGTs with a 2-h PG between 7.8 and 9.3 and between 9.4 and 11.0 mmol/l, and in Type 2 diabetic patients with a 2-h PG greater than 11.1 mmol/l.

Lean and obese subjects showed coincident patterns of relation of 2-h PG to ΔI/ΔG÷IR.

Conclusion/interpreation. When the plasma insulin response to oral glucose is related to the glycaemic stimulus and severity of insulin resistance, there is a progressive decline in beta-cell function that begins in“normal” glucose tolerant individuals. [Diabetologia
(2004) 47:31–39]

[ShottleBop]

I would further note that this study was observational. Unless some error in the researchers' methodology can be established, they are reporting reality, not flying in its face.

[Larry H.]

One more opinion (this one from Dr. Bill Quick, over at Diabetes Health, from his sharepost for October 17):



Dr. Bernstein would not agree.

I doubt anyone here would think 400 was a point to be happy with. You really must have to dig to find an opinion this crazy, its the opposite of the point your making, which is no doubt also the point.

If the 100 point isn't being said to be a problem then why the relationship to it as a point where damage starts. Sounds like a catch 22 to me?

[ShottleBop]

I doubt anyone here would think 400 was a point to be happy with. You really must have to dig to find an opinion this crazy, its the opposite of the point your making, which is no doubt also the point.

I didn't do any digging to find it; Dr. Quick publishes Shareposts over at Diabetes Health, and his (as well as Gretchen Becker's and Dave Mendosa's) is one that I check periodically. I wasn't looking for this, at all--I was reporting, in another thread, about his experiences with do-it-yourself A1c tests (which he reports on in his most recent post, for Oct. 22)--and this post of his happened to be the second-most recent (Oct. 17), with a title--"A good number"--that made me check it out.

Moreover, if you read what he says carefully, he does not come close to saying that folks should be happy with anything under 400--he says really, really bad things begin to happen at that point--like, immediate (as in "acute") bad things. The real message concering to what we might consider setting our targets at was this: And the ultimate in BG control would probably be to keep almost all (maybe 90%) of before-meal BG levels between 70 and 100, and after-meal BG levels below 150. That's a goal that's pretty close to what non-diabetic patients might have.

I thought that Dr. Quick's take on the issue might be of interest to some here, so I posted it. The fact that I, personally, might have targets that are more strict for myself is neither here nor there.

If the 100 point isn't being said to be a problem then why the relationship to it as a point where damage starts. Sounds like a catch 22 to me?

There is a difference between "staying under 100 at all times," and "staying under 100 at two hours PP." This study might be a reason for trying to keep your two-hour PPs under 100, as opposed to some higher number (and remember, the ADA and the AACE themselves suggest different targets for two-hour PPs). That may not be a goal that everyone sets for themselves, but neither is it off the wall: I've heard, in an online presentation by Steve Freed, the publisher of "Diabetes in Control," that he expects the AACE to lower its recommended two-hour PP target to that level. (I watched that presentation over a year ago, however, and I wonder whether that expectation might not have been a trifle optimistic. I haven't seen any other indication that the AACE might do so.)

[Larry H.]

I may have misunderstood your point on the 100 reading and the 101 site. From what I recalled on that site they seemed to be saying that damage was being done with reading over 100. But on another point they mentioned that non diabetics often reached 120 at an hour after meals. So my question was if that is the case is everyone really at risk here, which I just find difficult to believe at that point.

Also the ADA guidelines from what I heard were doing to drop to I think it was 160 as the after meal upper reading they were comfortable with, lowering it from the 180 which like that 400 reading, almost no one seem to think is a good idea.

I generally feel that the 120 to 140 may be the goals to aim at. I just find the 100 point to be a bit low.

[ShottleBop]

An OGTT involves the quick ingestion of a solution containing 75 grams of glucose--something that is intended to give you a fast spike, to see how quickly your system reacts and gets your blood sugar level under control. It is very different from a meal, where the presence of other macronutrients, such as fat, could be expected to slow down the processing of carbs, or where the carbs actually require processing to yield glucose, causing your spike to come later, or even be lower, than if you were to ingest pure glucose solution.

With the OGTT, given the ingestion of the pure glucose solution, the vast majority of folks are expected to be higher at one hour than at two hours. The study in question found that folks who had not returned to under 100 by the two-hour mark exhibited impaired beta cell function. The heading used to introduce the study, "Beta Cell Destruction Begins at Levels Over 100 mg/dl (5.6 mmol/L)", is not a complete statement of what the study found, and is misleading, if not read in context with the write-up itself.

The second study--"Beta Cells Die Off in People Whose Fasting Blood Sugar is Over 110 mg/dl (6.1 mmol/L)" does in fact relate to measurements of beta cell mass in cadavers of people who were known to have fasting blood sugars over 110. The write-up, however, does not tie having a postprandial blood sugar level of 110 to damage to beta cells. Instead, it notes: Since the American Diabetes Association believes that a fasting blood sugar level of 100 mg/dl to 125 mg/dl corresponds to a 2-hour glucose tolerance levels of 140 mg/dl to 199 mg/dl, this suggests that patients whose post-meal blood sugars rise only to the non-diabetic "impaired" level may be well on the way to losing as much as 40% of their beta cell mass. It also suggests that people with abnormal glucose tolerance who wish to avoid further beta cell loss should try to keep their blood sugars under 140 mg/dl at all times.

[ShottleBop]

. . . Also the ADA guidelines from what I heard were doing to drop to I think it was 160 as the after meal upper reading they were comfortable with, lowering it from the 180 which like that 400 reading, almost no one seem to think is a good idea. . .

Remember that the ADA guidelines, like the AACE guidelines, are set to balance the desire to achieve "normal" blood sugar levels against the danger of hypoglycemia. This, for example, comes from the "Major Guidelines" (http://www.guideline.gov/summary/summary.aspx?doc_id=11094) for the treatment of diabetes set by the AACE:

All Patients With Diabetes Mellitus

Encourage patients to achieve glycemic levels as near normal as possible without inducing clinically significant hypoglycemia (grade A) . . . .