[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]

Originally Posted by solox316

... 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.

[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]

Originally Posted by BlueSky

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]

Originally Posted by 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.

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:



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