Diabetes Self-Management Blog

Have you been ordered by your doctor to get your A1C (HbA1c) level up? More people are having this confusing experience, as doctors try to implement the 2013 ADA treatment guidelines. Do these orders make sense? Not much, I’d say.

What is happening here? In 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) changed the targets doctors should aim for in treating diabetes. They went from a one-size-fits-all target of 7.0% HbA1c to a three-tiered guideline.

HbA1c is the test that gives an idea of the average blood glucose level for the previous two months or so. An A1C of 7.0% equals an average blood glucose of around 154 mg/dl, and many people think that number is too high to protect against complications. So there was pressure to lower the guideline.

At the same time, many older people found the 7.0% goal too strict. A few studies found an increased risk of falls in older people who run low glucose levels. There was concern about increased risk of hypoglycemia (low blood glucose).

As Diane Fennell wrote here, many think that aiming for lower A1C levels leads to an increase in low blood glucose episodes. As many readers commented, hypos are dangerous and unpleasant. For many, they are the worst fact of life with diabetes.

So the experts finally recognized that one size does not fit all. Unfortunately, their new guidelines have been misunderstood by some doctors, leading to people being told to raise their A1C numbers, even if doing so increases their complication risk. According to the new guidelines, older or sicker people, or those with many hypoglycemic episodes, might shoot for 7.5% to 8.0%. Younger, healthier, people might want to get their A1C below 6.5%, or even lower. People in between on age and health might continue to have a goal of at or below 7.0%

The target A1C levels are supposed to be individualized. According to ADA President for Medicine and Science Vivian Fonseca, MD,

The message is to choose an appropriate [blood glucose] goal based on the patient’s current health status, motivation level, resources and complications.

This sounds wonderful and easy to understand. But somehow many docs don’t seem to get it. Rather than seeing 7.0% as the upper limit for a person (if that’s the number chosen), they think those who keep their A1C lower than 7.0% are doing something wrong. They want to get those glucose levels up! We know high glucose levels are the main cause of diabetes complications. Is this as crazy as it sounds?

Tight control and hypoglycemia
It doesn’t seem that aiming for a lower A1C actually increases the risk of falls or hypos. According to this study from the University of California at San Francisco,

Achieving lower A1C levels with oral hypoglycemic medications was not associated with more frequent falls, except, among those using insulin, an A1C less than or equal to 6% increased risk of falls.

Below 6% is a pretty rare A1C for an older insulin-using adult.

A large study at Yale University found that

Contrary to conventional wisdom, hypoglycemia occurs just as frequently among those with poor glycemic control (higher A1C) as it does in those achieving near-normal glycemia.

And in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the more people lowered their A1C, the fewer hypoglycemic episodes they had. So there is no reason to assume risk of falls or hypos from tight control. It should be an individual decision.

Confusing tight control with control by drugs
Three large studies are driving the diabetes establishment away from “tight control.” These studies, ACCORD, the Action in Diabetes and Vascular Disease (ADVANCE) Trial, and the Veterans Affairs Diabetes Trial (VADT), showed no significant improvement in death, heart disease, or stroke rates for people with tighter control (lower A1Cs). So why bother with the risks, effort, and expense of tight control if there was no benefit?

But the problem wasn’t the tight control. It was all the drugs doctors used to achieve the control. Those drugs, especially insulin, thiazolidinedioines (TZDs), and sulfonylureas, can have negative effects that sometimes outweigh the benefits of lower A1C.

Those risks or side effects rarely happen to people who control their glucose levels with diet, exercise, metformin, and/or other approaches, or perhaps with incretin drugs. Even the ADA guidelines of 2013 admit that drug reactions may have contributed to the negative effects in the big trials mentioned.

Three sizes fit all
So three sizes fitting all may be better than one size. But it’s still not the same as working with individuals to find what works best for them. It seems that some doctors (not all) can’t give up their habits of bullying patients for their own good. They’re still treating numbers instead of people.

So with new guidelines saying older people should have a target A1C of 7.5% or 8%, somehow older people who are managing quite well with A1Cs in the 6% range are being told they must raise them. I don’t know how widespread this practice is, but I have heard about it from two different readers in different parts of the country.

I wonder just HOW they want people to raise their numbers. Eat more cake? Stop exercising after meals? What sense does this make? What they usually suggest is lowering insulin doses, which might not be a terrible idea, IF that particular person is dealing with hypos.

Other than that, I think people with diabetes should just let these guidelines go. Focus on healthy living and the things that are working for you. Use the A1C test to monitor how well you’re doing, but don’t trip on a specific number goal. Just live the best life you can.

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