Doctors’ Group Issues Controversial Type 2 Diabetes Guidelines: What You Need to Know

When you have diabetes, it is always important to “stay in the know.” Taking care of yourself means knowing your blood glucose targets and the results of an important blood test called hemoglobin A1c, or HbA1c. The HbA1c test is reported as a percentage and measures your average blood glucose for the previous two to three months. So, for example, if your HbA1c is 7%, your estimated average blood glucose over the most recent two to three months is 154 mg/dl. Your diabetes care provider will usually order this test every three to six months. That way, you will know your average blood glucose over the past year.

This month, the American College of Physicians (ACP) issued recommendations that in most non-pregnant adults with Type 2 diabetes, physicians should aim for an HbA1c range of 7% to 8%, which is an average blood glucose of 154 mg/dl to 183 mg/dl. The ACP cited the risk for hypoglycemia (low blood glucose) out of concern that hypoglycemia may lead to a somewhat higher risk of premature (early) death or be the result of aggressive treatment for diabetes.

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In contrast, the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the American Association of Diabetes Educators (AADE), and the Endocrine Society strongly disagree with the ACP recommendations. The concern stems from the suggestion by the ACP that the 7% to 8% range is appropriate for the majority of adults with Type 2 diabetes. The ADA, AACE, AADE, and the Endocrine Society advocate for an HbA1c of less than 7% in non-pregnant adults with diabetes. These organizations have guidelines and recommendations that are based on years of research in people with Type 2 diabetes. Serious complications such as heart disease (cardiovascular disease), eye disease (retinopathy), kidney disease (nephropathy), and amputations can result from elevated HbA1c levels. In fact, for each percentage point of HbA1c above normal, the risk for such complications goes up. Consideration of the risk of these complications is essential to the HbA1c recommendation in patients. Additionally, diabetes care providers have a number of treatment options for Type 2 diabetes that can assist with minimizing the risk for hypoglycemia.

The bottom line is that you need to stay well informed. All physicians and diabetes care providers agree that your treatment plan should be individualized. The Institute for Healthcare Improvement (IHI) recommends that you ask three specific questions of your health-care providers to better understand your health conditions and what you need to do to stay healthy:

1. What is my main problem? Relative to this discussion, your diabetes;

2. What do I need to do? In this case, keep your blood glucose levels under the best possible control;

3. Why is it important for me to do this? To understand that your health is important, both short-term and long-term.

Your diabetes care provider’s clinical judgement is important to your diabetes health. Make sure you understand where you stand with respect to your diabetes control and any risks that are specific to you. And never be shy about asking why.

Laura Hieronymus is a doctor of nursing practice and master licensed diabetes educator. She is associate director at the Barnstable Brown Diabetes Center. John Fowlkes is a physician and pediatric endocrinologist. He is the director at the Barnstable Brown Diabetes Center. They are at UK HealthCare at the University of Kentucky in Lexington, Kentucky.

Want to learn more about HbA1c? Read “H-B-A-1-C: What It Is and Why It Matters” and “What Does A1C Stand For?”

  • Gordon Morrison

    My main problem with the A1c number is that everyone says it is an average blood sugar reading for months or even 1 year. How can you measure an “average over time” with ONE READING????? It is really my blood sugar reading at that one moment in time.

    • RAWLCM

      The short answer is that your body produces blood cells all the time, and they live a few months. At any given point in time there are cells of varying ages present in your blood -sort of like multiple generations of a family living together. The A1c blood test can tell how much glucose a given cell has, and how old it is. They check the values of a number of cells of specific ages, and do the math to get an average. So although it is “one reading” it’s actually reading the values of many different blood cells.

  • mick koz

    “So, for example, if your HbA1c is 7%, your estimated average blood glucose over the most recent two to three months is 154 mg/dl. Your diabetes care provider will usually order this test every three to six months. That way, you will know your average blood glucose over the past year.”

    Dr Richard Bernstein’s A1c table indicates an avg blood glucose of 154 at 6.5 A1c and the conversion from 7.0 A1c to be 172.

    Who’s correct.

    I have been an acolyte of Dr. B for the past 10 years, and so far all of his treatment modalities have consistently been most beneficial, even those in direct contradiction with the ADA.

    Frankly, I would take Dr Bernstein’s treatment protocol over the ADA every time. This is the same ADA that at one time advocated a high carbohydrate diet? Rest my case. When I radically reduced by carb intake my blood glucose began to be controlled.

    With daily levemir injections of about 50u/day after almost 10 years struggling with just oral meds (metformin and glipizide) I now have ‘near’ normal blood glucose meter reading and A1c of less than 7.0

    Dr Bernstein’s insistence glipizide and other sulfonylureas only serve to deplete the efficacy of production of insulin and should not be considered a long term treatment. I can personally attest to his wisdom.

    Mi dos pesos (.0002US)

  • Gordon Morrison

    I have a problem with the A1c reading. It says it is an average for the previous 2 month to 3 months. How you get an AVERAGE using one reading? The definition of an average is done by adding 2 or more numbers together and dividing by the number of numbers you have. They do not even take your previous reading and your newest reading and average them. Aic is not an average since you have to have at least 2 numbers to make an average. A1c is an instantaneous reading for that moment in time. They say 7 to 8% is 154 to 183 mg/dl. But it can not be an average. Just the reading and that moment in time.

    • IrishKing

      Gord, Gord, Gord…. You need to read up on how a single A1c test is able to measure the blood sugar levels of the previous three months. Thanks to medical science it’s sophisticated enough to do that. Having said that, bear in mind that the most recent thirty days are more heavily weighted than the previous thirty and the weight of the first thirty has less impact on the final number than the following time periods. It’s not the same as using your blood monitor that you use at home to measure one drop of blood for an immediate assessment. Read up bro.

    • anne_c

      Not quite. The A1C is one reading, but corresponds to a mean blood glucose. This is because the blood cells in that sample are anywhere from 0-120 days old, which is the life of a red cell. Since many different cells are being evaluated, that’s how it’s possible to get a mean.

  • Donald Morgan

    As soon as I saw the unbelievable new recommendation, I was more than shocked. I am a former victim of type 2 diabetes and suggesting a A!C between 7-8 is irresponsible. I hope to see an detraction of this dangerous suggestion!