Group Issues Controversial Type 2 Diabetes Guidelines

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.

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?”