Blood Glucose Targets

1

Firstly, I'm in England, so subject to the vagaries of The NHS[National Health Service] and NICE[ National Institute of Health and Clinical Excellence!]

We also have the advice of Diabetes UK[ our national diabetes charity]of which I'm a member.

I have a major beef with all of them. TARGETS!!!!

Blood glucose levels and Hba1c levels.

WHY are these so High?

To me it only makes sense that diabetics aim for NORMAL blood sugars[as Bernstein says, we have the right to normal blood sugars]

the targets set by the medical profession are much higher than that. some are double. A normal A1c is around [or below] 5%} so why a 7% target? and non diabetic blood glucose rarely deviates far or for long from around or just below 5mmol/l [90mg/dl]

Especially in the US where a 7% A1c in a new patient allows for a diagnosis of diabetes.

I accept that not everyone can hit the normal levels, but if you were at an archery competition, You wouldn't move the targets to where nearly everyone could hit them.

You would accept the target and work to improve your aim.

That's where I think the Healthcare profession is letting the patients down.

the only reasons for these unhealthy tarets that I can find are to do with protecting the medical profession.

Thus if patients hit the targets as set, and still develop complications, it's bad luck or the normal pattern of the disease. It can't be blamed on their healthcare team.

I do loads of voluntary work and recently at a meeting, I challenged a representative of NICE on this point. He agreed with me. Maybe we'll get somewhere???

My main quarrel with these targets, is not that lots of people can't or won't hit them[over 50% DO NOT in my area], but that loads of people who do, think they are protecting themselves from developing complications. So many who could get nearer to normal levels, don't because they don't know what they are.

Even many Healthcare professionals don't know what they are.

I know that I'm the ONLY patient of my health centre who consistently gets HbA1c results in the 5% range.[of hundreds perhaps a couple of thousand] My nurse says it's patients' choice. It's not if they Don't KNOW. So much for informed consent to treatment.

At an event I attended recently, I met a man diagnosed diabetic[T2} 15 years who is losing his sight and has suffered an amputation of a great toe. His Hba1c have been consistently wihin the targets.

It's these targets too which convince many doctors and diabetic specialist nurses that T2 is inevitably progressive.

Since at an HbA1c of 6.5% it's uncontrolled and uncontrolled diabetes is definitely progressive, they are right. However I'm certain that if diabetes is controlled[and it is possible] it does not need to progress.

Another target I hate ios 4mmol/l [72mg/dl] as a dangerous hypo. Most people can function perfectly well at that level, provided their system isn't used to "running high".

Thus a reading at this level to my mind doesn't need teating unless insulin is still in the process of driving it down. Danger level is much lower, probably below 3 [54] The hypo number and the focus on the danger of hypos takes away attention from the much more common danger of consistently HIGH blood glucose. I have tried to find figures for deaths from hypos, but have failed. I know they are an unpleasant experience, but not nearly as dangerous as some people think.Most hypos are mild and easily corrected.

This is a case where the treatment is the problem not the disease itself.

However deaths from kidney failure or the after effects of amputations are big numbers.

2

Extremely disheartening. I believe that targets are too high in the US, but beyond reason what the UK standards are. I've had discussions with several CDEs who agreed, but quickly added they were taught to set achievable goals for patients. What? Should the role of healthcare professionals to be to decide? The patient needs to have all available information. The gate-keeping of medical info is unethical & unconscionable.

Doctors appear to have hypo phobia everywhere. I'm not suggesting that this isn't a real threat, but for liability reasons many go overboard.

3

(Cont'd. Sorry, comment area bouncing up & down & I couldn't finish below.)

They can't be held accountable for complications from highs & can potentially be held responsible for severe hypo events. Advising patients not to go to bed with BG lower than 150-180 is absurd.

4

I believe most of our British targets are similar to US ones, nowever 150 - 180 are pretty high numbers.

The only way to deal with insulin treatment and high numbers, isthe one taught by Bernstein. If you eat low carb, you need far less insulin and are in less danger from its effects. Hence those high bedtime targets

I'm a T2 on minimal Metformin[2 x 500 pd] and have considered going off it, but since it definitely suppresses Dawn Phenomenon, I'm keeping it for a bit.

Hana

Ps didn't Bernsteein say somewhere that the high numbersw were to protect medics from being sued over deaths from hypo.

I've tried to find figures for such deaths and can't even with the help of David Mendosa and Gary Taubes, I've got nowhere. I don't think these figures are kept.

5

PS a culture of "achievable targets is ridiculous. It's also what is destroying our education system. No kid can fail.

Hana

6

People should be given targets that will promote health. If they can't or won't achieve them that's one thing. The sad part is when someone thinks they are doing OK, folowing their Dr.s advice, and then get hit by complications.

Someone who is web literate and decides to do a little research can at least learn the facts and make their choices. But this profile does not cover a large portion of the diabetic population.

I agree, in the end it's unethical.

I have an acquaintance who was given insulin with absolutely no instruction. Given the dangers Of hypos this seems crazy.

7

I agree 100% that the targets in the 7% range are absurd. It is certainly a lot of work to consistently beat those numbers but the way it worked for me, it was a lot of work even when I blew off going to the doctor for like three years and wasn't 100% sure what my numbers were (5.5 when I finally got in...*whew*. The doc, a GP was amazed but gave me a little "<7%" "medal" some pharmeceutical salesperson had given him a bunch of to pass out?).

I think that some of it is that doctors only see their patients every so often and don't want to, or perhaps are not "allowed" by insurers/ gov't health systems to say "OK, I'm going to have to see you every two weeks for the next 6 months until we get your BG where it will make you feel better". W/ infrequent visits, all a doctor can do is adjust a couple of numbers here and there and maybe improve something and maybe not. While running along in the mid-5s for a few years now (after a >7 excursion too...), all my docs (2 sets, as we moved in 2009) are keen on 'why don't you turn your basal down a bit to get rid of those 70s' instead of 'why don't you get MORE 70s instead of the 80s and 90s?

8

That is a great example! I also agree that comprehensive education, perhaps 'coaching' or 'seminar' might be good words too, is a great idea. I think thought that the benefit of education is limited by the big scheme of the medical industry, where standards are set and doctors are taught what to teach their patients. It seems as if that works from the top down organizationally, which is where the notion that 7% is all what PWD should shoot for seems to come from. I think that a lot of doctors, or at least the ones that don't actively mess up their patients, perhaps like your brother's experience, will run into patients who treat themselves agressively and not only beat the goal but are looking to keep improving. I think that access to assistance would be the big thing for a lot of people and the barriers to that are cost and resources.

9

Hana

NICE has certainly raised the quality indicator upwards from 7%-7.5% following the recent T2 trials. They are frightened of people dying from too aggressive a treatment resulting in deaths.

Two options had been considered: either lowering the DM23 threshold from 40-50% down to 30-45%, or raising the HbA1c target to avoid GPs treating patients too aggressively and putting them at risk of harm – with the latter option preferred by the committee.

Howwever that is the level which GPs are supposed to get a large percentage of patients over to fulfill their quality targets.The actual guidance for treatment was below 6.5% and as far as I can see still stands .(March 2010) This says

When setting a target glycated haemoglobin (HbA1c):

involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with type 2 diabetes in general

encourage the person to maintain their individual target unless the resulting side effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life offer therapy (lifestyle and medication) to help achieve and maintain the HbA1c target level

inform a person with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health

avoid pursuing highly intensive management to levels of less than 6.5%.

Not quite as low as you would like, and I dare say that many docs will use the QFF as their actual target.

10

Oh! I thought that was just another one of the problems my computer was having. Sounds like it's a TuD problem.

11

And so many people have grown up with a special regard and respect for doctors that they think "if he tells me it must be correct" and don't look further. I have a friend whose husband is a type 2 on insulin - NPH BID and only checks his fasting blood sugars, eats whatever he wants. That is what Kaiser (big HMO) told him to do.

12

I a normal hbA1c is 5% ,6.5% as a target is,

therefore,ridiculous, even more so since doctors and other "experts" encourage an "eat what you like and increase the medication" policy.

A controlled carb diet and minimal medication is SAFE, but they don't like it for some reason. I suspect that it would take too much power away from medics and put it into the hands of patients.

The medical profesion is killing diabetics and blaming it on the patients.

13

Believe it or not, there was actually an argument that dropping the NHS blood sugar A1c targets from 7.5% to 7% was actually killing diabetes (http://www.straightstatistics.org/article/how-overtreatment-diabetics-may-have-cost-lives). Of course, what they actually found was that diabetics didn't do well that had been poorly controlled for years, didn't follow any diet or exercise and were then treated with multiple oral medications and insulin mix in a crazed attempt to get their blood sugars down to < 7%. From this we can obviously extrapolate. Right? If the people that work for NHS ever get fired, they could work for the ADA.

14

Lies, damn lies & statistics, right? Geesh. Perfect potential candidates for ADA hires.

15

Believe it or not, but my T1 husband was told by a temporary doctor at the diabetes clinic that "tight contol is dangerous"

If you read the ACCORD study carelessly, it may seem that way, untill you look at the high doses of which medications[including AVANDIA!!!!] which were used.

In any case the ACCORD study only dealt with T2.

However, the medical profession should be utterly ashamed. It's difficult to get to them. Still I am finding chinks and working on exploiting them.

Hana

16

Dear Hana,

I agree with all you've said. At a recent appointment with a diabetes nurse, I was lectured ad infinitum about having too many hypos, and that my HBA1C was too low! The doctor insisted that any improvements in health outcomes below 6.5 were so minute that they were not worth the risk of hypos. She also claimed there was more danger in hypos than highs. I guess she was more concerned about rapid, short-term mortality risk from a hypo, than the long-term, horrible morbidity and mortality from highs. Sigh.

I'm not totally dissing my medical team though; I have to say that at no time did anybody push any sort of diet on me.

17

I am not sure the doctor would actually have any evidence to support that there' 'minute' health benefits because doctors in general are too chicken to study people who have 5.x A1C's because they are nervous that a goal like that would get them sued? I would certainly volunteer for a study like that, mostly because I am curious but I simply don't believe that he can say that. She has no proof whatsoever?

How does that work when you've seen 'a diabetes nurse' who doesn't like what she sees? Does she call the doctor in to yell at you and present their apocryphal evidence to support their opinion?

18

Hi acidrock23, they were both in the room nagging at me. I had brought my blood glucose diary along and the nurse flipped through it and immediately zoomed in on the lows. Thing is, to me, 3.5-4.0 I don't consider lows, but they're all red-flagged in their opinion. Indeed, I was given an Excel template for blood glucose monitoring, and anything below 4.5 was literally flagged in red. Anyway I think my team knows me well enough to know that I pick and choose what to listen to.

19

I moved last year and the new doctor asks more 'are you comfortable with these lows' which I like better than the 'red flag' approach. It's like they don't have anything else to add?

20

Know ing Dr's as I do,and to use an old phrase " There is nothing like God in Health Care like a Doctor. Diabetes is not taught as it should be in med. schools unless they specialize. Give me a health care team whose members are Diabetics and I believe things will change. My PCP has diabetes in her family and she is knowledgeable and listens. My Endo has specialized, I think and is advise to anything new. I will take my PCP over the Endo any time. My target range is an average between 10 days of highs and lows. Every 2 months I average again and adjust my target. My A1c is 5.8% down from 7.1% 4 months ago. Target is 70/120 and rarely use Novolog for correction. Now I need to adjust sliding scale for present weight and carbs. once done, I will work on something else. So THANKS to every one and Dr. B's group for heading me in the right direction.

Former RN