Disagree with relaxing diabetes standards

1

I’m a registered dietitian and CDE who works in the outpatient setting of a large hospital, primarily in diabetes and weight management. I teach diabetes classes weekly and also counsel people on a 1:1 basis. Recommendations in our handouts and presentations generally fall in line with ADA guidelines, i.e., fasting BG of 70-130, postprandial BG <180 at 1-2 hours, and A1c 6-7%. I think most of these goals are too high, and I tell my patients to aim for postprandial readings <150 and an A1c of 6% or less in most cases in order to reduce their risk for complications. Although not everyone is able to achieve these goals, I believe it’s important to strive for optimal glycemic control, if possible

At a recent department meeting, my supervisor told us that are standards are being relaxed, and that we should now consider an A1c of 7-8% as acceptable control. This equates to an average blood sugar level of 154-183 (other equations for A1c calculation would be even higher than this). I was completely floored. This wasn’t my supervisor’s decision; it came from someone at a higher level. As it was explained to me, the reason for this change is because many of our patients have multiple comorbidities and will be unable to achieve such “tight control.” Well, 180 after meals with an A1c of 6-7% isn’t really tight control in my book! And if one’s average blood sugar is 183, then much of the time he or she is probably well into the 200s. That’s just too high, plain and simple.

I was so upset when I heard about this. Telling people that they’re doing well when their blood sugar levels are placing them at risk for retinopathy, nephropathy, neuropathy, cardiovascular disease, stroke, amputation, etc., is something I just can’t do. I honestly love my job, my coworkers, and my patients, but I refuse to give people a false sense of security. Sure, some will continue to eat whatever they want and be lax with their meds regardless of what I say, but for those truly interested in preventing complications, I want to be there to advise and guide them on successful BG management. And, yes, I am a low to moderate carb advocate (35-120 grams per day; I personally do about 70-90), but I respect those who want to eat more carbs and am very happy to guide them in making better food choices, increasing exercise, timing and dosage of meds, etc.

I wanted you to know that there are dietitians out there who don’t agree with ADA standards and certainly don’t agree with relaxing them any further! BTW, I have been on this site for a while using my real name and have participated in a few threads. But I have also seen lots of posts that I wanted to comment on but didn’t feel comfortable doing so in a public forum with my photo, name, and other identifiable information. I hope you can all understand this and realize that I’m doing my best to effect change in my facility on my own.

Sorry this is so long – brevity was never my strong suit!

2

Thanks, Maurie. It’s my understanding that those deaths were more likely due to worsening health and/or side effects of oral meds rather than improved glycemic control.

3

I’m confident that you will as well :slight_smile:

4

Thanks, Leo and Peetie. My ultimate goal is going into private practice specializing in diabetes management that includes a low-to-moderate carb approach. Someday! :slight_smile:

5

I’ve read lots of stuff challenging the ACCORD study. But the APN at my PCP believes that I shouldn’t try to get my A1c lower because of it. But you know what? She has no control over my diabetes. I’m going to do what I’m going to do. Period.

The people I feel sorriest for is the ones who don’t have the educational background or ability to research for themselves. Who will just blindly follow what they’re told, and faithfully too, and when the complications hit, oh gee, I’m really sorry that happened to you!! Pfeh! as my grandmother used to say!

But I do think there is a time to use professional judgment. If I were terminally ill with cancer, or suffering from dementia, I think I would like to have angel food cake or chocolate ice cream. I won’t live long enough to worry about complications, and if my A1c is high, then so be it. There is a time when daily quality of life is all there is.

And I’m certain that you know the difference, although maybe your colleagues don’t! :frowning:

6

Hi BadMoon,

Yes, the Endocrinologists’ standards are <140 at 2 hours and fasting <110, so why are the American Diabetes Association’s recommendations considerably higher? The American Association of Diabetes Educators textbook “The Art and Science of Diabetes Self-Management Education Desk Reference” clearly states that either set of goals can serve as targets for most people with diabetes. I’ll stick with the lower ones.

I do have a little leeway at work, but it’s difficult. I’m the only dietitian who ever presents LC as an option. The others feel it’s unbalanced and are worried about hypoglycemia. But I’m the only CDE aside from my supervisor, so they don’t argue with me :slight_smile:

As far as success in getting my patients to follow a low or moderate carb diet, well, some of them are able to do it, at least a good portion of the time. Others say they can’t live without having bread, rice, potatoes, etc. every day. I recommend that if they’re going to eat those items they should try to at least limit the quantity, but I find that most have an even harder time with that than not eating them at all.

7

Oh, I’m all for relaxing standards for people with end-stage illnesses, as well as for older people 70+. (although Dr. Bernstein still has amazing control :)) And there are other exceptions as well. But for the majority of PWDs, I think tighter control is better to improve chances for a long and healthy life.

8

I think too that goals should be different for different people. If you are X diabetes, then you should shoot for Y but if you are Z diabetes, you should shoot for Q or whatever. That’s where having goals for everyone doesn’t work. My goal is still to improve, maybe not so much A1C for now, although I suspect it’s gone up a bit with the pump failure and challenges getting the CGM to sync up, but whatever. I try to beat every test. If a number is off, I try to do the best job I can fixing it. The main goal is not to let diabetes get in the way of anything. So far so good on that.

9

Agree about the pregnancy targets. Why is tight control only important during pregnancy? It’s true that hyperglycemia can result in maternal and fetal complications, but it’s also well known that uncontrolled BG can lead to problems in every organ/system regardless of a person’s age, gender, or reproductive status.

Glad your friend has you for guidance! I have patients who come to me with A1cs of 6.5 and higher who tell me that they are only “borderline.”

10

Maurie - part of the reason for increased mortality in that group you mentioned was that they were given Avandia. A drug that’s now been taken off the market due to safety concerns. Read more here

11

Interesting that limiting quantities of fast acting carbs is so hard, This seems to parallel the experience of most who have tried a low carb approach. The carbs in question do have an addicting quality, for many people, and the easier approach, actually, is to just eliminate them. Most peoples experience is that the cravings quickly disappear.

I feel an eat to your meter approach is more powerful, as opposed to a top down carb target. Set a target and then modify your diet to meet that target. Personally, I fought going low carb as I didn’t want to give up bread etc. but over the course of a few weeks of frequent testing it became apparent that It was give up certain foods or raise my targets. As I was unwilling to raise my targets, the course forward was clear, and much easier than I would have thought possible.

Glad you have a little leeway at work, a pragmatic approach is usually superior to a dogmatic one IMHO.

12

Another thing that seems to help is simply treating lows or correcting lower BG more conservatively, w/ like 8G of carbs (store still out of Starburst jelly beans… so I’m on Skittles which have the advantage of being more homogenously sized at 1G of carb…although they are much more prone to drooling if I eat them when I’m running…) instead of the 15/15 mantra that I was taught when I went back in for refresher education before I got my pump in 08. My goal is simply to nudge my BG back to where it’s supposed to be and to avoid going too far, to rush up > 100. Most of the time, a very small corrective dose works. This is with a goal of balance rather than a goal of eating something. While I eat quite a few carbs, I am pretty compulsive about staying balanced while I do it…

13

Every time the ACCORD study has been mentioned, I asked if the person read it & their opinion of the methodology. No doctor or CDE I’ve dealt with actually read it. All they read were the headlines. Of course, they didn’t admit to not doing their homework, but the mumbling & fumbling around & quick topic change made it clear they hadn’t. Rather upsetting that people are advised to raise their A1c based on a terribly flawed study (using subjects with advanced heart disease who were given a risky med cocktail) that wasn’t even read. Scary to consider how often this happens with any medical study.

14

We had a discussion here recently about “limiting” stuff and one of our members, Jean, said she has had a lot of dieticians/CDEs tell her that. Her response was that she has not been able to eat just two Oreos since she was a kid. I am the same way, I do better not having something than trying to limit myself to something.

15

I have had 2 doctors try to tell me that having a normal A1c was bad because of ACCORD.

16

Friend Natalie, Low Carb Dietitian, Help! Dr. Bernstein said PWD’s deserve to have “normal” blood sugars. I’ll bet he’d also say that as people approach 70, go beyond 70, they also deserve normal blood sugars, which means also that such people have a shot at feeling well, functioning as well as possible, enjoying the best health possible. Hey, everybody at every age deserves to feel well! Relax a little on the OCD maybe; daily cake and ice cream–NO! Eating yourself into the grave–NO! OK, rant over–I’m actually enjoying this discussion.

17

It may be different in your line of work, but I see the “little leeway” you describe stretched to the limits everywhere in the diabetes-care world. Take the standard education for the Medtronic CGMS sensors for instance, from CDE’s everywhere, and even Medtronic’s own reps: " You should only use them for three days, (wink, wink) and only in your abdomen (nudge, nudge), although many patients use them at other sites, and they bypass the three-day limit by doing the following … . Of course, it’s not approved (another wink, wink) for use in this manner."

My (non-D) child’s doctor does this too. He’ll tell you what the American Association of Pediatrics suggests for tummy-time, introduction of foods, when to use a forward-facing car seat, etc; but then will tell us, with a wink-wink (followed by a brief legal disclaimer) what his real beliefs are.

18

Re: “brief legal disclaimer” as usual when lawyers enter the picture things get even more complicated. I wonder if you could get sued presenting low carb as an option because the ADA says it’s dangerous?

19

I agree. The worst thing in the world is having doctors and dieticians lecture you for not meeting their target, and ignoring other difficulties you are facing, aside from just food. Everyone’s body is different. If a person is having extreme difficulty meeting a lower target, then they should be congratulated for the target they ARE able to hit. It might seem mean of me, but I often wish ‘healthcare professionals’ were required to have diabetes to teach you how to take care of it. There is no other way to understand how hard it can be to manage a BG that can even go up from stress alone (how the hell can you predict what to compensate for that? and even if you figure it out, some people–like me–have a peak time of 1.5 hours for even humalog…you can’t plan stress!), or fluctuating basal requirements due to what time of the month it is.



I’m not a big fan of the 5% A1C idea, mostly because if I sit at a reading of 5 mmol/L (90 mmol/mg), I will go low almost instantly as soon as I perform any activity, and there is nothing more frustrating than dealing with a difficult life and constantly going low. I am much more comfortable around 6.5-7 mmol/L (117-126) if I can manage to get my reading down to that. It gives me the few minutes to pop some carbs if I need it.

20

Hi Trudy,

Yes, I think it’s great if people 70, 80, 90, and beyond want to continue working toward having exemplary control a la Dr. Bernstein. That’s certainly what I would choose. But I think relaxing the guidelines somewhat for others at that stage is okay. Depends on the person and what their goals and quality of life are.