Looking for the new recommended standards for BG control

They were just released recently, I think.
I might have seen them here.
I recall reading them, laughing, and saying, “Well, I’ll never meet those standards.”
Then I never looked at them again.

Anybody know where they are posted?

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Is it this from Diabetes Daily?

https://www.diabetesdaily.com/blog/ada-makes-important-updates-to-standards-of-care-adding-time-in-range-and-more-632094/

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Some text from this site:
care.diabetesjournals.org/content/42/8/1593



The primary goal for effective and safe glucose control is to increase the TIR (time in range) while reducing the TBR (time below range).

Really?!? So time above range is less important than time below? :roll_eyes:

It was agreed that CGM-based glycemic targets must be personalized to meet the needs of each individual with diabetes. In addition, the group reached consensus on glycemic cutpoints (a target range of 70–180 mg/dL [3.9–10.0 mmol/L] for individuals with type 1 diabetes and type 2 diabetes

Look at a comparison to illustrate. One person spends a year at 69 (1 point under), and the other spends a year at 181 (1 point over). Who do you think has done more damage to their body? Is this even debatable anymore?

It was agreed that CGM-based glycemic targets must be personalized to meet the needs of each individual with diabetes…and 63–140 mg/dL [3.5–7.8 mmol/L] during pregnancy

See the difference there? When pregnant, suddenly 180 is not good enough. Then it becomes 63-140. That standard would be much better for the entire diabetic population than the 70-180 target.

In both approaches, the first priority is to reduce TBR (time below range) to target levels and then address TIR or TAR (time above range) targets.

What in the world are they doing? Why are they prioritizing it that way? What do you think high BG does to you? If you are not driving, a 60 does nothing to significantly harm you. Spending a lot of time above 200 certainly does.

Over the past several decades, the inordinate fear of hypos by the medical community is driving diabetics in the wrong direction.

Look at this graphic for the target numbers. According to this, you can spend 24% of your time over 180 and you are within target. But spend just 6% below 70, and “Oh no! You are not hitting your targets!”

image

Think about it. They are saying 24% above 180 (which would still be within target) is better than 6% under 70 (which would be out of target).

Absolutely ridiculous.

I am not advocating people spend more time low than they need to. But really, people - high BG is what jacks up your health. They have it backwards.

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Thanks so much, you all !!!
Yes, these the the reports I seek. Published 2019.

Hehehe, dont show these to the Docs, or I will be in trouble.

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Clinical standards for diabetes have always frustrated me. Why should a pregnant woman be considered any differently than any other human? It amuses me that my target range, 65-140 mg/dL, closely matches the pregnancy standard!

The tepid goals that these standards embrace do underwhelm me. But I must remind myself that I am not the typical patient. Clinicians must deal with the reluctance of the typical patient to do whatever it takes to manage diabetes well. To be fair, good diabetes management is hard, and family, work, and other distractions make the job tough. Only one in four T1Ds have an A1c under 7.0%.

So, I see these standards as a reach in the right direction for the entire cohort. I know I continue to live in the skirts of the bell-curve and I can only hope that my clinicians will see my behavior as inspirational and not alarming.

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Terry, that seems unimaginable. I mean, I don’t think your lying to me, but can anybody find the source of the 1/4 stats. It feels nuts.

Yes, the whole thing is a balancing act. But do you think they are too far on the anti-hypo side of the fence?

It blows my mind because their “edges” are so different to me. 70 is practically perfect. 180 is way to high. I would obviously correct a 180, but I would not correct a (flat) 70.

A 70 and a 180 are not even close in terms of damage.

The reason they say 70 is so you don’t go to 55. And that is bothersome.

Say 55, and mean 55!

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I remember seeing this figure at the T1D Exchange but their site has changed and I can’t find it there anymore. Here’s a diaTribe column that covers this issue and their statistics suggest numbers closer to one in five.

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Yes, I often say that clinicians suffer from hyperphobia about hypoglycemia. Their fear of death caused by a severe hypoglycemic incident in one of their patients paralyzes their rational judgement. I’m sure some, if not most of that fear, is driven by their sense of legal vulnerability.

Instead, they should focus their attention on glycemic variability. If they can moderate wildly swinging glucose, then they can help their patients safely lower average blood glucose levels. Some of their more successful patients could help with this project but most docs are just not interested.

I don’t start to feel hypo symptoms until I get to 65 mg/dL. Why would I want to correct a 69 mg/dL and sideways trend?

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@Terry4 , I’m gonna post something. I’m gonna tag you. Can you just give me a ‘like’ so I know you saw it? That would make me feel better, lol.

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I think there is good reason to have a buffer between a clinically significant low (55) and target blood sugar. There are times when my ability to perform tasks is degraded in the low 60s and the tools we have aren’t reliable enough to tell us that the 69 on a CGM isn’t a 61 heading to a 52. In some situations a low blood sugar is an acute risk. I would say that is especially true for the frail elderly for whom a fall can be a disaster.

Having a moderately high blood sugar for a few hours is no fun and does you no good but it is rarely an immediate threat.

Since I’m going to be 70 in December and I often spend more than 1% of my time below 70 I hope they give me extra supplies and tools to keep myself safe :slight_smile:

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Actually, there’s a very good reason for this.

As I understand it, this unborn child (because it’s almost certainly non-diabetic) is able to metabolize the extra sugar that it gets from it’s mother’s bloodstream, so the child actually gains weight in utero. This causes what used to be a common and widespread major risk factor in pregnancy among T1s … the big bad baby.

Ask anyone who has ever given birth if they want to have a 10 to 15 lb baby. It causes a world of trouble for mother and child. T1 moms are still considered high risk, but the ability to closely monitor BGs during pregnancy makes this complication much less common.

I was diagnosed in 1986 (age 21), and I remember being told a few years later that more and more T1 women were able to healthily give birth to normal size babies. Suddenly, we were no longer being told by everyone that we shouldn’t have kids (only by some people :wink: ).

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This is a good point. While the proximate reasons that motivate someone like me to aim for a more normal glucose range are materially different from a pregnant T1D woman, in both situations we each see normal glycemia as protective from bad health outcomes.

There’s a good reason the healthy human glucose metabolism evolved to maintain such tight homeostasis, normal glucose numbers are good for all humans, whether they are pregnant, young or elderly.

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I am learning all these CGM stats too. I am averaging about 88% TIR (70-180), with 7-9% above 180, and 3-5% below 70. Since getting a CGM I’ve never had it say that I am anything other than 0% below 55 (really I might be briefly below 55 but evidently never enough to reach 1%).

I have figured out that Dexcom Clarity will say my hypo risk is “minimal” if my below 70 stats are below 3%. And it will say hypo risk is “low” if my below 70 stats are 4% or 5%.

I myself am comfortable with a 70 cutoff on the low end. When I have good hypo awareness I start to get the bare beginnings of feeling jittery in 70-75 range.

I would never be comfortable driving at a bg of 56. Never ever. I like to be in the 80’s or above.

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Really, @Yve65 !?!?! Thats awful. Never thought about it before. Thanks for that unsettling thought, OMG.

Yes, it also causes heart problems for the unborn child. Both my girls were on the large side for my size, I’m 5’1” and weighed around 115 at the start of pregnancy. Both my girls were over 8 lbs and ended up having an in-depth fetal echocardiogram that lasted around an hour. My OBgyn was constantly upset with my numbers. I saw my endo CDE who would adjust my nasal rates and calm me down weekly from 22 weeks on. My basal & bolus rates changed weekly from 18 weeks on. By the 8th month my carb ratio was like 1:3. When it started out 1:12.

Both girls had low blood sugar immediately after birth and needed formula and to be taken to PICU for a couple of hours for monitoring.

All was fine but the drs were worried they’d have a hole in their hearts. It’s less scary to have babies now, but it’s a lot of work and higher risk. And super hard to achieve those goals for a T1D. Those recommendations are for gestational diabetes too, which is MUCH easier to care for.

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I love the TIR standard. Dexcom and Tidepool reports show I’m well within the standard. So it gives me something to push back on hypo scared endos who don’t like high 4s HbA1C.

This thread started me wondering why I need HbA1C tests. For now, I plan on humoring endos by continuing the tests. But if I can’t find a good endo after I move back to Ohio, I might stop the HbA1C tests.

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It might be an insurance requirement. I’m not sure.

You have an excellent point - what’s the purpose of A1cs with CGM data? I think it is still ordered because SO many people don’t have access to CGM, and although it doesn’t tell the whole picture, it does give an idea of how people are doing. That being said, Dexcom estimates my 3-month average to be around 6.8, but my most recent A1c was 6.2 - so what do I trust?? Obviously the one that gives me more data. Dexcom, hands down.

You should always trust the a1c average. That will be more accurate. CGM averages can be pretty off.