I am sure some have already seen this latest research and I am also sure that some of you have known for years that the ADA glucose levels for diabetics were to high for good health. I personally made a decision about two years ago when my pill medications stop working and I went on insulin to keep my glucose levels as close to normal as possible, which we all know is sometime very difficult to do. Anyway you need to read this article and believe it.
Most of us are already aware of Jenny Ruhl's work; she's one of us.
Thank you, Bob.
I didn't mean to sound un-appreciative; I'm sure there are people, especially newcomers who haven't read this yet and may be influenced by the ADA and their doctors giving out inadequate expectations
I look to Mother Nature and her exquisitely tight control of blood glucose in a healthy individual. Healthy non-diabetics don't usually exceed 140 mg/dl after meals and usually wake up in the 75-95 mg/dl range.
This is a controversial topic among people with diabetes. I think the ADA blood glucose and A1c goals are too loose. People can do better. When an organization like the ADA puts out mediocre goals, it often gives permission for people to do worse than they otherwise may.
I think carb limitation is an excellent and under-utilzed tactic for controlling BGs. The mainstream medical community and the advocate organizations share responsibility in failing to vigorously embrace this tactic. They have done the diabetic community immeasureable harm in their past rejection of this therapy and only now give begrudging ambivalent endorsement.
Terry I totally agree with your assessment and that is the reason I finally took control of my diabetes on my own three years ago. I now have those numbers that you mentioned in your reply. For two years now I have maintained a 5.1% A1C average, a wake up fasting of less than 100 mg/dl 95% of the time and post meal levels of less than 140 mg/dl. It wasn't easy, but I did it by counting carbs and monitoring my blood sugar levels 24 hours a day with my Dexcom G4 that I actually pay for out of pocket, since my insurance will not cover it. I just wish that I would have been more serious about my diabetes 20 years ago. My doctor was always happy with my control efforts and I was too. I thought I was really doing good with a 6% to 7% A1C average following my Doctor's and the ADA guidelines. Sad.
Doctors, especially endos, underwhelm me with their expectations. Your BG control is stellar, better than I've been able to achieve. Doctors are part of the problem.
Like you, once I took total control and responsibility for my BGs, things got much better. Back in the day when I was eating high carb, I took huge doses of insulin, had volatile high and low BGs, became insulin resistant and put on weight.
I used to take 80 units a day; now I take less than 30 units per day. As time goes by, we'll hear more and more about the downside of hyperinsulemia. I think taking too much insulin is bad for blood vessels and the heart.
For A1c's 5's are better than 6's and 4's are nondiabetic. If you don't obsess on carbs you have a much easier time avoiding hypos. Fewer carbs = less insulin = smaller mistakes.
Terry: I am not disagreeing with your general points, but the idea that healthy non-diabetic people do not usually exceed post-prandial BGs of 140 mg/dl has been superseded by some of the more recent data from trials using CGM on healthy individuals. Transient spikes of 8 or 9 mmol/L (140-160)are routine, particularly after a large ingestion of high GI carbs. The big difference is that in non-diabetic persons, these spikes are short lived and BGs return to the "normal" range within a maximum of a couple of hours (presumably as a consequence of the phase 2 insulin response).
As far as the laxity of the ADA recommendations are concerned, in the UK (where the recommended standards are similar), fewer that 20% of T1s actually achieve HbA1cs below 7.0%. If this were to be lowered to say 6.5% then the proportion that are compliant would fall even further. Real difficulties follow when the great majority of people with a health condition are unable to meet the recommended standards and are then labeled as (or consider themselves to be) failures.
The stats from DCCT and UKPDS suggest that the risks of complications rise by ~40% for each 1% increase in HbA1c. The increased risk of going from 6.0% to 7.0% is statistically significant but it remains quite small in absolute terms (particularly compared to the majority with much higher HbA1Cs). From a public health perspective, what needs to be done is to get the 8 and 9 percenters down to 7.0.
It is also worth pointing out that the linked article cited by the OP is not a new scientific study but a lay overview of existing studies plus some non-reviewed online material. It may or may not be true but it is certainly NOT New Research.
When we talk about these studies of non-diabetics blood sugar we must remember that they are inherently flawed. Remember, a non-diabetic is simply someone not diagnosable as diabetic (or pre-diabetic). Basically anyone having an A1c less than 5.7%. One could easily see how someone with an A1c of 5.7% could have blood sugar excursions up to 8/9 mmol/L, but I wouldn't call that normal. The studies you refer to seem to have included people with A1cs up to 5.6% as non-diabetics.
I agree with you that there is strong evidence that better blood sugar control translates into lower complication rates, but I would beg to differ that it doesn't matter. CVD rates double (100%) for every 1% rise in A1c. Studies seem to show that the first 1% rise in A1c (over normal 5%) actually raises your risk by 236%. Having an A1c of 7% exposes you to nearly 5 times (500%) the risk of CVD. That is by no means insignificant. And keep in mind this is independent of cholesterol. And now that we talk about significant and cholesterol it is important to note that the risk from the most dangerous alarming hair raising levels of cholesterol is only an increased CVD risk of 30-40%. Compare this to your CVD risk from elevated blood sugars and you can see all the deranged effort to control cholesterol seems a waste of time.
And you are right, this blog is like 2 years old and not new, but some of the work he refers to is peer reviewed and nothing is really controversial. It is just that our health system fails to understand and act on it and many people are unable to translate it into personal change.
Even a figure like 5.7% isn't exactly set in stone. I read medical records at work all day and have seen many different clinical standards in use as far as "standard" or "normal" and standards which might prompt some action on the part of the doctors. I'm not dealing with it very much however I can't help but glance at the A1C, along with the broken ankles, dog bites, etc.
Brian - Your point about comparison of people with diabetes to a flawed "normal population" is a valid one. We now live in a culture where our collective blood glucose metabolism has been degraded in a significant way in the last 30 years or so. We know that the drastically increased rates of diabetes and obesity has impacted the normal population.
Instead, we should view normal blood glucose as spread out over a spectrum that includes some significantly compromised metabolisms. Perhaps when using a population to reference to, it should be the active and fit young adult demographic that usually walks around with a BG of 83 mg/dl. I see that metabolism as the gold standard reference, not the fuller demographic with a significant slice already sliding toward diabetes.
Joel - See my comment above to Brian. I think that the "healthy non-diabetic" population that we currently use for comparison has been degraded in the last 30 years by burgeoning rates of blood glucose metabolic impairments short of actual diabetes diagnosis. Our medical establishment has even granted a misleading euphemism of "prediabetes" to a whole swath of people that are, in my mind, actually diabetic.
Terry (and Brian).
There are a number of recent published studies. As you would expect, the authors made efforts to ensure that the participants had "normal" glucose metabolism and to exclude potential undiagnosed T2s or "prediabetics". Therefore I do not accept that the studies are inherently flawed.
One large study from the ADAG group is reported in Borg et al (2010) Diabetologia 53:1608-11 (and see also other smaller scale studies cited in this publication). The authors used 80 subjects. Subject with a FbG of >5.4 were excluded (although the authors did not carry out an OGTT). Subjects were average age 40, mean HbA1c of 5.2 and mean BMI of 25. They wre trackedb y CGM for 3 days.
The bulletpoint take-home results were that 93% of subjects had at least one excursion of >7.8 mmol/L (customarily defined as the top end of the normal range) per 24 h period. The average time spent at >7.8 was 26 mins per day. It is worth noting that 9% of subjects had at least one excursion of >11.1 mmol/L per day and one of >16.7. The authors themselves note that the latter is a likely undiagnosed T2.
HOWEVER, 93% of subjects showed BG excursions to >7.8 mmol/L. Even allowing for the possible inclusion of a few undiagnosed prediabetic subjects, the overwhelming majority would be expected to be "normal". Other smaller scale studies, cited in Borg et al., pre-screened their subjects with quite a severe OGTT but found similar results (excursions to 8 or 9 mmol/L).
It is worth noting that these excursions, although common in non-diabetic subjects, appear to be transient (averge of 26 mins/day at >7.8). It may be that this is the better defining parameter of abnormal glucose homeostasis.
Brian: The figures from UKPDS suggest an increase risk for CHD of around 40% per 1% increase in HbA1c, not 100%. This implies that the risk of going from HbA1c of 5.0% to 7.0% approximately doubles (not a 500% increase). Risk factors for microangiopathy-associated disorders increase by a similar factor. It needs to be noted that UKPDS was a study on T2s and the results may not necessarily hold for T1s. T2D is often associated with abnormal or elevated levels of cholesteerol especially trigycerides that are themselves risk factors for CHD. Thes lipid abnormalities are not a commonplace feature of T1D.
So it is true that reducing BG levels will produce statistically significant reductions in risk and it is up to individuals to aim to mimimize these risks. My point was that setting standards that appear to be unachievable for 90% is likely to be a self-defeating strategy at least in terms of the overall population.
Bernstein would argue that someone with an A1c of 5.4% is already showing abnormal glucose metabolism. I would suggest that young non-diabetics with an A1c < 5% would show virtually no large excursions. The UKPDS looked at HbA1c that were all elevated. Here is a Japanese study that compares the risks against a non-diabetic population, note that the risk is 443% higher in the HbA1c range of 5.5-6.4% and 515% higher for HbA1cs > 6.5%.
I agree that it is inappropriate to have standards given to us as commandments, but as individuals we deserve to have good information so that we can make our own choices. I think most patients are denied good information about the risks. Heck, I've found most doctors have no clue about risks and don't even understand relative and absolute risk.
well said, terry. completely agree!
I think that Joel's point about setting standards "My point was that setting standards that appear to be unachievable for 90% is likely to be a self-defeating strategy at least in terms of the overall population" is a good one but I also think that what needs to be done is, rather than setting a "standard" target, is to re-conceive diabetes as something to be attacked and over which victory can be attained. An improvement of 1% A1C is equally valuable to someone with a 7.0 A1C and a person with an 8.0 A1C, in terms of reduced risk of CVD, retinopathy, neuropathy and all of the other horrors.
On the other hand, the current standards seem to be perpetuate and maybe aggravate the challenges of diabetes in that people who are "ok" at an EAG of 130-140 are still told "you're ok, don't change anything because I'm the doctor and you're ok..." whereas my stumbling path to 5.0ish A1Cs seems to have been simply to try to reach normalish BG, and finding it to be less work than the craziness I used to do! Maybe I was uber-crazy but I recall Clare and Sportster and Terry and some other folks sharing that they have also taken the leap to success, succeeded and are managing very well. Of course, I'd like to think that I'm special in some way however I am very skeptical of any such suggestions which, to the scientific part of my mind means that anyone should be able to do it. The other large cohort of people who are able to tap into "■■■-kicking mode" are D-moms and there are many online examples of D-moms who have found it possible to run their A1C right down for 9 months. We should all keep that in mind as a goal. Maybe longer term if you're not there yet but if you're at 10.0 A1C,work to 9 and then 8 and then 7 and don't pull over and stop, keep driving.
Even if we may disagree about what levels of blood glucose may cause people with diabetes harm, there is one point that we will agree. Blood glucose levels that young, fit, healthy people experience will not do any harm to people with diabetes. Bernstein is absolutely right that we diabetics have a right to these blood glucose levels.
People may think that tight blood glucose control is not attainable by them for any number of reasons. I don't believe that to be true. I know there are exceptions but I think most people with diabetes share way more than they differ. I'm not a big fan of the your diabetes may vary camp. I think variations are the exception, not the rule.
We can do better.
how much does your dexcom g4 cost? how did the dexcom data change your dietary habits? couldn’t you have been successful just by cutting down on carbs and just doing a lot of finger sticks?
I have to agree with Joel in most points. I've been testing many Friends and Family members through the years at their requests. Almost all have had higher than normal blood sugars sometimes before a meal(because they had a pop or other high carbs) and after a high carb meal like Chinese, etc.
My Mom recently was hospitalized with gallbladder problems(which had nothing to do with high blood glucose). Three months earlier after eating a typical meat, gravy, potatoes, vegetable AND chocolate cake, she ran a 9.4mmol/L(169.3). It came down within an hour. This has happened many times before. Last week I specifically asked 2 Specialists if she has Diabetes and they both answered, "No" after reviewing her test results. This is not the first time I have asked one of her Doctors about her possibly being a Diabetic. I am thankful she is not since she hates needles.
Years ago I watched a Documentary by a young Lady and her Physician from the UK on our network. She ate the normal cheeseburger, fries, soda and small dessert. Her blood glucose went to 10.4mmol/L. I was astonished since she was not a Diabetic.
Perhaps more non-Diabetics should monitor their blood sugars. But in all it may mean nothing, since it is not long term highs. It scares me to think that the fast food chains serve meals that are worth 2400 calories a meal when a normal male should eat only 2000 - 2200 calories in a whole day.
I participated in the Diabetes 50+ Years Longevity Study. We received the results and I was surprised to see that the average A1C was 7.6. We are over 365 diabetics with minor or no complications. Way more of the same in the U.S., of course.
I would like to come to an agreement on this site about A1c's and blood glucose meters. Some say their A1c's are 5.3 give or take but then others say that A1c's are inaccurate since the lower blood sugars can be caused by highs and lows. Others go by their blood glucose meter numbers but then we are told that the meters are 15 - 20% higher or lower. So inaccurate. That's been since meters began - inaccuracy. So how are People answering important questions concerning a Person's high and low causes by the Diabetics meters, when they know not what meters they are using since they vary?
Years ago, the 6.0 was a "normal" blood glucose, then 5.7 max was "normal", now 5.4 is "questionable"? Where does it stop??
In all, as usual YDMV, so what is perfect for one is not right for another. Be informed in what numbers and regimes that you are safe with and what you are content living with. Beware the consequences, of the latter. In my case, 6.6 - 5.9, is good for me.