Monday, March 12, 2018

Type 2 Diabetes: New Guidelines Lower Blood Sugar Control Levels

The American College of Physicians have now published their new guidelines regarding the desired blood sugar control levels for people with type 2 diabetes. The recommendations aim to change current therapeutic practices, and doctors should aim for a moderate level of blood sugar when treating their patients.

According to the most recent estimates, almost 30 million people in the United States have type 2 diabetes, which amounts to over 9% of the entire U.S. population.

Once diagnosed with type 2 diabetes, patients are often advised to take what is known as a glycated hemoglobin (HbA1c) test in order to keep blood sugar levels under control. The test averages a person’s blood sugar levels over the past 2 or 3 months, with an HbA1c score of 6.5% indicating diabetes.

But some studies have pointed out that the HbA1c test may currently be overused in the U.S., and they have suggested that such over-testing may lead to over-treating patients with hypoglycemic drugs. These drugs often have a range of side effects, such as gastrointestinal problems, excessively low blood sugar, weight gain, and even congestive heart failure. Additionally, as some researchers have pointed out, “Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management.”

The existing recommendations of a score of 6.5% - or below 7% - decrease the risk of microvascular complications over time. However, the American College of Physicians (ACP) found that the evidence for such a reduction is “inconsistent.”

As Dr. Jack Ende – the president of the ACP – puts it. “analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7% or less compared to targets of about 8% did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms.” He continues, saying, “The evidence shows that for most people with type 2 diabetes, achieving an A1c between 7 and 8% will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

“However, reducing drug interventions for patients with A1c levels persistently below 6.5%,” Dr. Ende continues, “will reduce unnecessary medication harms, burdens, and costs without negatively impacting the risk of death, heart attacks, strokes, kidney failure, amputations, visual impairment, or painful neuropathy.

My Take:
The A1c is still used by less than half the physician in the U.S. to diagnose diabetes. That’s underutilization not overuse. The problem is not the test but the drugs.

If your A1c is less than 6.5%, then there is some emphasis on “reducing drug interventions” through lifestyle modification. However, once you pass the threshold of 6.5%, bring on the drugs and forget diet, exercise and weight loss.

The drugs do help glycemic control for a while but with ever diminishing returns, requiring higher doses and greater side effects. Patients graduate from Metformin, to Metformin and Glyburide, then insulin. Thirty million people being treated for a disease than can be reversed with diet and exercise.

The Bottom Line:
Much like the PSA for prostate health in men, the problem is not the A1c. It’s what physicians do with the test results. My goal with patients is an A1c below 5.7%, a healthy goal. Anything above that level creates microvascular damage, even in the pre-diabetes range.

Source: National Institutes of Health March 6, 2018

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