Yet another DSN who isn't a lot of use

[Grazer]

Interesting Zoroaster
Malc

 

[noblehead]

Because of risk, targets should vary according to meds and other criteria

My own diabetes clinic sets targets individually based on what you've wrote above, let's say for example a type 1 using insulin who has family around them can aim for a lower figure than the NICE guidelines, however someone who lives alone and uses insulin may want to keep to the NICE guidelines for fear of going hypo and not having anyone around to assist. Also whether one regonises the symptoms of hypoglycemia is another major factor in determining a realistic figure one should aim for.

Nigel

 

[Snodger]

Personal targets aside, can anyone cite me some solid evidence for asking non-pregnant T1s to maintain an HbA1c of lower than 7.2% - ? (the level achieved for a short while by the lower-risk, better-control group in the DCCT).
I'm not stirring, I'm genuinely interested for my studies as well as for for me personally.

 

[Pneu]

I keep getting drawn into this one!

What the NHS should be saying is hey... this is what you need to achieve to ensure you have as little risk as possible of developing complications... that needs of course to be assessed on a case by case bases and weighted up against the risk of hypo's in t1's, but lets assume that's say under 6.5% HbA1c...

Now yes that's going to mean that more people miss the target... but at-least those people will have the right information to make a decision.. and if I miss 6.5% by 2% then that's better than missing 7.5% or 8.5% or as advertised in my local diabetes centre 9% by 2%!

Frankly I would rather feel bad for missing a target and go on to achieve better control, than have to have an amputation, lose my sight, have a stroke, heart problems, etc.. which lets not kid ourselves is the outcome for long term poorly controlled diabetics, T1's especilly...

 

[Pneu]

Personal targets aside, can anyone cite me some solid evidence for asking non-pregnant T1s to maintain an HbA1c of lower than 7.2% - ? (the level achieved for a short while by the lower-risk, better-control group in the DCCT).
I'm not stirring, I'm genuinely interested for my studies as well as for for me personally.

I don't have them to hand as I am at work.. but..

what I will say is that if your body could operate happily at an HbA1c of 7%, 8% etc... then why does a non-diabetic operate at 4-5% HbA1c? I don't think may people would argue that being over weight is unhealthy and that we should all try and maintain a 'normal' healthy weight.. yet saying you should try and maintain a normal HbA1c is terrible?

 

[Sid Bonkers]

What the NHS should be saying is hey... this is what you need to achieve to ensure you have as little risk as possible of developing complications... that needs of course to be assessed on a case by case bases but lets assume that's say under 6.5% HbA1c...

Its important not to loose site of the 70% figure I quoted Pneu. I read somewhere * that 60% of T2 diabetics will suffer some form of complication prior to diagnosis, now I can't help wondering where the other diabetic complications come from, the 30% who achieve the NICE recommendations or the 70% who dont?

Now if like me you reach the conclusion that they would be most likely to come from the 70% then is it not also reasonable to assume that the NICE recommendations are not that far out?


* OK no source linked but if anyone wants a link I'll go find one.

 

[Pneu]

Just because something is hard doesn't mean it shouldn't at least be strived for...

I am not arguing that 70% miss the current guidelines frankly I think that's abhorrent and a ticking timebomb reference cost to the NHS... does it matter if that 70% is actually 80% if we drop the number.. not really the cost will be the same if people achieve the same results..

What I am arguing for is more transparency reference the complications and the targets people need to achieve so that they can make an informed decision to try and improve their diabetes management. This isn't going to happen if target numbers are sugar coated to make them easy to achieve.

 

[pianoman]

I'm joining the conversation late so apologies if this was already covered but I suspect the A1c guidelines are high with respect to safety margins and avoiding hypos: high BGs cause complications in the long-term but hypos (when driving for example) can be fatal. Given the older style insulins and pre insulin-pump days there was less flexibility so it was probably deemed safer to err on the side of caution.

Cynically I might also suggest that litigation-wise if an HCP prescribes an approach which results in hypos next week they may face more trouble than an approach that may lead to neuropathy 5 or 10 years later.

That said I also aim (not always successfully) to have as normal BGs as possible... so long as it is safe and reasonable to do so.

It frustrates me that with Diabetes we are held to higher standards for BP and Cholesterol but BGs are somehow OK at higher than normal levels -- almost as if there is a "normal-normal" BG range and a "diabetic-normal" BG range -- meantime I have found that the steps I take to control my BG, have brought my BP and cholesterol back into line as well.

I also agree about informed decision and not setting-up people to fail... it can become a self-fulfilling prophecy when HCPs don't expect too much of their Type 2 patients.

 

[Patch]

Nice post, pianoman.

Cynically I might also suggest that litigation-wise if an HCP prescribes an approach which results in hypos next week they may face more trouble than an approach that may lead to neuropathy 5 or 10 years later.

I suspect this has much more to do with it than they'd like to admit.

 

[Snodger]

Personal targets aside, can anyone cite me some solid evidence for asking non-pregnant T1s to maintain an HbA1c of lower than 7.2% - ? (the level achieved for a short while by the lower-risk, better-control group in the DCCT).
I'm not stirring, I'm genuinely interested for my studies as well as for for me personally.

I don't have them to hand as I am at work.. but..

what I will say is that if your body could operate happily at an HbA1c of 7%, 8% etc... then why does a non-diabetic operate at 4-5% HbA1c? I don't think may people would argue that being over weight is unhealthy and that we should all try and maintain a 'normal' healthy weight.. yet saying you should try and maintain a normal HbA1c is terrible?

Would be great if you could find them, I'd be really grateful.
If you can achieve a normal hba1c without harming your health and quality of life, of course that's not terrible - it's fantastic, well done, and congratulations. But what I'm saying is that for type 1s (I know nothing about t2, none of what I say applies there) getting to normal bg is not as straightforward. We start to lose our hypo symptoms, which is extremely disabling, and we get severe hypos, which are dangerous as well as terrifying.
In the DCCT the people who got to 7.2 (NB NOT normal, 7.2) got 3 x as many severe hypos - i.e. actual coma - than the control population. Severe hypos kill. Even in the 2002 DAFNE evaluation, where they said they had got people to reduce HbA1c without an increase in hypos, they only got HbA1c down to 8.4 AND they conveniently failed to include one of the study subjects who had died from unexplained 'dead in bed' syndrome. Dead in bed in a T1 usually means severe hypo (not me saying that, but 2003 NICE guidelines' comment on the DAFNE study).
We know from the DCCT that getting your HBA1c down to 7.2 for a few years can reduce your risk of long term complications. NB Few people in the DCCT trial could keep that up after the trial ended, and their risk of long-term complications remained lower - so actually it looks as though even a short term dip in HbA1c reduces risk of retinopathy, neuropathy and nephropathy. But as I say, they were going into coma 3 times more than usual!
I can also find you trials which show that depression is higher in T1s with lower hba1c (presumably because it's so hard to get the bg down).
These are serious complications just as much as the -opathies. I find it so weird that the medical profession only really focuses on the long-term complications.

Incidentally, trials suggest that some bits of the body CAN thrive at a higher bg - for example, there doesn't seem to be much benefit in reducing hba1c below 8 when it comes to risk of neuropathy. And if you think about it, lots of other bits of the body are fine with moderately high bg; it doesn't affect every single cell. (Eg at hba1c of say 9, your hair and nails don't fall out, you still get periods, you probably aren't even thirsty). But yes, it looks as though retinas etc don't like high blood sugars, fair enough. Unfortunately, my brain doesn't like low blood sugars...

So in short, yes, it would be lovely if T1s could easily get their bgs down like T2s do, without suffering any bad effects. But what I'm objecting to is the fact that severely disabling and even lethal side-effects of low hba1c are just brushed under the carpet. Normoglycaemia is not this golden risk-free target for us.

Sorry for the long rant... I'll go off and look at owls again.

 

[Dillinger]

It's very difficult as a Type 1 to get low a HbA1c if you are just upping the insulin.

It's however very easy if you drop the carbs; there is an element of lost hypo awareness, but this is more than made up for by the fact that your blood sugars are not wildly fluctuating. The body after is most sensitive to change; if you are constantly running low/normal blood sugars then a slight drop won't be as noticeable compared to people running at twice the normal levels.

The ACCORD (for Type 2) and DCCT (for Type 1) trials where first and foremost about intensive medication to bring down blood sugars. That is not the only way; or the sensible way.

The reason that there are a paucity of studies on this is probably that there is no financial incentive to fund a study that merely reduces carbohydrate; what drug company would ever improve its bottom line as a result? As in so many things in life, alas, you have to follow the money.

However, think about the tight blood sugar control that a non-diabetic exhibits; evolution does not mess around - homeostasis is an 'expensive' procedure from the long view of evolution; if it were not necessary there would be widely fluctuating blood sugars in healthy people, but there are not. Non diabetic people have a very limited spectrum of blood sugar ranges with corresponding HbA1C’s of 3.5-5.5%.

The fact that the damage from high blood sugar levels builds up over years is why they are particularly damaging; they creep along damaging every cell in your body and for days and days and months and months you don't notice it. Until one day you have reached a point of no return.

My current HbA1c is 6.2% - I want that lower and am doing all I can do get it down.

Dillinger

 

[jopar]

Patch

Hypo next week could kill you, neuropathy in 5 -10 years time may never happen you've do get time to avoid it.. But you've also got the problem of aggivating any underlying complications such as background retinopathy... Fancy being blind in a week?

Personally more so for the T1 diabetic too much fuss is made over the HbA1c and to the certain extent for the T2 as well...

If you focus too much on the HbA1c that's in 3 months time, you actually stop focusing on what you should be focusing on.. Which is day to day control

It's the control that I have today that will make up my HbA1c in 3 months time and look after today the rest sorts itself out.. Works pretty well as my HbA1c is in the 5% with excellent control, full hypo awareness etc.. But I've not aimed for that figure, just good tight stable control from one day to the next, so minium hypo's and rare high etc..

Perhaps that's the answer getting people to focus on today and not what is going to happen in 3 month's or 5 years time..

 

[noblehead]

I remember Phoenix posting about The Joslin 50 who had a average Hba1c of 7.2 yet most had no complications whatsoever.

I tend to agree with Joper that we should focus on today and not what might be tomorrow, I set out to get my a1c down to the low 6's (currently 6.2) without compromising my hypo awareness or swinging from high to low and vise-versa, I believe I've arrived at a safe limit acceptable to myself and my HCP have no issues as long as my awareness remains intact, what happens tomorrow is any-one's guess but it's important that we don't let diabetes consume our lives and get obsessed with achieving the unachievable.

Nigel

 

[jopar]

It's very difficult as a Type 1 to get low a HbA1c if you are just upping the insulin.

Which ever dietary diet you'll following you always 'topping' up with insulin it's called controlling your blood sugar levels!

It's however very easy if you drop the carbs; there is an element of lost hypo awareness, but this is more than made up for by the fact that your blood sugars are not wildly fluctuating. The body after is most sensitive to change; if you are constantly running low/normal blood sugars then a slight drop won't be as noticeable compared to people running at twice the normal levels.

You've got to be joking,hypo unawareness is not to be treated thriftily at all, one doesn't make the other up, hypo unawareness has a major impact on daily life for the individual and poses an very increased of dying from an hypo, at best one might just lose their driving licence at worst 24/7 carer to provide medical support ASPA because the lower the BG is when the body pegs out the less time their is to insigate medical treatment to prevent death... So you need stable bg's that don't run on the borderline of hypo or creates unhypo unawareness

The ACCORD (for Type 2) and DCCT (for Type 1) trials where first and foremost about intensive medication to bring down blood sugars. That is not the only way; or the sensible way.

The reason that there are a paucity of studies on this is probably that there is no financial incentive to fund a study that merely reduces carbohydrate; what drug company would ever improve its bottom line as a result? As in so many things in life, alas, you have to follow the money.

However, think about the tight blood sugar control that a non-diabetic exhibits; evolution does not mess around - homeostasis is an 'expensive' procedure from the long view of evolution; if it were not necessary there would be widely fluctuating blood sugars in healthy people, but there are not. Non diabetic people have a very limited spectrum of blood sugar ranges with corresponding HbA1C’s of 3.5-5.5%.

Now different sources will differ over this slightly, I watched an interesting ducomentary on Monday night concerning do our building effect us, An experiment was carried out to determine the effect that the ever decreasing sizes of windows that restricts light has on the human body clocl and health... They used the presenter and his flat, the covered his large 50's windows us, so that only the new adverage window area would let in light, he had to stay in his flat for a fortnight, taking a fasting BG every morning, then verious urine samples etc, blood tests, fill out mood charts etc... The blood glucose one was very interesting indeed as he started out with a fasting BG of 5.2 mmol/l by the end of the fortnight this had crept up to 6.8mmol/l putting into border line diabetes but he wasn't a diabetic! Once they processed all the data to get his body clock, it had gone from a 24 hour cycle to and 24.2 hour cycle in just two weeks!

The fact that the damage from high blood sugar levels builds up over years is why they are particularly damaging; they creep along damaging every cell in your body and for days and days and months and months you don't notice it. Until one day you have reached a point of no return.

My current HbA1c is 6.2% - I want that lower and am doing all I can do get it down.

Dillinger

My current HbA1c is 5.8% (due another one, and hopefully be better due to more improvement made a long the way, and no air bubles in pump tubing to shove up the BG) I have full hypo awareness (pick them up around 3.7-3.9mmol/l) I've never aimed to be in the 5% club, just aimed to get stable control from one day to the next, that maintains my hypo awareness and avoid an high (which in my books is in the 7's for myself) I do this on a normal moderate carb diet.. If my HbA1c can in the 6% range I would personally for myself be happy with it, as I'm not willing to compromise my hypo awareness as I'm not willing just yet to hand my driving licence back!

 

[Grazer]

Love the bedside manner

 

[pianoman]

Is hypo-unawareness inevitable in a Type 1 with stable, near-normal BGs or does this vary from person to person?

 

[Pneu]

My current HbA1c is 5.8% (due another one, and hopefully be better due to more improvement made a long the way, and no air bubles in pump tubing to shove up the BG) I have full hypo awareness (pick them up around 3.7-3.9mmol/l) I've never aimed to be in the 5% club, just aimed to get stable control from one day to the next, that maintains my hypo awareness and avoid an high (which in my books is in the 7's for myself) I do this on a normal moderate carb diet.. If my HbA1c can in the 6% range I would personally for myself be happy with it, as I'm not willing to compromise my hypo awareness as I'm not willing just yet to hand my driving licence back!

I can only agree with this... If you look after control today and go from day to day then long term everything else will take care of it's self. I do not think anyone on here would advocate a lack of hypo awareness for improved HbA1c, but consistent and stable control should mean very few hypo's, no server hypo's and good HbA1c.

Personally I have a hypo awareness that kicks in between 3.6 - 4.0 mmol/l depending on the speed of my blood sugar drop and I haven't had a reading bellow 3.3 mmol/l in over a year... consequently I haven't had a reading about 8 mmol/l in a similar time-scale.

I don't think anyone on here is saying that HbA1c's are the be all and end all... but with 70% of people failing to meet the current targets then something must be wrong... the current approach and guidelines can not be working if this is the case. To be honest with the information and equipment that is available these days there is little excuse for poor management in adults. Yes there are going to be some people who have diabetes and other conditions where the other condition take priority... but for Joe Bloggs whose T1 or T2 there should be no reason why with the correct training, information and monitoring that an HbA1c of 7% is not achievable. That says to me that people are not receiving the correct information, training, monitoring, etc... and that the current practice and guidelines are wrong.

 

[Pneu]

Is hypo-unawareness inevitable in a Type 1 with stable, near-normal BGs or does this vary from person to person?

I don't know.. from what I read on here and from personal experience it differs from person - person.. my HbA1c are normally around 5% and I still have a hypo awareness after 2 years + of this level of control... that said there is very little range in my blood sugars between 96% of my last 600 readings (covering the last two months) have been between 4.0 and 5.5 mmol/l.. If my sugars were more erratic I might not notice the subtle changes? I am not sure.

 

[fullfathomfive]

Even if the 'correct information, training, monitoring, etc...' were available and 100% irrefutable, people are still people. They still smoke, drink to excess, fail to attend appointments etc. We all do things that we know are not good for us.

Maybe a lot of people are simply ignoring advice (whether this advice is correct or not).

 

[noblehead]

Is hypo-unawareness inevitable in a Type 1 with stable, near-normal BGs or does this vary from person to person?

I suppose it will vary from person to person to some extent and of course will depend upon what you call ''near-normal''. Pneu says that his/her (sorry not sure) hypo awareness is intact despite having a hba1c of 5 which is excellent stuff, however generally the lower you go the less likely you are to feel the hypo's coming on or are more inclined to lose them altogether.

Nigel