Revision of HBA1c targets?

I seem to have upset people by trying to interpret the cited report. Further comments in blue.

IanD said:

cocacola said:

Can someone please explain this report in plain English?

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But it also showed there was a U-shaped association between increased all-cause mortality above and below an HbA1c of 7.5%. Changes above or below an HbA1c of 7.5% was associated with a greater risk, regardless of whether treatment was intensified with oral hypoglycaemic agents or insulin injections.

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They have found that using high medication to achieve HBA below 7.5 may be counter-productive because of the adverse effects of the medication. At higher HBAs, the adverse effect of diabetes becomes more significant.

I understood that "intensified treatment" implied high medication. If HBAs below 7.5 increase the risk, then non-diabetics & diet/exercise controlled diabetics are also at increased risk.

There is a line of thought that diabetes (particularly T1, with DAFNE) can be controlled by medication, while eating normally. That is where Hana & I & others take issue. A reduced carb diet will not have such adverse effects. Hana's husband has been T1 for many years.

Dose Adjustment For NORMAL Eating. I am not challenging the experts but commenting on the cited study. High BG is bad, & intensified drug treatment to achieve BG<7.5 is also bad. Did the study consider reduced carb, so that BG could be reduced below 7.5 with less intense oral hypoglycaemic agents or insulin injections?

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What are you talking about now?
You aren’t citing the case study at all, you are making assumptions and reference to area’s that the study isn’t citing as part of its remit...

In plain English, the report has looked at out-come of several research projects, compared the results of HbA1c and was there any relationship to outcome... It showed that for those that had aggressive therapy to maintain control that the groups that fell outside a certain range had problems increased death rate... It seems that being over aggressive with medication to lower the patients Hba1c to below a certain target had the adverse effect of maintaining a slightly higher level...

You’ve made two assumptions one being that an aggressive therapy has been instigated purely based on an high carb diet/food intake, that anybody non-diabetic, those who control by diet alone, and even T1’s are all at risk... But if we follow your advice we could lower our medication etc...

How do you know that the amount of oral medication you take isn’t aggressive treatment when you consider the lack of carbs you permit yourself to eat? Virtually no carbs, and having to still take 3x500mg of metformin HbA1c of 5.9%, high A1c’s and a lot of meds for such small amount of carbs...

By the way, I think a few of us would be interested to know what you consider 'normal eating' please explain what you mean by this...

In my books normal eating, is you eat what you choose that suits you, it provides the energy to maintain the body at an ideal weight, taking in consideration of activity levels etc...

We can fight against all kinds of diseases if we have a healthy and immune body. That's why all of us want to become healthy. Others are doing all the best ways just to have it. Working out in the gyms, following balanced diet and taking vitamins are the popular ways.

jopar said:

T2 will always be difficult as in the main it hits later in life, when many life style choose have become ingrained, bad eating habbits are harder to break, it's more diffiuclut to maintain motivation or physically difficult to maintain a good level of exercise there are many factors involved in their outcomes...

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T2 almost always comes down to problems associated with either Leptin or obesity.

can some one tell me what Leptin is because my DB is not caused by obesety as I am more than 1 stone under weight and I have never been over weight in my 66 years

I am type 2 diagnosed October 09 I am lucky enough that I am able to eat carbs without any adverse effects on my readings.
My HBA1c readings have been 5.5% and 5% on one 500g met.
I am not fat but was fat when diagnosed if proved to be true that a higher level is better for my health it just makes everything more confusing.
I am glad of all the years I had eating and drinking anything I wanted I am 53 and feel for the people diagnosed at a young age with either type 1 or 2.
We all just do the best we can and all have different levels of pancreatic function and it is that which dictates our treatment.

For T2s doesn't making a "target" A1c depend on
a) what that individual makes their target and
b) what percentage of functioning beta cells remain on diagnosis?

If I have less functioning beta cells on diagnosis than my neighbour then I suspect that my neighbour could eat far more carbohydrates than I do and still get a better A1c than me.
This is why (and I am begining to hate this catchphrase) we are all different.
It is why I might need 2 x Metformin 500 and my neighbour none.
It might be why my neighbour can have some bread and retain an A1c of 5.1 and me who has none can only get an A1c of 5.3.
Until research can match groups with functioning beta cells, then add in the complications of medication and perhaps a universal diet, can we trully compare anything. Too many variables aren't there?
It is not ever going to happen is it?
So another research project that does nothing to identify anything useful.

Jopar,

You asked me a lot of questions, but I'm not sure you want MY answers.

To go back to the OP, do YOU consider an HBA=7.5 minimum to be generally advisable, regardless of medication & method, including my reduced carb & 2-3 metf daily? I would have to go to the "50% calories from carb" DUK diet that caused the crippling muscle pains. That was with HBA=6.7. I'd have to eat sugar as well to get my HBA to the "safe" minimum level of 7.5. It was 8 on diagnosis. Stopping the metf would be a good start...

No, that study considered "treatment ... intensified with oral hypoglycaemic agents or insulin injections." I do not think anyone would suggest that a low carb diet supported by metf is "intensive treatment." Nor that achieving an HBA in the non-diabetic range but such means increases our risk of
"cardiovascular events" as the cited article implies.

To quote the opening paragraphs of the cited article.

An NHS prescribing advisory body has called for a change in diabetes guidance to include a minimum HbA1c target level, reflecting the weight of trial data suggesting lowering blood sugar below a certain level may harm patients.

The National Prescribing Centre suggests the change may have to be considered in light of mounting evidence that driving levels down to below the 7.5% recommended in the QOF increases the risk of cardiovascular events.

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To quote my comment on that article: "A reduced carb diet will not have such adverse effects." If "normal eating" as in DAFNE requires correcting by insulin for the carbs eaten, then that may be contributing to the problem reported in the article.

If "normal eating" as in DAFNE requires correcting by insulin for the carbs eaten, then that may be contributing to the problem reported in the article.

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Sorry still can't see the relevance. DAFNE as a course is generally only available to type 1. It's techniques are only suitable to a basal bolus regime. Even if on this regime some people (including the DAFNE authorities) feel that as type 2s normally have insulin resistance it wouldn't work so well. Many people with type 2 also need to take much larger doses of insulin. (actually I do know of people with type 2 who sucessfully use MDI and dose adjust but they're not in the UK)

More to the point, given the period of the study I very much doubt many of the people were on a basal bolus regime that they could adapt in this way. They are very much more likely to have been on mixed insulins a couple of times a day and told to take so much insulin at certain times.

Incidently I assume you realise that people with type 1 need insulin even if they don't eat, thats what the basal insulin is for.
Even if they are eating almost no carbs they will need to calculate a bolus dose which accounts for the protein. Fergus in fact uses about the same amount of insulin for his protein breakfast as I do for my porridge.

So, Phoenix, do you think all our HBA targets should be 7.5 rather than below 6, & that we are in danger because of an HBA that approaches non-diabetic levels? Is reduced carbing + metf to achive such levels a risk increasing "intensive treatment?"

As a low carber for three years on no medication I will quite happily stay in the 6 bracket of Hba1c levels. I would certainly resist any suggestion to raise my Hba1c.

If it went lower then that would be OK as well.

Ian my objection was to your comments on insulin and DAFNE and to be honest not relevant to the original topic. Actually I don't consider injected insulin that is used as a replacement for missing natural insulin as a medication in the same way as many other drugs.

In repy to your question. I think that people with diabetes are individuals .
In the case of people with type 2 some will have more than one medical condition ( there are a large number at diagnosis who already have some complications), some might have had really high levels causing glucose toxicity that killed off a large number of beta cells. Some may have extreme insulin resistance to overcome. These people may have to use all sorts of medications including very high doses of insulin. For them aiming for 'normal' levels may be inappropriate/ impossible. I think that in those cases it is probably very important for doctors to take into account the recent spate of trials showing adverse effects at lower HbA1cs.
I would point out that the writers of the lancet study itself said

Whether our data and findings from
the ACCORD study apply to patients with type 1 diabetes
is unclear and needs to be investigated. These data imply
for oral combination therapy that a wide HbA1c range is
safe with respect to all-cause mortality and large-vessel
events, but for insulin-based therapy, a more narrow
range might be desirable.This implication does not
mean that there is unquestionable value in achievement
of present glycaemic targets for reduction of microvascular
disease.

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Of course ten percent or more diagnosed as type 2 probably aren't and will have to use insulin, probably within 6 years of diagnosis
The case of people type 1s is different. For many (most?) a very low HbA1c is totally inappropriate as a guideline, high levels may lead to complications, however any reduction below 7% Hba1c does not reduce the risks by nearly as much as the reduction from higher levels to 7-7,5%. On the other hand the risk of serious hypoglycaemia, or hypo unawareness increases sharply as HBA1c falls below 6.5%.(I am very aware of this one).
Some people may have a small amount of beta function left. This residual function can last a long time as it has been fond in the 50 year medal study. I think (don't know) that I am lucky and this applies to me at the moment and helps me keep a lower A1c. than would be possible or sensible for some others.

I don't know how relivent to this thread this is but.

I read last year that the units for results of HbA1c test are changing. It is going from a % to millimoles per mol (mmol/mol)

From 31 May 2011, HbA1c will be given in millimoles per mol (mmol/mol) instead of as a percentage (%).

To help make this transition as easy as possible, all HbA1c results in the UK will be given in both percentage and mmol/mol from 1 June 2009 until 31 May 2011.

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From diabetes.org.uk/About_us/News_Landing_Page/Change-in-how-HbA1c-results-are-reported/