Survival as a function of HbA1c in people with Type 2

[xyzzy]

Pretty grim title and a pretty grim read.

Below is one of a number of links I have found to the article in the threads title. This link provides the most info I've found online as I haven't yet found a site that lets you download the complete study free of charge. The article was originally published in The Lancet as far as I can work out so it has pretty good credentials.

http://www.sciencedirect.com/science/article/pii/S0140673609619693

Basically my interpretation of what the study found (please correct me if you think I'm wrong as I'm no expert) is...

In a survey of 27965 people with Type 2 diabetes who were on more than just taking Metformin (or a single Metformin equivalent drug) and of which 20005 had progressed to taking insulin the best survival rate, they call it Hazard Rate (HR) was found to be in the group who had an HbA1c of about 7.5% (yes SEVEN point FIVE). They state that although survival rates decrease above an HbA1c of 7.5% they also DECREASE for people less than 7.5% as well

They also conclude that within their sample of people, age, sex, smoking status, cholesterol, cardiovascular risk, and general morbidity (generally how ill you are) were also major contributing factors but that there is a definite link between having a too low or too high HbA1c and that if their results are repeated their recommendation would be to alter current guidelines to include a MINIMUM HbA1c recommendation.

Anyone read this before?

 

[Grazer]

There was a previous thread on this. A long one as I recall! Key here i think is that, as your quote showed, the study looked mainly at people who had progressed to insulin or similar meds. The ossue is perhaps that these people are liable to large'ish ups and downs if they try to maintain very low HbA1C's, and perhaps take more medication. My believe is still that if you're maintaining what MUST be healthy levels of HbA1C (because non-diabetics have lower HbA1C's even than the figures mentioned here - 4.6 to 5.5 max normally) by largely diet and exercise, then how can your mortality be worse than having higher HbA1C's? I'd like to see the same study done on people on diet only/Metformin and see the results then. I won't rant on, but this looks like another exercise in re-assuring those who can't rweach lower HbA1C's that it's fine, and stop pestering for more drugs/treatment. Also a bit protectionist as insulin users are at less risk of a hypo if they settle for higher numbers. I don't know much about insulin use, and don't profess to, but I bet a lot on this site wouldn't settle for 7.5!
I'll certainly still be aiming for sub 6!

 

[hanadr]

I truly believe that it's NOT HbA1c, which determines health, but how you achieve that figure. If it were ONLY the number, ALL non-diabeics [who have Hba1cs around 5% would be at risk.
However since there's no medication without risk, using larger doses of multiple drugs is bound to have a payback.
Hana

 

[xyzzy]

Overall I agree Grazer but with basically the same rationale as Hana.

I must admit to being quite shook up when I came across the article as it's patently real science but is opposite to my current plan of getting back to a non diabetic range as quickly as possible. You can't even hide behind the "contributing factors" as if you read it carefully they have been factored into results.

Yet like you I can't see why eating a healthy balanced and moderate to low carb diet and doing reasonable exercise i.e. becoming a more healthy person than I patently was could actually do me harm long term. What the study suggests to me is but this is my opinion only with no scientific basis (did I just write that!):

"Try your best not to have to use more drugs than Metformin for as long as possible"

and

"Be patient and approach your long term BS goals using the most healthy and maybe not the fastest route possible"

of course there will be debate amongst all of us as to what "most healthy" is but each of us must decide that ourselves.

I would like to hear someone like Phoenix's view on this as well as a confirmation that I am roughly interpreting the studies apparent results correctly. Any chance of that Phoenix?

 

[Grazer]

Your two thgoughts are right, and I think actually a similar rationale. YES, stay off other drugs as long as poss. Some drugs stimulate the pancreas into producing more insulin but hasten the demise of the pancreas, but we're talking about achieving lower BGs through diet & exercise, not use of other drugs.
Yes, don't try and get there overnight if your BG was very high to start:- there is evidence I understand that dropping too quick can cause some complications particularly with eyes.
Overall, doesn't take away the theory that as near norm as poss on diet/met and exercise without going mad on things like zero carb diets has got to be what we aim for. Perhaps they're worried about extreme diets like the newcastle experiment?

 

[Etty]

Funding: Eli Lilly and Co.

 

[xyzzy]

Funding: Eli Lilly and Co.

Why is that a bad thing in the context of this study? All they did was take a sample of Type 2 people and saw what HbA1c they were when they died. Don't go much on conspiracy theories myself. The main research seems to have been done by profs and phd students at Cardiff University, pretty normal to get funding from somewhere and I'll bet they would feel really offended if they thought someone thinks they were paid or persuaded to falsify results so please consider that before making accusations of those kinds. If you feel that strongly perhaps you should write your accusation down and send it to the lead professor.

 

[Unbeliever]

Yes, I am pretty sure the oral meds pose a risk in themselves. A friend was diagnosed T2 yeserday and my advice to him was to stay off medication for as long as possible.

I won't bore everyone by re-telling my story of the harm done to me by attempts to reduce my levels oo quickly. I am totally convinced that this not only caused complications but made the condition worse.

I now find myself in a sort of no-man's land. I don;t feel I can do much more with diet and exercise
but would dearly like to drop he Img of glimepiride I am now aking. I am afraid to do so because
the Diabetic police are out there waiting for my levels to rise so that they can put me on insiukin as well as medication. I am convinced this would be a recipe for disaster as I experienced hypos several imes daily with 2mg of glimepiride. I also experienced weight gain as I would with insulin
and I have nightmares about the possible results.

A few years ago I was at the centre of certain hostilities between the opthalmology dept and the Gp about whether or not I should be on insulin.

Even when complications are present it is not necessarily the best thing to force levels down too far.
Unfortunately in the absence of any definite guidelines I have to just go with my own gut feelings.

I just regret hat in the circulstances in which I was diagnosed I was put on medication immediately.

I suppose being a slim T2 they thought there was no point in rying diet and exercise. I know beter now - oo late! In fact, in some ways , I still feel my diagnosis was unfortunate and a disaser for me.

Had I reeived appropriate advice upon diagnosis he past four nightmare years and the prospect of blindness might have been avoided.

I only hope that the new drugs now available will prove to be less lethal- still best avaoided if at all possibe though.

 

[Pneu]

I believe that the sweed's have carried out some further analysis and looked at a number of studies with the general conclusion that the U or J curve observations are unfounded.

Some interesting reading here: http://www.healthcare-bulletin.com/...ascular_Disease__in_Diabetes_Care_-_2011_.pdf

 

[xyzzy]

Thanks, just what I hoped someone would provide. Looks like the Swede's are well ahead again in the research stakes and given the mass of reference data they are using it all looks very reassuring.

I have been extolling their health service regarding carbohydrate intake on the other thread just wish the NHS would catch up and smell the coffee!

Have read the info quite carefully and here are some important points imo

First the really important statement.

A recent observational UK General Practice Research Database
(GPRD) study has reported increased risk of total mortality with
lower HbA1c with lowest risk for HbA1c 7.5%, and also a 49% higher risk of total mortality with insulin treatment versus oral agents however, this was not verified in the NDR study [my highlight], showing no J-shaped risk curve for total mortality in patients treated with insulin or oral agents, and that the increased risk of total mortality with insulin was due almost exclusively to an increased risk of non-CVD mortality

On HbA1c targets...

A reasonable goal for many non-pregnant adults should be <7%.
A lower target can be applied for selected individuals, if achieved
without significant hypoglycemia, including patients with short
diabetes duration and long life expectancy.

That sounds like me and most newly diagnosed people or people who started a sensible low to moderate carb diet whenever the did

On BMI

The BMI goal for patients with type 1 and type 2 should be <25 kg/m

Still a bit of a way to go to 25 but I'm getting there.

On cholesterol

The primary goal for LDL-cholesterol should be <2.5 mmol/ in patients without a history of CVD, while a lower goal of <1.8 mmol/l is
an option in individuals with overt CV

That seems a lot lower target than here in the UK? I wonder if the Swedes own the worlds Simvastatin production!

On blood pressure.

... <135 mmHg based on.... over ...diastolic BP goal
should be <80

Well mine averages around 135/80 so maybe still a bit high.