I wonder if anyone can help me or direct me to help. The more I look into diabetes the more confused I get. My doctor wants me between a 6 and a 7, but lately tells me 6.5. I have read on various sites that a 6.5 is great for a diabetic. Now reading through the post on the Forum I notice that under 6 is best.. What should I be aiming at. At my last appointment my doctor told me that at a 6.5 I need insulin but the appointment before that he said I was doing great at 6.4. Any insite would be appreciated.
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As MCS said we all have our different goals. A normal non diabetic will have an HbA1c of 4.0-low to mid 5's. So many of us feel that if we can get close to normal that is the best approach. The American Diabetes Association recomends an HbA1c of 7.0. But that is an average bg of 154, which many of us think is way too high. A 6.5 is an average bg of 140 which I still think is high. Many think damage starts at 140. So if your average is 140 there may be many hours that you are over 140. So I would say 6.5 should be the highest you ever go. I really don't consider it good control. The closer you can get to 6 or under, the better. The higher your HbA1c's the more drugs or eventually insulin you will have to use.
At the present time, my goal is to stay under 6, and the lower the better. My first A1C was 6.9 which I was told was too low for diagnosis, but it went some distance explaining why my feet were getting numb, so I came home and dropped it as fast as I could. I did have the Atkins 'flu' for a week or so, but I've got it down and staying there for now!
As always, YMMV, but that's MY personal goal.
As always, YMMV, but that's MY personal goal.
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In my experiences, the goal should be to keep blood sugars in the normal range, with the only concern being with the elderly and people who perhaps aren't particularly able to sense if they're getting too low. The risk of a hypoglycemic incident (fainting, falling as a result of the brain not getting enough sugar) is very real among those who might be experiencing dementia or other "awareness-impairing" conditions.
I'm at 6 right now, but am aiming for lower. My understanding at the beginning was that doc wanted me under 6, so when I mentioned to him last week that I'm still working for a lower number, he said he's happy with 6. Well - that computes to 125 (6.9) average & I think that's too high - there's just no wiggle room. Besides which, there's no good excuse for a double standard - as jwags says, non-diabetic people carry 4s & 5s, and we can too - while also keeping in mind NB's cautions about lows in certain patients.
I define good bg control as having pretty stable bgs most of the day. That means no highs and no lows. If you are on some medication or insulins and often have lows you may need to keep them a little higher. But most Type 2's don't suffer lows if they eat on a regular time schedule. Also maintaining a good HbA1c does require lots of testing especially in the beginning so you know what food you should avoid. I had a doctor once tell me everything you eat will spike you. But some things spike you 10 points while other things spike you 100 points.
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Most doctors are looking for an HbA1c target that is simply 7% or under. I'm actually pleased yours is considering insulin-therapy at a 6.5% level - insulin is a healthy substance and not something anyone should ever be afraid of, if they need it.
The reason for this figure is the ADA (as well as CDA- Canadian Diabetes Association) both recommend this figure as a target for control.
HOWEVER in their own management guides (for doctors, which I've read) they do state that the only reason for not targeting lower than 7% is there is a slightly increased risk of hypoglycemia when therapeutically targeting for lower than 7%.
The risk of a non-insulin dependent diabetic going into hypoglycemia is very rare. However there are some glucose-lowering medications (some aren't even diabetes related) and some people who don't quite fit the norms, so it does (though rarely) happen.
They do state in their guides that a target goal for HbA1c should be something determined by both the doctor and the patient, but to ensure things are "simpler" in the clinical environment, they are hesitant to recommend differing figures for differing diabetes types, therapies, etc.
Because of this, they gave a blanket recommendation of 7% for both types of diabetes, and for all diabetics.
The kicker is, any diabetic CAN attain reasonably healthy levels, regardless of their type of diabetes or their various therapies.
Some of us may never attain low 5% values - but many do. I'm trying very hard for something in the 5% range next test. Since diagnosis I've taken mine from a 12.1% to a 7% and then to a 6.0% ... this was done with metformin, low-carb/high-fat diet, regular (daily) exercise and associated weight-loss.
If you're still eating 100g or more of carbohydrate daily, reducing that amount by 1/2 will likely both lower your A1c and help reduce your need for insulin.
Any of us Type 2's not already on insulin may need insulin therapy in the future. Never be worried about that - but it appears that we can put it off longer and longer by reducing our carbohydrate intake, and replacing those reduced calories with healthy fats.
Honestly I love my doctor but may be switching to someone who does want to work as a team.. My doctor never tends to explain his decisions, the reason I am getting confused on this. Actully its never been disscussed with me directly, just do it. He doesn't really want me to test myself either, this I have augured with him and got a meter via insurance. He feels that it isn't nessicarry.. Once I got him to agree on the meter He only wants fasting sugars done. I am doing more, since I need to figure out what is raising my level. Thanks everyone for your help/support.. Its nice to know I'm not in this alone and that others are dealing with the same issues.
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I'm stunned at how many physicians don't want people testing, or fasting-only, or they'll write prescriptions for maximum 2 strips per day, etc.
It's lunacy.
I test fasting, before some meals, after some meals (sometimes twice after meals. Always 2hrs to see if my BG's have normalized, and I will test at the 45 minute mark if it's a 'new-to-me' food), and anytime I feel 'off' - especially now that I know I can hypo. I test during exercise sometimes, just to be safe.
I test on average 5-6 times a day, but as much as 10 times some days, for safety's sake. Once I get used to what's happening with my hypo's I'll hopefully reduce it again. Fingers are sore.
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Yeah, as if testing strips were narcotics and the doc had to write triplicates.
Gingee4k - the endocrinologist I landed with after diagnosis told me to test once/day. Now, if you look in my sig and see my numbers, you'll see I needed to pay a tad more attention than that. I argued, and he relented w/ a script for 2/day. I bought more strips at Amazon and was testing about 6-10x/day and brought my numbers down.
A month later at my follow-up appt, I knew more and spoke more, telling him I wanted him to partner with me, the sort of relationship I wanted to have, and that included supporting my efforts to control my diabetes. He couldn't deny that what I was doing was working. Anyway, I walked away with a script for 4 strips/day, knowing he would be hit by insurance to justify, etc and it would be more work for him. Tough. We ended up with a great rapport at the end of the day.
I think you're exactly right about deciding to switch doctors if you can't get what you need from your current one. We all deserve a doc who respects us as intelligent human beings, and who actually wants us engaged. Our bodies, ourselves. Hey, what a great title for a book!
Gingee4k - the endocrinologist I landed with after diagnosis told me to test once/day. Now, if you look in my sig and see my numbers, you'll see I needed to pay a tad more attention than that. I argued, and he relented w/ a script for 2/day. I bought more strips at Amazon and was testing about 6-10x/day and brought my numbers down.
A month later at my follow-up appt, I knew more and spoke more, telling him I wanted him to partner with me, the sort of relationship I wanted to have, and that included supporting my efforts to control my diabetes. He couldn't deny that what I was doing was working. Anyway, I walked away with a script for 4 strips/day, knowing he would be hit by insurance to justify, etc and it would be more work for him. Tough. We ended up with a great rapport at the end of the day.
I think you're exactly right about deciding to switch doctors if you can't get what you need from your current one. We all deserve a doc who respects us as intelligent human beings, and who actually wants us engaged. Our bodies, ourselves. Hey, what a great title for a book!
G
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·I'm going to disagree with that. There are several common oral medications that can cause hypoglycemia and I don't believe that is a "rare" occurrence.
When I was first diagnosed they had me on Metformin, Actos and Gliburide. I would go hypoglycemic daily unless I ate every two hours. I had a reading as low as 39 once when a meeting ran long kept me from eating for 3 hrs.
After two weeks I told the doctor I wasn't going to take the Actos or Gliburide anymore and see what happens. I had to reduce the amount of carbs I was eating but I was able to manage my fasting numbers with just the metformin.
Several of the guys I work with are diabetic and one of them was also taking actos, he also had problems with frequent hypoglycemia.
Just wanted to let everyone know that I took the advise of all of you... I started a low or no carb diet.. Started with dinner.. my level 2 hours after dinner was 100... I was shocked since I felt crappy and figured it was because I was high not low.. Anyway... thanks... Now if I can get that craving for the Fudge ripple ice cream out of my head.... LOL.
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Well, you are free to disagree. However, the vast majority of non-insulin dependent T2's not on ANOTHER glucose-lowering medication do not suffer from hypoglycemia. Therefore, it's rare.
There are a couple, even on this forum. But very few.
First - I'm stunned that a physician would put you on Met, Actos and Glyburide WITHOUT trying insulin first... Considering insulin is a natural substance with no real side-effect (except possible hypoglycemia and weight-gain, obviously)... To pump someone so full of meds without trying insulin is kinda nuts, imho.
Second, those are ALL glucose-lowering medications. As such, it (hypoglycemia) can happen, which is what I meant. Most T2's are NOT on 3 oral medications for glucose control. Although it happened to you and one person at work, I doubt it happens to other than a small minority of T2's, and the research/statistics bear me out on this.
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·That is not what you said the first time. You didn't say anything about medication, just "non-insulin dependent" and that was the part I disagreed with.
Going hypoglycemic is a COMMON problem for people taking Actos with any other oral diabetic medication.
While taking three oral medications at the same time might be rare, taking two is pretty common, in fact many of the diabetic meds out there are combination drugs containing two or more in the same pill.
The primary side effect of all of the Sulfonylureas type medications is Hypoglycemia.
One of the most common side effects of Meglitinides is Hypoglycemia.
I'm pretty sure there is a reason they call most oral diabetic medications "oral hypoglycemic agents"
As for your claims that all the studies indicate that this is rare, again I'm going to disagree with you:
"Hypoglycemia is more common among type 2 diabetes patients with limited health literacy"
Hypoglycemia is more common among type 2 di... [J Gen Intern Med. 2010] - PubMed - NCBI
"hypoglycemia becomes progressively more common in patients with type 2 diabetes as they approach the insulin-deficient stage of
the disease, when beta cells fail."
"Compared with type 1 diabetes, type 2 diabetes poses a much lower risk of hypoglycemia. However, given the much larger number of patients with type 2 diabetes ... hypoglycemia is a major clinical problem in this population."
Hypoglycemia in diabetes: Common, often unrecognized
www.ccjm.org/content/71/4/335.full.pdf
"Mild hypoglycemia is common among people with type 2 diabetes. "
TYPE 2 DIABETES AND HYPOGLYCEMIA (LOW BLOOD SUGAR/INSULIN SHOCK) | Diabetes Management
So "Severe Hypoglycemia" might be less common amount type 2s than type 1s, but mild to moderate hypoglycemia is more common and given the much larger numbers of type 2s it appears that the total number of type 2s that suffer from mild to sever hypoglycemia is actually higher than type 1s.
You two aren't really disagreeing, the first statement simply forgot to mention OTHER glucose lowering agents besides insulin.
But the fact seems clear that barring chemical intervention actual hypoglycemic incidents are extremely rare to non-existent in T2s. A study which looks at a "population" and doesn't even go into exactly what chemicals they are using is clearly not very illuminating on the matter.
Some can fudge it by referring to "mild hypoglycemia" in T2s, even without meds or insulin. But again we come back to the fact that ACTUAL clinical hypoglycemia which is not caused by exogenous chemicals is extremely rare to non-existent in T2s.
Clinical hypoglycemia is usually defined as 1) BG below 55 or 50 (lower for women) AND 2) accompanied by hypoglycemic symptoms AND 3) rapid reversal of symptoms upon the administration of glucose. All three parts of this "triad" are required.
Those of us who have chosen to address our condition without any exogenous chemicals (or only those which do not directly lower glucose like Metformin) do not need to waste any of our time worrying about "lows". It's a non-issue IMO.
(Unless of course we become anorexic or starve ourselves for some other reason - that could in fact bring on hypoglycemia even in a non-diabetic.)
But the fact seems clear that barring chemical intervention actual hypoglycemic incidents are extremely rare to non-existent in T2s. A study which looks at a "population" and doesn't even go into exactly what chemicals they are using is clearly not very illuminating on the matter.
Some can fudge it by referring to "mild hypoglycemia" in T2s, even without meds or insulin. But again we come back to the fact that ACTUAL clinical hypoglycemia which is not caused by exogenous chemicals is extremely rare to non-existent in T2s.
Clinical hypoglycemia is usually defined as 1) BG below 55 or 50 (lower for women) AND 2) accompanied by hypoglycemic symptoms AND 3) rapid reversal of symptoms upon the administration of glucose. All three parts of this "triad" are required.
Those of us who have chosen to address our condition without any exogenous chemicals (or only those which do not directly lower glucose like Metformin) do not need to waste any of our time worrying about "lows". It's a non-issue IMO.
(Unless of course we become anorexic or starve ourselves for some other reason - that could in fact bring on hypoglycemia even in a non-diabetic.)
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OK, I just don't want to get into another internet argument over hypoglycemia or what each of us said, like what happened with salim a while ago...
But, I *DID* mention medication (and so I do feel justified in explaining myself)... Exactly what I said WAS:
So yes, I did mention more than just insulin-dependence - mentioning medications specifically. I felt my statement should have implied, and I hoped people would infer, that what I mean was exclusive of those not on another glucose-lowering medication. However, you cannot always clearly state all your intentions and beliefs in one post.
As for hypoglycemia being "rare" among T2's ... I guess this depends on your definition of "rare". (Although clinically, it's certainly RARE, which I'll go on to show in just a moment if you continue patiently reading.)
To me, even though I can get hypoglycemic, it's rare. Usually I hit around a 4.0 - 4.5 mmol/l (about 72 - 81) and my liver releases more glucose. However, there are times it just keeps going down, especially if I don't eat at minimum of every 3-4 hours and I've been exercising a lot in addition to my low-carb diet. So it's not always happening to me, and I'm one of the T2's that is on a particular medication (not even diabetes-related) that makes it so I CAN experience it. If I eat properly, it will be a rare occurrence.
The research you link to just further proves my point. The first is specific to only certain segments of the T2 population - those "with limited health literacy". As such, it's a small segment of the T2 population - indicating the event is not commonplace among all T2's.
The second article clearly states...
"In type 2 diabetes, severe hypoglycemia appears to be much less common, but when patients with type 2 diabetes receive insulin they may become as susceptible to hypoglycemia as patients with type 1 diabetes."
...further proving my point. Also, the fact that they call it a "major clinical problem" doesn't make it "common" in type 2's, just perhaps common in a clinical setting (IE: doctors offices, emergency rooms, etc.).
The third article states:
"One of the most common causes of hypoglycemia is injecting too much insulin. People with diabetes who inject insulin are at high risk of developing hypoglycemia. But anyone with diabetes using hypoglycemic (blood sugar lowering) medications needs to watch for signs of hypoglycemia."
... again, proving my point. Also, nowhere on this article does it state hypoglycemia is a common condition among T2 diabetics.
Now here's why I state it's rare...
From this article:
"Results: We studied 1055 patients. Prevalence of hypoglycemic symptoms was 12% (9/76) for patients treated with diet alone, 16% (56/346) for those using oral agents alone, and 30% (193/633) for those using any insulin (P,.001). Severe hypoglycemia occurred in only 5 patients (0.5%), all using insulin."
*Note, this is a cut/paste from the full article, not from the abstract linked to above. I actually go crazy and purchase full articles to read...
*Note, this is a cut/paste from the full article, not from the abstract linked to above. I actually go crazy and purchase full articles to read...
Less than 1/2 of one percent of Type 2's in their survey experienced severe hypoglycemia - thus making it extremely rare.
... many people confuse hypoglycemic SYMPTOMS with hypoglycemia (a severe, dangerous medical condition), and they are not the same thing. Even if you choose to use the data for those that only experienced symptoms (12% and 16% for the two non-insulin groups), we're still looking at it NOT being a commonplace occurrence.
That report concluded with:
"Mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. "
Aggressive Diabetes Management, according to both the IDF (International Diabetes Federation) and the AACE (American Association of Clinical Endocrinologists) is generally described as much lower targets than the current recommendations, and includes (especially in studies) multiple glucose-lowering agents as well as insulin therapy. (Somebody needs to tell them to try lowering carbohydrate first ....)
Another study (published by the AACE) on hypoglycemia in NIDDM (Non-Insulin-Dependent Diabetes Mellitus) goes on to say:
"Results: Of the 262 study participants interviewed, 172 insulin-using and 90 sulfonylurea-using patients were asked whether they had ever had hypoglycemia severe enough to require the assistance of another person. Of the 90 sulfonylurea-treated patients with NIDDM, 3 (3.3%) reported experiencing severe hypoglycemia on one occasion only. Of the 172 insulin-utilizing patients, 13 (7.6%) had had severe hypoglycemic episodes"
And those ARE for those on both Insulin-therapy AND sulfonylureas. Those numbers are not what we'd call "common". The risk of severe hypoglycemia is still rare.
They also concluded:
"On the basis of this study, we conclude that severe hypoglycemia is extremely uncommon in NIDDM. When it occurs, it is usually accidental and seldom recurs. Patients with multiple bouts of severe hypoglycemia have almost complete insulin deficiency. Thus, aggressive treatment of NIDDM to avoid diabetic complications is rarely associated with severe hypoglycemia and is usually well tolerated."
Like I said, I don't really want to get into an argument here. I've spent a lot of time researching this disease, and I can provide article after article to back me up, whereas it's my opinion that what you've provided doesn't back up your statements.
You are entitled to your belief, but even if a primary side-effect of sulfonylureas is hypoglycemia, it doesn't change the fact that all the research and evidence states that severe hypoglycemia in a Type 2 is rare. EVEN if they're on sulfonylureas or any other glucose-lowering agent.
Edit: Also, when you state...
Just because there are more Type 2's than Type 1's, it doesn't make it common among the Type 2's. Hypoglycemia, even mild symptoms, is still rare, unless you consider 12% and 16% occurrence to be commonplace.
Another EDIT: And with that, I believe we've most certainly hijacked this thread on A1c targets enough, oops. I suggest if we want to continue a respectful debate, we do it in our own thread, if that's ok.
I think it's an exercise in risk management. My endo say's we should get the A1C as normal as possible, as long as I'm not going low. I started out 12.5 in June, at last check 6.0. I expect to be 5.x next time. That said, I'm honeymooning and things are relatively easy for now. When/if things get more volatile, I'll adjust my goals accordingly. Do not hesitate to switch to another endo until you find that you're happy with!
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