For many people with types 2 diabetes, and their doctors, managing this vexing condition has been all about the numbers. One number, to be precise: the hemoglobin A1c reading. It’s a measure of the average blood sugar level over the preceding three months. New guidelines from the American Diabetes Association (ADA) and European Association for the Study of Diabetes recommend taking a more “patient-centered approach” to managing type 2 diabetes.
Type 2 diabetes occurs when a person’s muscle cells stop responding to insulin, a hormone made by the pancreas. You can think of insulin as a tiny molecular key that opens the door through which glucose (blood sugar) flows into cells. When muscle cells resist insulin’s “open up” signal, glucose builds up in the bloodstream. Over time, this harms tissues throughout the body, from the brain to the toes. It can damage nerves, rob vision, and cause heart disease.
A simple way to check blood sugar is to measure the percentage of hemoglobin molecules (the oxygen-carrying protein in red blood cells) that have become coated with glucose. This is known as the hemoglobin A1c (HbA1c) test. The higher the average daily blood sugar over a three-month period, the higher the HbA1c value.
People who don’t have diabetes have HbA1C readings below 5.7%. For years, the American Diabetes Association recommended that almost everyone with type 2 diabetes should aim for an HbA1c level less than 7%. Keeping blood sugar as low as possible, called “tight control,” was thought to limit the havoc caused by diabetes.
But a series of studies have shown that tight control for people who have had diabetes for many years doesn’t improve quality of life or longevity. And for some people, trying to keep blood sugar low enough to hit the HbA1C target of 7% or lower means experiencing episodes of low blood sugar (hypoglycemia). Hypoglycemia can cause blackouts, seizures and strokes. In older people, frequent bouts of low blood sugar can worsen brain function.
One size doesn’t fit all
The new guidelines acknowledge that people are different. TheADAnow recommends that individuals and their doctors decide together on a blood sugar target.
For people who are newly diagnosed with type 2 diabetes but who are otherwise in good health, the ADA still suggests aiming for tight control. For them, an HbA1C of 6.0% to 6.5% is ideal. This is especially true if the goal can be met with lifestyle changes only (such as losing weight and exercising more), or with lifestyle plus the medication metformin (generic, Glucophage, Fortamet).
For people who have had diabetes for a while, an HbA1c goal of 7.5% to 8.0%, or even higher, may be more appropriate. Reasons for “looser” blood sugar control include:
- Older age
- Frequent bouts of hypoglycemia
- The presence of other medical conditions requiring multiple medicines and needing more than 2 drugs to lower blood sugars
- Limited financial resources
Controlling blood sugar is only one part of managing type 2 diabetes to limit its effects on health. Controlling weight and blood pressure are very important, as are efforts to prevent heart disease, stroke, and kidney disease, all of which can occur as a result of diabetes.
These new patient-centered recommendations are a breath of fresh air. They will be good for people with type2 diabetes and for their doctors. Patient-centered care should be main theme of all health guidelines.