A new report is challenging decades of diabetes treatment dogma by advising that people with type 2 diabetes should have more relaxed targets for a blood protein used to help monitor blood sugar levels.
Some patients are even advised to “de-intensify” their medication or go off it altogether.
The recommendations from the American College of Physicians (ACP) centers around a protein called hemoglobin HbA1C or “A1C,” which is key in helping people with diabetes to monitor their average blood sugar level. Sugars or glucose bind to hemoglobin as they travel through the bloodstream.
A new look at A1C
For years, the American Diabetes Association (ADA) has recommended that all people with diabetes aim for a target hemoglobin HbA1C level below 7 percent.
Even more stringent, the American Association of Clinical Endocrinologists (AACE) recommends A1C targets below 6.5 percent.
But the recent report from the ACP completely contradicts the ADA and the AACE. It recommends most patients with type 2 diabetes should aim for much higher A1Cs — between 7 and 8 percent.
Your A1C measures the amount of advanced glycogenated end products (AGEs) that have accumulated in your bloodstream during the prior three months.
This measurement is then translated into a person’s average blood sugar level for this time, also known as your estimated average glucose (eAG).
The ACP recommendation works directly against decades’ worth of diabetes education guidelines that suggest an A1C over 7 percent increases a person’s risk of developing diabetes complications such as retinopathy and neuropathy.
People without diabetes generally measure with A1Cs below 5.7, with the healthiest individuals measuring below 5.0 percent, which means blood levels rarely wander out of the 70 to 130 mg/dL range.
For diagnosis, having A1Cs higher than 5.7 is considered prediabetes, and A1Cs at 6.5 or higher is diabetes.
Suggesting people purposefully allow their blood sugars to remain consistently high enough to measure an A1C between 7 to 8 percent translates to blood sugar levels persisting between 150 to 200 mg/dL, well above what’s considered healthy.
However, the ACP is recommending these high blood sugar targets because the evidence suggesting A1Cs in this higher range contribute to complications is “inconsistent” and only seen in patients with an excess of protein in their urine, suggesting preexisting kidney issues.
Instead of focusing on the fear of complications, the ACP’s primary focus is vastly different and centered on patients’ individual needs.
“The ACP recommends that clinicians should personalize goals for blood sugar control in patients with type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care,” explained the report.
Additionally, the ACP is suggesting that patients who have achieved A1C targets below 6.5 percent should actually “de-intensify” their diabetes management by reducing their medication doses or even taking them off one of their medications altogether.
New recommendations may face backlash
Considering how much pride and effort goes into achieving an A1C below 6.5 percent, many people will likely balk at the suggestion that after years of hard work they ought to let their blood sugar rise above traditionally healthy ranges.
“General recommendations like these are of limited value,” said Gary Scheiner, CDE, MS, of Integrated Diabetes Services. “I believe this recommendation in particular fails to individualize care to the patient.”
“Many patients with type 2 diabetes can and should be aiming for tighter control than what is recommended here. Those at low risk of hypoglycemia but high risk of vascular complications would likely benefit from an A1C below 7 percent,” added Scheiner, author of the acclaimed diabetes management guide, “Think Like a Pancreas.”
“In addition,” Scheiner warned, “the day-to-day function of the individual is affected greatly by glucose control, not just long-term health risks. Targeting higher glucose levels limits a person’s ability to perform optimally from a physical, intellectual, and emotional standpoint.”
One aspect of the ACP’s recommendations that may be less controversial is the emphasis that patients with a life expectancy of 10 years or less (who are generally 80 years or older) or people with chronic conditions on top of diabetes, should focus on minimizing high blood sugar symptoms rather than focusing on their A1C levels.
The only exception to their looser guidelines?
People who are managing their type 2 diabetes through diet and lifestyle modifications alone have their blessing to continue aiming for A1C targets below 7 percent.