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Permalink Reply by Doris D on May 17, 2012 at 5:08am

Whoops make that more like 15 years Sorry about that

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Permalink Reply by Brian (bsc) on May 17, 2012 at 5:06am

There are no guarantees. This is about statistics. And the statistics are absolutely clear, ever since the DCCT in '93. As your blood sugar rises above about 5.5%, your risk of complications rises exponentially. It doesn't mean you will absolutely get any complication, only that on average people get complications. Non-diabetics get complications and supermen like Richard157 don't get them. But the statistics are clear. If you don't care about complications and you don't care about a shortened life then fine, keep your blood sugar higher. If I found out I had incurable cancer and three months to live, I'd probably be fine walking around at 250 mg/dl all day. But I want to live decades more, so I'll normalize my blood sugar, I'll continue to ignore the ADA and I'll make every effort to give my charitable dollars to organizations that work on my behalf (like the Diabetes Hands Foudation)

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Permalink Reply by still_young_at_heart on May 17, 2012 at 6:18am

Agreed. But another way to say that the risk of complications rises exponetially above 5.5% is that the curve begins to flatten out around 7% which is the reasoning that the original target of 7% was set after the DCCT. Tools have improved since 1993 and it is easier to achieve more aggressive targets but it's still hard work.

The other problem is that achieving tight control for Type 2s using the normal oral drug cocktail approach is probably more dangerous than achieving tight control for Type 1s using a pump or even MDI.

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Permalink Reply by Brian (bsc) on May 17, 2012 at 9:41am

Unfortunately, one aspect of exponential curves is that the scale can make it seem like important and significant risk reduction disappears below 7% and this is not true. Studies such as EPIC-Norfolk showed that statistically significant (and meaningful) risk reductions in retinopathy complications occured all the way down to 5.5%. It is true that the improvement going from say 6% to 5.5% is not as great as going form 7% down to 7.5%, but it is real.

And I don't think that the problem is solely the negative effect of drugs, it is also the encouragement of high carb diets. The ACCORD study had most patients in the intensive arm following a high carb diet, using insulin and medications. This was a recipe for bad outcomes either way.

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Permalink Reply by acidrock23 on May 17, 2012 at 5:29am

I think the main "target" needs to be the American Medical Association as that'd be where insurance companies derive support for the standards of care (sic) they use, although Blue Cross has decided to go a step farther and cite Medicare as justification (sic) for their "obligation" to cover 4x strips/ day. I am not a huge fan of the ADA but have been a member for years and, as a disclaimer, was the centerfold in the April 2011 issue. At the same time, the tightwad in me wonders about a charitible organization maintaining an office on Broadway in downtown Manhattan? There's a centrifuge for some lab tied up in real estate...

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Permalink Reply by Sam Iam on May 17, 2012 at 9:55am

re: centerfold 2011

haha that's awesome. I take back all the bad things I said about them.

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Permalink Reply by BadMoonT2 on May 17, 2012 at 6:35am

Type 2's still making insulin also need to be concerned about further degradation of their capacity to produce insulin by time spent above 140, in addition to other complications. These guidelines are not very helpful in this regard. This is something that happens in the short term as opposed to most of the other complications which happen over the long run.

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Permalink Reply by Sam Iam on May 17, 2012 at 9:21am

It's easy to rail on endlessly against the ADA. If you follow their history, they tend to be wrong about pretty much everything, then gradually take a half step in the right direction, as to not admit wrongdoing.

In their defense, they do conduct an interesting study once in a while. Although generally on small test groups. With flaws of design, and of theoretical, rather than applicable value.

I'm sure at some point the ADA was better than nothing. As pointed out earlier, their BG and A1C targets are, for many of us, a step in the right direction. The problem is that if you follow their other advice (eat plenty of carbs and take lots of insulin), you are bound to spend lots of time unconscious (if not dead) with an A1C under 7.

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Permalink Reply by Tim on May 17, 2012 at 9:52am

Those targets are less than the average diabetic A1C levels right now, for either T1 or T2.

Those targets are not less than the A1C's of the most frequent posters here and other bulletin boards.

I know we have at least one problem you identified, but I look at the above two facts in context and I think there may actually be 2 or even 3 real problems, and those real problems seem way more significant than any ADA press release. Maybe I'm just too cynical.

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Permalink Reply by Super_sally on May 17, 2012 at 6:55pm

Following is from the transcript of Richard Bernstein's latest teleconference, his take on the new ADA guidelines. I think he does have a point.

"And that brings me on the second subject for this week.

The American Diabetes Association, jointly with the European Association for the Study of Diabetes, came out with new treatment guidelines for Type 2 diabetes.

Unfortunately, these guidelines still advocate very high blood sugars, and even higher than before, and a lot of carbohydrates in the diet. It’s interesting that they sort of sleazed out of the problem that was facing them in the past when they put a lower limit on the amount of dietary carbohydrate. They said no less than 137 grams of carbohydrate per day, or your brain will die. That is an absolute lie, and they got caught in it. It was so embarrassing that they don’t say that anymore.

But, they now say to eat a lot of fruit and whole grain breads. These foods are sure to raise your blood sugar sky high.

With regard to blood sugar guidelines, they say that hemoglobin A1c should be around 7%, and you should not change the mode of treatment of your patient until the hemoglobin A1c exceeds 9%. So they want A1cs to be between 7 and 9.

Blood sugar-wise, this means an average blood sugar of anywhere from 180 to 260 mg/dl, and you don’t do anything to improve your treatment until the average blood sugar exceeds 260 mg/dl. This is the latest ADA guidelines.

By sheer coincidence, someone was telling me the story of a drug called Provengia, which is used to treat breast cancer. It’s a last resort for people who are dying of breast cancer. It was shown to give women maybe another four months of life, and it was very expensive, about $8000 a dose. So, the FDA allowed it to be on the market briefly, then took it off the market. But, the protest from women with cancer and their families was so great that the FDA caved in, and allowed it to come back on the market.

Here we have between twenty and thirty million diabetics in the USA alone, and we have the ADA recommending the kind of blood sugars that I just stated. The ADA is telling doctors all over the world that these are the blood sugars that patients should have.

Do we hear any protests? I haven’t heard anything on the news or television. There are a few voices on the internet, people who have blogs that are protesting this. The Nutrition and Metabolism Society, which is a small organization, is protesting this. But, where are the thirty million diabetics? We don’t hear a sound! I think the women with breast cancer are embarrassing us."

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Permalink Reply by acidrock23 on May 17, 2012 at 6:59pm

And, FWIW, not just the people w/ diabetes but heart disease, hypertension, cholesterol issues, etc. would all also benefit from exploring carbs. I still think that the problem isn't the ADA, it's the AMA that needs to be poked and prodded, with 30 million lancets if necessary....

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