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Medical Forum / Diseases and Disorders / Diabetes / January 2004Is a good A1c enough for glycemic control?
G'day G'day Folks, Here is a partial answer to the puzzle. It basically says if you make it to the 5% club the risk of coronary heart disease is still double if post prandial glucose rises above 140 mg/dL (US units) or 7.8 mmol/L for the international units. Notice the post prandial reading is taken at 2-hour not 1-hour. 1: Arch Intern Med. 2003 Jun 9; 163(11): 1306-16. Clinical significance, pathogenesis, and management of postprandial hyperglycemia. Gerich JE. Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA. mary_little@urmc.rochester.edu It is well established that strict glycemic control (hemoglobin A1c <7.0%) can prevent the microvascular complications of diabetes mellitus. Recent studies indicate that elevated plasma glucose concentrations are an independent and clinically significant risk factor for cardiovascular disease in nondiabetic and diabetic individuals. Thus, isolated postprandial hyperglycemia (2-hour postprandial glucose level >140 mg/dL [>7.8 mmol/L]) in the face of normal fasting plasma glucose (<110 mg/dL [<6.1 mmol/L]) and normal hemoglobin A1c (<6.1%) values is associated with a 2-fold increased risk of death from cardiovascular disease. These observations imply that more strict glycemic control is required to prevent macrovascular disease than microvascular disease. This review summarizes epidemiologic and experimental studies linking postprandial hyperglycemia to cardiovascular disease and therapeutic approaches available and in development to treat this disorder. Publication Types: Review Review, Academic PMID: 12796066 [PubMed - indexed for MEDLINE] Best wishes,  SignatureQuentin Grady ^ ^ / New Zealand, >#,#< [ / \ /\ "... and the blind dog was leading." http://homepages.paradise.net.nz/quentin This post not CC'd by email On Thu, 29 Jan 2004 17:04:18 +1300, Quentin Grady <quentin@paradise.net.nz> wrote: >G'day G'day Folks, > > Here is a partial answer to the puzzle. All in all it suggests control both A1c and post prandial glucose makes sense if it is achievable. Note the spelling of Hanefeld One reference had the name misspelt as Henefeld which made is hard to find. <grin> Best wishes, 1: Nutr Metab Cardiovasc Dis. 2002 Apr; 12(2): 98-107. Control of post-prandial hyperglycemia--an essential part of good diabetes treatment and prevention of cardiovascular complications. Hanefeld M, Temelkova-Kurktschiev T. Center of Clinical Studies, Technical University Dresden, Fiedlerstrasse 34, 01307 Dresden, Germany. hanefeld@gwt-tud.de AIM: This article reviews the relationship between the control of post-prandial hyperglycemia and diabetes-related complications. DATA SYNTHESIS: Hyperglycemia is a modifiable risk factor that has a deleterious effect on the development and progression of microvascular and macrovascular complications in patients with type 2 diabetes. The UK Prospective Diabetes Study revealed how reductions in hemoglobin A1c (HbA1c) correlate with a significant reduction in all-cause mortality and the incidence of myocardial infarction. The Diabetes Intervention Study showed that poor control of fasting glycemia does not increase the risk of myocardial infarction or mortality, whereas poor control of post-prandial glucose is associated with a high all-cause mortality rate. HbA1c is the standard measure for metabolic control and therapeutic efficacy, but does not reflect fluctuations in glycemic control. Plasma glucose concentrations in healthy subjects remain within a narrow range, which suggests that the fluctuations in glucose levels caused by inappropriate treatment may have negative consequences. These fluctuations have been associated with acute adverse effects (particularly excessive post-prandial hyperglycemia, pre-meal hypoglycemia and weight gain) that counteract the positive effect of lowering fasting plasma glucose and HbA1c. Post-prandial hyperglycemia and spikes also have deleterious effects on insulin secretion and sensitivity. Prandial oral antidiabetic agents such as alpha-glucosidase inhibitors (acarbose, miglitol) and rapidly acting insulin secretagogues (nateglinide, repaglinide) have recently been introduced to improve the control of post-prandial hyperglycemia. CONCLUSION: Near-normal post-prandial glycemic control is associated with lower rates of cardiovascular and all-cause mortality than excessive post-challenge hyperglycemia. In addition to the aggressive control of HbA1c and fasting plasma glucose, the strict normalisation of postprandial hyperglycemia is an essential part of good diabetes treatment. There is growing evidence from epidemiological and clinical studies that this also reduces the risk of cardiovascular complications. Publication Types: Review Review, Tutorial PMID: 12189909 [PubMed - indexed for MEDLINE] SignatureQuentin Grady ^ ^ / New Zealand, >#,#< [ / \ /\ "... and the blind dog was leading." http://homepages.paradise.net.nz/quentin Quentin, As long as "normal" is defined as hba1c of 6.0% or FPG of 110 mg/dl or lower all related research is going to be contaminated by the large numbers of people with early diabetes in the study. The more I read, the more convinced I am that 4.7% hbaic and under 90 mg/dl are normal and everything else is part of the diabetes continuum. P.S. did you see the rat study just published today about maternal diet and longevity. It dovetails all too well with the earlier finding that maternal starvation leads to diabetes in humans. -- Jenny - Low Carbing for 4 years. At goal for weight. Type 2 diabetes, hba1c 5.2. Cut the carbs to respond to my email address! Low carb facts and figures, my weight-loss photos, tips, recipes, strategies for dealing with diabetes and more at http://www.geocities.com/jenny_the_bean/ Looking for help controlling your blood sugar? Visit http://www.alt-support-diabetes.org/Newly%20Diagnosed.htm > G'day G'day Folks, > [quoted text clipped - 56 lines] > > http://homepages.paradise.net.nz/quentin > Quentin, > > As long as "normal" is defined as hba1c of 6.0% or FPG of 110 mg/dl or > lower all related research is going to be contaminated by the large > numbers of people with early diabetes in the study. There's a whole lot of problems with most studies. Many studies are not comprehensive enough to account for the many differen variable which also affect CVD, eyes, kidneys..etc. Things such as lipds and blood pressure are not always taken into account as a risk factor along with hyperglycemia. > Quentin, > > As long as "normal" is defined as hba1c of 6.0% or FPG of 110 mg/dl or lower > all related research is going to be contaminated by the large numbers of > people with early diabetes in the study. I think so too, although I prefer less than 5.0% and less that 100 mg/dl as my goals. > The more I read, the more convinced I am that 4.7% hbaic and under 90 mg/dl > are normal and everything else is part of the diabetes continuum. Remember it wasn't that long ago that sugar in the urine was used to diagnose and monitor. This approach at least will be a very aggressive and at the same time conservative approach. SignatureK'neH'a'Iw Uncloaking, Shields up. So... could I extrapolate and say that this is even more reason for more frequent small meals? Signature-- t2_lurking geabbottATabbottandabbottDOTcom Do not mail to t2_lurking (auto-delete) ============================ "Off with her head!' the Queen shouted at the top of her voice. "Who cares for you?' said Alice, "You're nothing but a pack of pixels"! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ New to Diabetes? Go to: http://www.alt-support-diabetes.org ********************************************************* > G'day G'day Folks, > [quoted text clipped - 48 lines] > > Best wishes, > Recent studies indicate that elevated plasma glucose concentrations > are an independent and clinically significant risk factor for [quoted text clipped - 12 lines] > values is associated with a 2-fold increased risk of death from > cardiovascular disease. I looked to see if there was any additional statistical data but couldn't find it. If you know where it can be found please post a link. I wonder how "isolated" these postprandial excursions need to be to cause an increase in marked cardiovascular disease, every meal, once a week, once a month? It seems obvious that regular excursions are included but what about occasional ones. I maintain pretty good control, but occasionally I either get it wrong or just decide to eat things I don't normally. I've always thought that the occasional spike was not too bad. SignatureK'neH'a'Iw Uncloaking, Shields up. This post not CC'd by email On Thu, 29 Jan 2004 13:05:30 -0600, K'neH'a'Iw >> Recent studies indicate that elevated plasma glucose concentrations >> are an independent and clinically significant risk factor for [quoted text clipped - 16 lines] >couldn't find it. If you know where it can be found please post >a link. G'day G'day K'neH'a'Iw, There isn't a lot of data that is readily available. Pubmed has a lot of abstracts that basically say something like "In this study we looked at why post prandial glucose excursions are important ... " To get the details one has to pay a subscription to download a full text or .pdf file. No one is paying me to do so, so it isn't in my budget. I find it very frustrating that I have to rely on a consensus document without being able to view the original research. >I wonder how "isolated" these postprandial excursions need to be >to cause an increase in marked cardiovascular disease, every >meal, once a week, once a month? So do. I'll have to live with that until the full texts become free reprints or I find some form of employment that allows me to do the downloads. >It seems obvious that regular excursions are included but what >about occasional ones. I maintain pretty good control, but >occasionally I either get it wrong or just decide to eat things >I don't normally. I've always thought that the occasional spike >was not too bad. IMHO the occasional spike isn't too bad. Occasional can all too easily drift into habitual. So long as we understand the difference. I find it easier to make decisions when I have very simple rules. Here are my current ones, subject to update at any moment. The CVD risk for early stage diabetics or those A1c below 6.1% and frequent excursions at 2-hours over 140 mg/dL (7.8 mmol/L) is about double that for non-diabetics. That is actually quite a good risk level. For those that have A1c of about 7% the risk is IIRC about four times that for non-diabetics. (I'd need to check those figures) Put simply the people in this group would appear to be twice as well off as those whose A1c is higher. People who are obese but exercise have half the mortality rate of those who have ideal weight but live sedentary lifestyles. (5 years study a few thousand people.) Put simply there is a reasonable chance that one risk offsets the other. Getting together a long term study for a small select group who exercise vigorous but have this IGT hyperglycemic profile might be a bit daunting. Uncontrolled T2 diabetics have a risk of CHD over four times that of non-diabetics. People think of diabetes as an error of blood glucose metabolism. In practice it is an error in fat metabolism, protein and carbohydrate metabolism. As the worst excesses of blood glucose are dealt with there rapidly becomes a point where dealing with the lipid imbalance becomes more important. My simplistic approach has been to follow triglyceride:HDL ratio. Dealing with inflammation and blood pressure also rapidly assume centre stage. Best wishes, SignatureQuentin Grady ^ ^ / New Zealand, >#,#< [ / \ /\ "... and the blind dog was leading." http://homepages.paradise.net.nz/quentin > G'day G'day K'neH'a'Iw, > IMHO the occasional spike isn't too bad. Occasional can all too > easily drift into habitual. So long as we understand the difference. How do you define occasional? I am currently at sorta once a week. I can reduce it if I believe that that there is a benefit. > The CVD risk for early stage diabetics or those A1c below 6.1% and > frequent excursions at 2-hours over 140 mg/dL (7.8 mmol/L) is about > double that for non-diabetics. That is actually quite a good risk > level. My recent A1c's have been 5% or less, how do you define frequent? > People who are obese but exercise have half the mortality rate of > those who have ideal weight but live sedentary lifestyles. (5 years > study a few thousand people.) OK, I'm now simply overweight and sedentary. > Uncontrolled T2 diabetics have a risk of CHD over four times that of > non-diabetics. How do your define uncontrolled? > People think of diabetes as an error of blood glucose metabolism. In > practice it is an error in fat metabolism, protein and carbohydrate > metabolism. I think of it as carbohydrate intolerance. Where does the fat and protein metabolism come in? > As the worst excesses of blood glucose are dealt with > there rapidly becomes a point where dealing with the lipid imbalance > becomes more important. In my case I tried that and am now taking Lipitor, it seems to be working. The lipid problem seems to be genetic. My grandmother lasted to 99 years 6 months with a total cholesterol of 300+ > My simplistic approach has been to follow > triglyceride:HDL ratio. Doing good there 93/64 at my last test. > Dealing with inflammation OK, how do you do that? I'm doing lots of fresh/frozen vegetables and aspirin therapy. > and blood pressure This is a weak point I'm at the high point of acceptable for non-diabetics pushing 140/80 -- K'neH'a'Iw Uncloaking, Shields up. This post not CC'd by email On Fri, 30 Jan 2004 22:57:15 -0600, K'neH'a'Iw >> G'day G'day K'neH'a'Iw, > >> IMHO the occasional spike isn't too bad. Occasional can all too >> easily drift into habitual. So long as we understand the difference. > >How do you define occasional? G'day G'day K'neH'a'Iw, I don't make the definitions ... thank goodness. Every so often groups of learned people get together to refine the definition of diabetes. Now you have to ask yourself, why would they do that? There is nothing to be gained from a definition that doesn't lead to practical decision making in some way. >I am currently at sorta >once a week. I can reduce it if I believe that that >there is a benefit. We all take some risk ... living is a risky business. I'd like you to think about what you are asking. How likely is it there is a study where people have one spike a week and where their rate of complications over five or ten years is compared with another group who have two spikes per week. Complications are often assessed as a rate over ten years. I don't think anyone has the detailed sort of information you are seeking. >> The CVD risk for early stage diabetics or those A1c below 6.1% and >> frequent excursions at 2-hours over 140 mg/dL (7.8 mmol/L) is about [quoted text clipped - 3 lines] >My recent A1c's have been 5% or less, how do you >define frequent? I don't. The people who wrote the paper must had some working definition as part of their experimental procedure. Sorry, I don't have the cash to read the full text. I can guess for you. If I did, I think it meant most days of the week. >> People who are obese but exercise have half the mortality rate of >> those who have ideal weight but live sedentary lifestyles. (5 years >> study a few thousand people.) > >OK, I'm now simply overweight and sedentary. Sedentary is definitely not good. Sorry. I think the point of the experiment was to compare the effects of being overweight and leading a sedentary lifestyle independently. They are so often co-related that this was a pretty bold question to ask and try to find an answer. The answer they found sure gave me a wake up call. Sedentary is twice as bad as obesity as a killer. >> Uncontrolled T2 diabetics have a risk of CHD over four times that of >> non-diabetics. > >How do your define uncontrolled? This time there are working definitions. That doesn't mean they are internationally agreed or that the figures are applicable to testing done in different labs. Poor control would appear to be an A1c greater than 8.0 1: South Med J. 2002 Jan;95(1):72-7. Role of exercise for type 2 diabetic patient management. Pigman HT, Gan DX, Krousel-Wood MA. Office of Performance Improvement, Veterans Affairs Medical Center, New Orleans, LA 70031, USA. BACKGROUND: Exercise is integral to the management of type 2 diabetes. Unfortunately, the majority of adults with type 2 diabetes do not engage in regular exercise. METHODS: Three hundred patients with type 2 diabetes were randomly selected from a patient pool of diabetic patients encountered in 1996 at the Department of Veterans Affairs Medical Center in New Orleans, Louisiana. Medical records from October 1996 to June 1999 were reviewed. Information about exercise, alcohol intake, smoking, medications, laboratory results, and other variables was extracted from medical records. Patients with mean glycosylated hemoglobin (HbA1c) < 8.0 (good diabetic control) were compared with those who had poor diabetic control (mean (HbA1c) > or = 8.0). The effect of exercise in the management of type 2 diabetes was assessed. RESULTS: After adjustment for other variables, patients without exercise had an odds ratio of 2.71 (95% CI, 1.38-5.32) for poor diabetic control compared with patients with exercise. CONCLUSIONS: These findings suggest that exercise by itself is important for type 2 diabetes management. PMID: 11827248 [PubMed - indexed for MEDLINE] >> People think of diabetes as an error of blood glucose metabolism. In >> practice it is an error in fat metabolism, protein and carbohydrate >> metabolism. > >I think of it as carbohydrate intolerance. Where does >the fat and protein metabolism come in? In the early stages of Metabolic Syndrome (Syndrome X) blood glucose levels stay relatively normal but the liver loses the plot and fails to switch of fat production when food is eaten. >> As the worst excesses of blood glucose are dealt with >> there rapidly becomes a point where dealing with the lipid imbalance [quoted text clipped - 9 lines] > > Doing good there 93/64 at my last test. Both those figures look excellent. In countries using mmol/L, the optimal cut-points were 1.47 mmol/L for triglyceride, 1.8 in SI units for the triglycerideHDL cholesterol ratio, and 109 pmol/L for insulin. In countries using mg/dL the optimal cut-points were 130 mg/dL for triglyceride, 3.0 for the triglycerideHDL cholesterol ratio, and 109 pmol/L for insulin. IMHO the trick to face up to whatever personal challenge we have. In the first instance that means having these things tested then tackling them in earnest. >> Dealing with inflammation > >OK, how do you do that? I'm doing lots of fresh/frozen >vegetables and aspirin therapy. Well that is a good start. Think also improving omega-3 to omega-6 ratio. Put simply ... eat fish or FREE RANGE meat. Eat berries, include cocoa in your diet. Use turmeric and ginger. Eat salads or some other vegetables RAW. RAW foods are a source of MSM, methyl sulphonyl methane, which is anti-inflammatory. Even boiling evaporates MSM. >> and blood pressure > >This is a weak point I'm at the high point of >acceptable for non-diabetics pushing 140/80 Think anti-inflammatory. Best wishes, SignatureQuentin Grady ^ ^ / New Zealand, >#,#< [ / \ /\ "... and the blind dog was leading." http://homepages.paradise.net.nz/quentin |
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