The ACP lowered the boom on glucose control: Is it right for you?

Recently diagnosed with diabetes, Al, 65, a chopper pilot and chef, is taking two drugs, still short of ideal control.

Last month, he was relieved when the American College of Physicians (ACP) proposed a more relaxed goal for Type 2 diabetics (or adult-onset diabetes, 90 percent of all diabetics). But as soon as the guideline was released, it came under fire from multiple well-respected organizations including the American Diabetes Association (ADA).

“What do you think?” he asked.

Personally – and call me what you want – until the thinking caps calm down, I’m hiding. Staying dry, upstream, above the fray.

So, what’s the rationale behind the ACP’s change in attack plan?

First, a word on A1C, a measure of long-term glucose control. Because glucose molecules cross red blood cells freely and tag their proteins, A1C measures these tagged proteins, permanently marked like a tattoo. It reflects glucose control over a three-month time, the lifespan of a red blood cell.

Diabetes is A1C over 6.5 percent. The ADA recommends treating to keep A1C less than 7 percent (average glucose of 154 mg/dL). The ACP wants to raise the goal to 8 percent (average glucose 184 mg/dL) and to ditch some drugs if A1C falls below 6.5 percent.


ADA is concerned. There isn’t a single organ in the body diabetes doesn’t damage. Some damages begin when A1C exceeds 6.5.

But the ACP, upon reviewing numerous studies, concluded that controlling diabetes with medications to get below 7 percent compared with 8 percent did not reduce heart attacks, strokes, or prolong life “but did result in substantial harms, including but not limited to hypoglycemia.”

This last part, hypoglycemia or low blood sugar worries me the most. The human brain is unique because it depends almost entirely on glucose as a source of energy. While resting, our brains consume 60 percent of total body glucose. Low blood sugar hits the brain early and hard; people get confused, pass out, and lapse into a coma if not treated promptly. Studies in elderly diabetics showed that severe hypoglycemia, acting like a chemical concussion, increases the risk of dementia.

Diabetic medications, even insulin, cannot control glucose perfectly; they can reduce but not prevent all complications. There’s a tipping point where the harms of medications equal or outweigh the benefits. It’s different for everybody. And it’s the doctor’s job to figure out where.

My clandestine A1C goal: Do your best.

I have diabetics who run 10K for warmup and nibble tree bark for fiber supplements. I have diabetics who nibble on the run and have in-depth inner dialogues about exercising at all tonight.  

All of them are doing their best. And together we’ll work out the best combination of drugs and A1C goals.

On two drugs, Al’s A1C is down from 12 to 9. Instead of adding a third drug, he wants to eat better, start walking and lose some weight. “Give me four months.”

Fine with me, though I may or may not come out of hiding by then.

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Volume 10, Issue 9, Posted 10:11 AM, 05.01.2018