The American College of Physicians (ACP), a major force in creating practice standards for primary care doctors has called for moving the A1C target level of 6.5% or below to a target level between 7-8% instead. If you're not familiar with A1C (aka HbA1C or glycohemoglobin), this is a blood test that reflects your average blood sugar for the past 2-3 months.
Whereas your fasting blood glucose just provides a single glucose data point at a given point in time, your A1C is a more comprehensive snapshot of your 24/7 blood glucose control over the last few months. It is a useful test to monitor diabetics and prediabetics.
Why Did They Loosen the A1C Target Range?
The practice of medicine and managing chronic health conditions like diabetes is complex. Producing lower numbers, whether it's blood pressure, cholesterol, or A1Cs, often comes at the risk and cost of adding more medications.
Since the ACP is led by practicing physicians who are acutely aware of the fine line between hitting target A1C ranges and producing unintended side effects, they performed an exhaustive analysis of the research and Dr.Jack Ende, president of the ACP, summarizes the conclusion as follows:
“[Our] analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms.”
This statement completely resonates with my own clinical experience, especially in many of our elderly patients. An overzealous effort to continuously drive down numbers by adding various classes of diabetes medications has produced all types of side effects which frankly have caused myself and many of my colleagues to already implement a looser approach to the existing guidelines.
In fact, my current practice setting is almost exclusively focused on lifestyle changes to prevent and reverse diabetes as a consequence of the long term effects of using multiple drugs to reach aggressive target levels. I'm glad to hear that the ACP is endorsing a more thoughtful approach.
Lower A1Cs are Still Important!
The ACP recommendations were met by some strong sentiments from specialty groups like the American Diabetes Association and American College of Endocrinologists who stand by their previous recommendations. Their fear is that doctors and patients will start taking a lax approach to their A1C numbers as a result of these guidelines.
I do agree that we still need to take A1C numbers very seriously. There is no doubt based on studies that when A1C levels reach a level above 6.5%, the risk of complications like blindness, heart attack and stroke increase. In fact, even prediabetes level A1Cs can increase the risk of complications, especially if you have other cardiovascular risks (obesity, high blood pressure, abnormal cholesterol, etc.). I've also discussed the compelling connection between Type 2 diabetes and Alzheimer's disease in this post.
The main issue the ACP addresses is being conscious of the potential long-term impact of using multiple drugs to achieve an A1C of less than 6.5%.
I am a strong advocate of maximizing lifestyle changes as much as possible since these have a greater impact on lowering A1C without side effects.
Beware of the Influence of Big Pharma
There will continue to be a huge backlash against these latest guidelines supported in the background by drug companies and also specialty societies led by doctors with strong ties to drug companies. When a physician group highlights changes in guidelines whose implications are using less medication, that translates into the potential loss of billions of dollars by pharmaceutical companies.
Big pharma will make every effort possible to paint these recent recommendations as being careless and dangerous to patients. More medications to achieve greater reductions in numbers like A1C and LDL cholesterol is always the most profitable strategy for these companies.
If you are on multiple medications to control your Type 2 Diabetes, talk to your doctor about these latest guidelines. Are there opportunities to cut back on medications or dosages to minimize the cumulative side effects over time?
More importantly, if you've been putting off making lifestyle changes to make an impact on your diabetes, now is the time. Medications do not compensate for or protect you against the damaging effects of a poor diet and lifestyle. I see plenty of heart attack patients in my clinic who were already taking 3 or more diabetes medications along with cholesterol and blood pressure medications as well.
Drugs don't bulletproof you against chronic disease and in many cases perpetuate more health issues since patients feel falsely protected by normal appearing lab results. Aim for lower A1Cs with an effective diet and lifestyle strategy first, and then talk to your doctor about using the least amount of medications necessary (if indicated) to reach a more rational target level.
In terms of resources to support your efforts to improve or reverse your diabetes and get your A1C to target without drugs, consider using my book as a guide, try my online program or join me in May for an immersive weekend wilderness retreat at the spectacular 1440 campus in Scott's Valley with a dietitian, where we will teach you how to reverse diabetes and other chronic health conditions through lifestyle.