March 27, 2009

When The Doc Says Lowering A1c Below 7% is Dangerous

I've been receiving a depressing amount of email from readers whose doctors or diabetes nurses have warned them that recent studies have proved it is dangerous to lower A1c below 7.0%.

I've blogged about this before. You can read why doctors are giving this advice--and why it is flawed--here:

A Giant Step Backwards: Misinterpreting ACCORD Harms People with Diabetes

Why Doctors are Telling Type 2s Not to Lower Blood Sugar--And Why They Are Wrong

But what I want to do in this post is different. I want to give you a brief list of questions to ask the doctor or diabetes nurse who tells you that lowering A1c is dangerous.

Ask these questions and suggest that these supposed professionals read the studies this flawed advice was based on before they give their patients advice that will enhance their risk of neuropathy, blindness and kidney failure.

Questions Ask Your Doctor Who Discourages You From Attaining A Normal Blood Sugar

1. Are you aware that the ADVANCE study, which was larger and lasted longer than the ACCORD study, found no increase in cardiovascular death when people lowered A1c to 6.5%?

2. Are you aware that the major difference between ADVANCE and ACCORD is that people in ACCORD were older and sicker and that ADVANCE did not use TZD drugs (Actos or Avandia) used in ACCORD, drugs which have both been shown to cause heart failure in people who did not have it before starting these drugs?

3. Are you aware that ACCORD and ADVANCE both found that lowering A1c to 6.5% lowered the incidence of kidney failure and other microvascular diabetic complications?

4. Are you aware that the Veterans study being used to support the idea that lowering A1c is useless for people with diabetes involved people who were substantially older and sicker than most newly diagnosed people with Type 2 diabetes--who had already developed irreversible heart disease after decades of maintaining extremely high A1cs, so that their experience is not applicable to recently diagnosed younger Type 2s? Do you also know that they were put on the high carb diet combined almost certainly with the outdated sliding scale insulin protocols that are known to lead to hypos?

5. Are you aware that in all these studies the subjects were eating hhigh carbohydrate diets and counteracting the high blood sugars this caused using a cocktail of drugs, all of which have known, dangerous side effects?

6. Do you know that no study has followed people with Type 2 diabetes who lower their A1c using diet alone, most specifically by cutting carbohydrates out of their diet, though what data we have shows that doing this drops A1c dramatically, improves lipids, and lowers blood pressure without side effects?

7. Did you know that the study showing intensive care patients do worse with tight control reflects the fact most hospitals still dose insulin using the dangerously inaccurate "sliding scale" method that bases dose on pre-meal blood sugar, not carbs consumed per meal, and almost guarantees hypos?

As these questions. If your doctor doesn't respond positively, find a new doctor.

It's tragic to think how many people are going to suffer blindness, amputation, and kidney failure because their doctors only read newsletter summaries of these studies, rather than the studies themselves.

Even more frightening is the fact that insurers will seize on this to cut costs by claiming it is a waste of money to pay for strips or insulin for people whose A1cs are lower than 8%.

What these studies really show is this: If you've had Type 2 for 30 years, there probably isn't much you can do about the advanced heart disease you've developed but at least lowering blood sugar may mean you don't have to go on dialysis or go blind.

If you eat a high carb diet that raises your blood sugar unnecessarily high and then take a cocktail of drugs including TZDs along with huge doses of insulin prescribed without reference to your carb intake, you may suffer cardiac side effects and hypos.

But if you are newly diagnosed, have no complications at diagnosis, and lower your A1c by cutting out carbohydrates and normalizing blood sugar, lipids, and blood pressure, there is NO research that suggests you can't have completely normal health.

And if you are recently diagnosed but diet alone is not enough to control your blood sugar it is completely possible to normalize blood sugar by adding metformin and/or insulin to your low carb regimen. Type 2s who control carbohydrates and learn how to dose insulin properly do not need to experience hypos.


Alan said...

You wrote "Ask these questions. If your doctor doesn't respond positively, find a new doctor."

Excuse my cynicism, but although I agree with your logic I think that finding a doctor who responds positively to all those questions may take longer than finding a cure for type 2.

So I wouldn't fire the present doc until one that answers positively to at least SOME of the questions is discovered. That may still take a long search.

Cheers, Alan, Australia

Jenny said...


There are a growing number of doctors in the US who are starting to see the benefits of cutting carbs and who are energetically supporting patients who take that approach.

So, particularly for people who live in larger cities, it is possible to find such a doctor. But it takes hunting.

Trinkwasser said...

It's become part of the Official recommendations in the UK

− avoid pursuing highly intensive management to levels of less than 6.5%.

that line has now appeared in the NICE documentation in several places

Along with the major clampdown on testing this is a time bomb

Anonymous said...

The ADA, in their recent consensus algorithm statement published in December of 2008, states that patients should have Dr visits every three months and additional therapies added or uptitrated until the patient is <7%. Most Drs tend to follow the ADA these days, for good or for ill so it would be surprising to find a Dr. opposing this type of control

Jenny said...


What is new here is the idea that it is dangerous to go below 7%. The ADA recommendation was only to shoot for 7% as a target.

Now we are hearing that any target LOWER than 7% is dangerous. New, different, and very appealing to insurance companies and others looking to cut back on paying for diabetic supplies, insulin etc.

The ADA hasn't addressed this yet.