Setting Slack Standards

"We live in a culture of low targets," writes Hana, one of my regular correspondents in England who has diabetes. For example, her nurse told her that that walking for half an hour three times a week was enough exercise to make a difference, and it doesn't have to be fast walking. "I do a lot more than that," she says.

I agree with Hana. Like Western culture as a whole, the medical establishments in the U.S., the UK, and probably most of the rest of the Western world set the bar far too low for people with diabetes. In the U.S. the American Diabetes Association sets the standards that count.

Every year the ADA looks at the goals it thinks that those of us with diabetes should reach and summarizes them in "Standards of Medical Care in Diabetes." It is gradually setting higher standards, and not all of the standards that it sets are slack, particularly those for cholesterol and blood pressure control.

But many of us who have lived with diabetes for many years think that in four areas the standards are too lax, and that if we personally don't choose to set the bar higher we won't have as many years left.

A1C
No standard is more important than our A1C level, which measures our average blood glucose over the past two to three months. The ADA says that generally its goal for non-pregnant adults in general is less than 7 percent.

Considering that the average A1C level of American adults with diabetes is between 8.5 and 9 percent, as an ADA doctor once told me, it's the right direction. But is it enough?

The answer to that question is what is an average level. The large UK Prospective Diabetes Study said that it's up to 6.2. The Accu-Chek meter company says that it's 5.0. Dr. Richard K. Bernstein told me that it's about 4.5, where he has been able to keep his own level for many years in spite of his type 1 diabetes.

Personally, I have recently been able to get my A1C level down to 4.6 to 5.4 in different tests from different labs recently. I'm pleased, because it's clear that the closer we bring our levels to normal, the fewer complications we are likely to get.

New studies are coming forth regularly that show the closer our A1C levels are to normal the better. Just this month a study in the top medical journal, Lancet, demonstrated that more than 60 percent of retinopathy cases were among patients with levels below 7.
Then, why set the goal at 7 percent? The ADA says that it's because of the greater problem with hypoglycemia when we shoot for a normal level. Certainly, if you are taking one of the diabetes medications that can make you go hypo -- specifically insulin or one of the sulfonylureas -- you need to be careful. Otherwise, we have no reason not to shoot for a normal level.

Exercise
Hana's nurse in suggesting that all the exercise she needs is 90 minutes a week is indeed stetting a low standard. Even the ADA aims higher. It recommends that those of us who can do it get 150 minutes of moderate-intensity aerobic physical activity a week as well as resistance training three times a week.