Setting Goals for Diabetes Management
"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.
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.
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.
But even the U.S. government's current recommendation for adults to lose weight is 60 to 90 minutes of exercise on most days of the week. That works out to up to 360 minutes of exercise a week.
Dr. Alan Rubin, an endocrinologist in San Francisco and the author of Diabetes for Dummies told me that he personally gets at least 90 minutes of exercise per day and that the only way his patients have been successful in losing weight is getting several hours of exercise every day.
Taking heed, I make sure that I get about 14 or 15 hours of exercise every week. I needed it to lose weight and to maintain that weight loss.
When I started taking Byetta in February 2006, I weighed 312 pounds. Today I weight 158. That's almost a 50 percent weight loss.
The ADA, on the other hand recommends that, "For obese individuals, a modest weight loss of 5 to 10 percent of body weight may be indicated."
If I had paid attention to the experts, I could have hoped to reduce my weight by 31 pounds and would weigh 281 pounds today. On my 6' 3" frame I would still be obese with a BMI of 35.1, instead of having the low normal BMI that I have today of 19.7.
Of all of the ADA's lax standards, nothing disturbs some people with diabetes more than its recommendations that we eat a lot of carbohydrates. It recommends that we get 130 grams of digestible (net) carbohydrates per day. The big beef of most detractors of a low-carb diet is that it's too difficult for us to follow.
Dr. Bernstein stands at the low-carb end of the spectrum. His recommendation is essentially about 42 grams of carbs per day.
The jury's still out on this one. But the remarkable new book, Good Calories, Bad Calories, by Gary Taubes, finally persuaded me that a high fat-diet -- in other words one that makes a low-carb diet possible -- is safe for my heart.
The common complaint about the ADA's lax standards is organizational inertia. But that's not fair.
Diabetes can be overwhelming, especially when we get our diagnosis and realize that we have to totally change the way we live. The ADA certainly realizes that if it told us to change our lifestyles this drastically, even more of us would go into denial and essentially say, "Shove it."
If the ADA had set honest standards, it would be little like telling someone to eat an elephant, my favorite Certified Diabetes Educator tells me. "Initially seems overwhelming and impossible," she says. "But if you do it one bite at a time, especially by setting smaller more easily attained goals, you'll get there eventually."
But those of us who have lived with the disease for several years know well that we feel better and can expect to live longer, healthier lives when we set our own standards much higher. For us, getting to these goals eventually means getting there now.