06 Dec LIVING WELL WITH DIABETES NEWSLETTER – Fall 2016
The Holiday Season Begins!
By: Gail Starr LCSW, CDE
It’s the holidays again! Whew! Where did the year go? Time appears to be like a roll of paper towel. The nearer you get to the end, the faster it goes. Wouldn’t it be nice if you could make it slow down a bit? There may be some ways you can try to do just that. You can try focusing on the present and not dwelling on the past. It’s over and done. You can focus on the present and stop worrying about the future. It hasn’t happened yet, therefore worrying about something we know nothing about is a waste of your precious time.
Your mind is very powerful and you can use it to help you stay in the present. Mindfulness helps you pay attention to what is going on right in the moment. It means focusing on that which is happening around you. It means making every moment counts by being functional and not being a couch potato. Mindfulness means deciding to take care of yourself by eating healthfully, choosing fewer carbs over the holiday season, and eating more vegetables. Making changes in those holiday food rituals can make a big difference in how you feel and your blood sugars!
Doing some kind of physical activity such as walking in a pool, walking in your home during TV commercials, walking with a buddy outdooors in our beautiful Florida weather, or by doing whatever gets you moving keeps the body functioning better. What is in motion, stays in motion.
Meditation, yoga or relaxation breathing can help you feel more grounded, focused, relaxed, lower blood sugars and can help you find your spiritual self. Be aware of your surroundings such as stop to smell the flowers, listen to the breeze rustling in the trees, observe the movement of the clouds, see the blue of the sky, and smell the rain. Practice observing the sights, aromas and sounds around you and time will slow just a bit.
Remember to connect to friends and family. We need other people in our lives for support, fun, connectedness, smiles and hugs. Volunteer to help someone less fortunate than you. Volunteering helps you feel very good about yourself. Please remember it is the season for giving thanks. It is time to say thank you and to allow yourself to feel grateful for all the good things in your life.
What You Need to Know About Glycohemoglobin A1c (Glyco A1c)
By Gary Pepper, M.D.
At each visit with the endocrinologist, those with diabetes are eager to learn their latest glycohemoglobin A1c (glyco A1c) blood test result. Glyco A1c represents the sum of all the efforts to achieve good glucose control during the previous 3 months. Think of the glyco A1c as the grade given at the end of a semester representing the average of all the tests taken during the prior months.
As you may know, hemoglobin is a molecule found in red blood cells which brings oxygen to all he tissues in the body. This unique molecule incorporates iron which carries oxygen and gives blood its red color. The more oxygen in the blood the more brightly red the blood becomes. Not only does hemoglobin carry oxygen but it also binds glucose. The higher the concentration of glucose in the blood the greater the amount of glucose which binds to the hemoglobin. Since a molecule of hemoglobin lasts 3 months in the circulation the measurement of the amount of glucose clinging to hemoglobin (the glycohemoglobin A1c) represents the average glucose content of the blood for the past 3 months. If you ever wondered how a single blood test can indicate the average of blood sugar for the prior months, this is the explanation.
Although the upper limit of glyco A1c for a non-diabetic is considered 5.7% (average blood glucose 111 mg/dL), having a glyco A1c somewhat above this level does not indicate the presence of diabetes. The glyco A1c cut off between non-diabetic and diabetic is somewhat controversial and most experts do not advocate using the glyco A1c measurement as a way to screen individuals for the presence of diabetes. Despite this an increasing number of health providers are testing their patients for glyco A1c levels and if above 5.7% inform them they are “diabetic”, which in fact, they may not be.
Another controversial aspect of the glyco A1c measurement is the establishment of an ideal level for those with diabetes. Why set a target for glyco A1c in the first place? This is because several large studies starting in the 1970’s found that the lower the glyco A1c the less frequent the occurrence of diabetic complications such as kidney and eye disease. For many years it was thought that the lower the glyco A1c the better for the patient, without a lower target level. This theory continues to shift based on more recent studies, however. A decade ago the target was considered to be 6.5% (average blood glucose 135 mg%) or less but now target levels of 7% (average blood glucose 150 mg%) in younger people and 8% (average blood glucose 180 mg%) in the senior or very ill population have been advocated. Even more recently the accuracy of the A1c level as a predictor of diabetic complications has come into question. Some experts suggest that finding a more robust way to summarize several months of the latest glucose control needs to be found. None the less, your endocrinologist at PBDES will work with you to establish your individual goals for glyco A1c as this is still considered the best way for those with diabetes to preserve their health.
A Clarifying Perspective; Seniors You Are Not a Basket of Unfixables!
By: William A. Kaye , M.D., F.A.C.P.
Seemingly conflicting studies in our quest for perfecting sugar levels researchers have come across some very interesting results. While several past studies conclude that lower A1C reduces the complications of diabetes, a 2010 large study called the ACCORD trial was conducted to learn if “even tighter glucose control was better,” and yielded unexpected results.
To be clear, the ACCORD trial was not applicable to all elderly persons. It was limited to patients who already had heart disease or were at very high risk for heart disease, and thus prone to heart attacks and death. They included people with long standing diabetes, people with pre-existing heart disease, smokers, hypertension, high cholesterol, obesity, etc.
The results demonstrated that intensive treatment was associated with worse cardiovascular outcomes in certain high-risk individuals. The beauty of this surprising outcome is that doctors now scrutinize who should be aggressively treated with an A1c goal under 7.0, and whose treatment should be loosened up to allow a higher A1c (even occasionally as high as 8).
Who may be a candidate for looser goals?
Right now the standard of care that your doctor should adhere to is a follows : Every patient should be critically evaluated as an individual, not as “one size fits all.”
Factors to be considered are:
- Life expectancy
- History of severe hypoglycemia
- Advanced diabetic complications
- Evidence of preexisting heart disease
- Presence of other conditions such as cancer, Alzheimer’s,
- History of difficulty getting to goal despite multiple glucose lowering medications
Rules of Thumb:
Healthy, non-pregnant individuals with no suspicion of a shortened life expectancy should have A1c under 7.0% and in selected cases under 6.5%. Very elderly, elderly with a shortened life expectancy (cancer, Alzheimer’s, etc.), elderly with renal failure or unstable heart disease, elderly who cannot easily get A1c to lower levels without multiple medications, elderly with a history of recurrent hypoglycemia could be candidates for a more lax A1c goal such as 8.0%
For patients disturbed or confused by their doctor’s advice that their A1c should be 8 % instead of 7.0 % , consider the following facts:
Running moderately high sugars for a few days, a few months and even a few years does not necessarily cause overt organ damage. Damage to these organs does not occur overnight. Damage to the eyes and nerves takes an average of 5 years to occur. Damage to the kidney takes longer, sometimes 10-15 years. Before obvious damage occurs there are often subtle changes in our tissues that ultimately, overtime, lead to more apparent changes.
It is important to remember that we want good sugar levels because high sugars can “ultimately” damage to the eyes, kidneys, and nerves. As stated in the New England Journal of Medicine, “The ACCORD trial does not undermine the importance of meeting the current guidelines for care, and it should not be interpreted as diminishing the importance of glycemic control For now, rather than changing our current glycemic target, we may best serve our patients with type 2 diabetes by implementing programs to help more of them reach the currently recommended goals.
So if you are 95 and you do not have kidney disease or eye disease, the chances are that an A1c goal of 7.0 vs. 8.0 is not going to make a big difference in your vision or how well your kidney’s are functioning or how much feeling you have in your feet .
If you are 70 years young, however it might.
Thus it is important that your doctor knows a lot more about you than the sole fact that you have diabetes.
Lastly, I would like to offer my personal opinion as it relates to the interpretation of the ACCORD trial. Not only is the ACCORD trial limited to a particular pool of high-risk patients and other special subsets, but also it is not up-to-date as new treatments have become available after this trial was conducted. Medical treatment of diabetes have significantly evolved in the last 6 years New classes of medications have been developed since then that offer the promise of changing the playing field for the same type high-risk individuals as seen in the ACCORD study.
For instance, two medications (Liraglutide and Empaglifloxin) have been shown to reduce cardiac death in high-risk patients. Empaglifloxin was not available when the ACCORD trial was being conducted and neither was Liraglutide. However, a medication in the same class as Liraglutide, i.e. Exenatide, was available but due to its newness was not widely used in the ACCORD trial. People who received it actually showed a decrease in cardiac deaths.
It is important to point out that the field medicine is a slow boat to turn and it take a while to convert research studies to practices that doctors apply and implement in their clinical practices. It is very important for your doctor to not only know you, but also to understand how cutting edge research may benefit you.
Are you nervous about holiday weight gain and losing control of your blood sugars?
Don’t worry come attend our Healthy Meal Planning for Diabetes Class!
Learn how to plan healthy meals & snacks, receive a grocery shopping list, learn foods to limit, healthy dining out, diabetes friendly alternatives when cooking, glucose monitoring, exercise and learn how to lose weight during the holidays!
If interested in attending this program please contact our scheduling department at (561) 659-6336 Extension 8001 today!
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