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Achieving Optimal Glucose Control in Type 2 DiabetesAchieving optimal blood sugar control -
The correlation between A1C and average glucose was 0. Adapted from Nathan et al. In the ADAG study, there were no significant differences among racial and ethnic groups in the regression lines between A1C and mean glucose, although the study was underpowered to detect a difference and there was a trend toward a difference between the African and African American and the non-Hispanic White cohorts, with higher A1C values observed in Africans and African Americans compared with non-Hispanic Whites for a given mean glucose.
Other studies have also demonstrated higher A1C levels in African Americans than in Whites at a given mean glucose concentration 14 , In contrast, a recent report in Afro-Caribbeans found lower A1C relative to glucose values Taken together, A1C and glucose parameters are essential for the optimal assessment of glycemic status.
A1C assays are available that do not demonstrate a statistically significant difference in individuals with hemoglobin variants.
Other assays have statistically significant interference, but the difference is not clinically significant. Use of an assay with such statistically significant interference may explain a report that for any level of mean glycemia, African Americans heterozygous for the common hemoglobin variant HbS had lower A1C by about 0.
Whether there are clinically meaningful differences in how A1C relates to average glucose in children or in different ethnicities is an area for further study 14 , 21 , Until further evidence is available, it seems prudent to establish A1C goals in these populations with consideration of individualized CGM, BGM, and A1C results.
Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen Table 6. CGM is rapidly improving diabetes management.
As stated in the recommendations, time in range TIR is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies 23 — New data support the premise that increased TIR correlates with the risk of complications.
CGM, continuous glucose monitoring; CV, coefficient of variation; TAR, time above range; TBR, time below range; TIR, time in range. Adapted from Battelino et al. For many people with diabetes, glucose monitoring is key for achieving glycemic targets.
Major clinical trials of insulin-treated patients have included BGM as part of multifactorial interventions to demonstrate the benefit of intensive glycemic control on diabetes complications BGM is thus an integral component of effective therapy of patients taking insulin.
In recent years, CGM is now a standard method for glucose monitoring for most adults with type 1 diabetes Both approaches to glucose monitoring allow patients to evaluate individual responses to therapy and assess whether glycemic targets are being safely achieved. The international consensus on TIR provides guidance on standardized CGM metrics see Table 6.
To make these metrics more actionable, standardized reports with visual cues, such as the ambulatory glucose profile see Fig. BGM and CGM can be useful to guide medical nutrition therapy and physical activity, prevent hypoglycemia, and aid medication management.
While A1C is currently the primary measure to guide glucose management and a valuable risk marker for developing diabetes complications, the CGM metrics TIR with time below range and time above range and GMI provide the insights for a more personalized diabetes management plan. The incorporation of these metrics into clinical practice is in evolution, and remote access to these data can be critical for telemedicine.
A rapid optimization and harmonization of CGM terminology and remote access is occurring to meet patient and provider needs 35 — Key points included in standard ambulatory glucose profile AGP report. Reprinted from Holt et al.
With the advent of new technology, CGM has evolved rapidly in both accuracy and affordability. Reports can be generated from CGM that will allow the provider and person with diabetes to determine TIR, calculate GMI, and assess hypoglycemia, hyperglycemia, and glycemic variability.
As discussed in a recent consensus document, a report formatted as shown in Fig. Note the goals of therapy next to each metric in Fig. Overall, regardless of the population being served, it is critical for the glycemic targets to be woven into the overall patient-centered strategy.
For example, in a very young child, safety and simplicity may outweigh the need for perfect control in the short run. Simplification may decrease parental anxiety and build trust and confidence, which could support further strengthening of glycemic targets and self-efficacy. Similarly, in healthy older adults, there is no empiric need to loosen control.
However, the provider needs to work with an individual and should consider adjusting targets or simplifying the regimen if this change is needed to improve safety and adherence.
Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management. Follow-up of the DCCT cohorts in the Epidemiology of Diabetes Interventions and Complications EDIC study 38 , 39 demonstrated persistence of these microvascular benefits over two decades despite the fact that the glycemic separation between the treatment groups diminished and disappeared during follow-up.
Patient and disease factors used to determine optimal glycemic targets. Characteristics and predicaments toward the left justify more stringent efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted with permission from Inzucchi et al.
The Kumamoto Study 40 and UK Prospective Diabetes Study UKPDS 41 , 42 confirmed that intensive glycemic control significantly decreased rates of microvascular complications in patients with short-duration type 2 diabetes.
Long-term follow-up of the UKPDS cohorts showed enduring effects of early glycemic control on most microvascular complications Epidemiologic analyses of the DCCT 32 and UKPDS 45 demonstrate a curvilinear relationship between A1C and microvascular complications.
Given the substantially increased risk of hypoglycemia in type 1 diabetes and with polypharmacy in type 2 diabetes, the risks of lower glycemic targets may outweigh the potential benefits on microvascular complications.
Three landmark trials Action to Control Cardiovascular Risk in Diabetes [ACCORD], Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE], and Veterans Affairs Diabetes Trial [VADT] were conducted to test the effects of near normalization of blood glucose on cardiovascular outcomes in individuals with long-standing type 2 diabetes and either known cardiovascular disease CVD or high cardiovascular risk.
These trials showed that lower A1C levels were associated with reduced onset or progression of some microvascular complications 46 — The concerning mortality findings in the ACCORD trial discussed below and the relatively intense efforts required to achieve near euglycemia should also be considered when setting glycemic targets for individuals with long-standing diabetes, such as those populations studied in ACCORD, ADVANCE, and VADT.
Findings from these studies suggest caution is needed in treating diabetes to near-normal A1C goals in people with long-standing type 2 diabetes with or at significant risk of CVD.
These landmark studies need to be considered with an important caveat; glucagon-like peptide 1 GLP-1 receptor agonists and sodium—glucose cotransporter 2 SGLT2 inhibitors were not approved at the time of these trials.
As such, these agents with established cardiovascular and renal benefits appear to be safe and beneficial in this group of individuals at high risk for cardiorenal complications.
Prospective randomized clinical trials examining these agents for cardiovascular safety were not designed to test higher versus lower A1C; therefore, beyond post hoc analysis of these trials, we do not have evidence that it is the glucose lowering by these agents that confers the CVD and renal benefit As such, on the basis of physician judgment and patient preferences, select patients, especially those with little comorbidity and a long life expectancy, may benefit from adopting more intensive glycemic targets if they can achieve them safely and without hypoglycemia or significant therapeutic burden.
CVD is a more common cause of death than microvascular complications in populations with diabetes. There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow-up of cohorts treated early in the course of type 1 diabetes.
In the DCCT, there was a trend toward lower risk of CVD events with intensive control. The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades 51 and to be associated with a modest reduction in all-cause mortality In type 2 diabetes, there is evidence that more intensive treatment of glycemia in newly diagnosed patients may reduce long-term CVD rates.
Thus, to prevent both microvascular and macrovascular complications of diabetes, there is a major call to overcome therapeutic inertia and treat to target for an individual patient 57 , ACCORD, ADVANCE, and VADT suggested no significant reduction in CVD outcomes with intensive glycemic control in participants followed for shorter durations 3.
All three trials were conducted in relatively older participants with a longer known duration of diabetes mean duration 8—11 years and either CVD or multiple cardiovascular risk factors. The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm 1.
Analysis of the ACCORD data did not identify a clear explanation for the excess mortality in the intensive treatment arm Longer-term follow-up has shown no evidence of cardiovascular benefit, or harm, in the ADVANCE trial The end-stage renal disease rate was lower in the intensive treatment group over follow-up.
However, year follow-up of the VADT cohort 61 did demonstrate a reduction in the risk of cardiovascular events Heterogeneity of mortality effects across studies was noted, which may reflect differences in glycemic targets, therapeutic approaches, and, importantly, population characteristics Mortality findings in ACCORD 59 and subgroup analyses of VADT 63 suggest that the potential risks of intensive glycemic control may outweigh its benefits in higher-risk individuals.
In all three trials, severe hypoglycemia was significantly more likely in participants who were randomly assigned to the intensive glycemic control arm.
As discussed further below, severe hypoglycemia is a potent marker of high absolute risk of cardiovascular events and mortality Therefore, providers should be vigilant in preventing hypoglycemia and should not aggressively attempt to achieve near-normal A1C levels in people in whom such targets cannot be safely and reasonably achieved.
Based on these considerations, the following two strategies are offered 67 : If already on dual therapy or multiple glucose-lowering therapies and not on an SGLT2 inhibitor or GLP-1 receptor agonist, consider switching to one of these agents with proven cardiovascular benefit.
Introduce SGLT2 inhibitors or GLP-1 receptor agonists in people with CVD at A1C goal independent of metformin for cardiovascular benefit, independent of baseline A1C or individualized A1C target. Numerous factors must be considered when setting glycemic targets.
The ADA proposes general targets appropriate for many people but emphasizes the importance of individualization based on key patient characteristics. Glycemic targets must be individualized in the context of shared decision-making to address individual needs and preferences and consider characteristics that influence risks and benefits of therapy; this approach will optimize engagement and self-efficacy.
The factors to consider in individualizing goals are depicted in Fig. This figure is not designed to be applied rigidly but to be used as a broad construct to guide clinical decision-making 68 and engage people with type 1 and type 2 diabetes in shared decision-making.
More aggressive targets may be recommended if they can be achieved safely and with an acceptable burden of therapy and if life expectancy is sufficient to reap the benefits of stringent targets.
Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals. Diabetes is a chronic disease that progresses over decades.
Thus, a goal that might be appropriate for an individual early in the course of their diabetes may change over time. Thus, a finite period of intensive control to near-normal A1C may yield enduring benefits even if control is subsequently deintensified as patient characteristics change.
Over time, comorbidities may emerge, decreasing life expectancy and thereby decreasing the potential to reap benefits from intensive control. Also, with longer disease duration, diabetes may become more difficult to control, with increasing risks and burdens of therapy.
Thus, A1C targets should be reevaluated over time to balance the risks and benefits as patient factors change. Recommended glycemic targets for many nonpregnant adults are shown in Table 6. CGM may be used to assess glycemic target as noted in Recommendation 6. Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals.
Postprandial glucose measurements should be made 1—2 h after the beginning of the meal, generally peak levels in patients with diabetes.
The issue of preprandial versus postprandial BGM targets is complex Elevated postchallenge 2-h oral glucose tolerance test glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose in some epidemiologic studies, whereas intervention trials have not shown postprandial glucose to be a cardiovascular risk factor independent of A1C.
In people with diabetes, surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia. However, outcome studies have shown A1C to be the primary predictor of complications, and landmark trials of glycemic control such as the DCCT and UKPDS relied overwhelmingly on preprandial BGM.
Additionally, a randomized controlled trial in patients with known CVD found no CVD benefit of insulin regimens targeting postprandial glucose compared with those targeting preprandial glucose Therefore, it is reasonable to check postprandial glucose in individuals who have premeal glucose values within target but A1C values above target.
An analysis of data from participants in the ADAG study with type 1 diabetes and with type 2 diabetes found that the glucose ranges highlighted in Table 6.
These findings support that premeal glucose targets may be relaxed without undermining overall glycemic control as measured by A1C. Fifteen minutes after treatment, if blood glucose monitoring BGM shows continued hypoglycemia, the treatment should be repeated.
Once the BGM or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. Caregivers, school personnel, or family members providing support to these individuals should know where it is and when and how to administer it.
Glucagon administration is not limited to health care professionals. Hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes.
Recommendations regarding the classification of hypoglycemia are outlined in Table 6. If a patient has level 2 hypoglycemia without adrenergic or neuroglycopenic symptoms, they likely have hypoglycemia unawareness discussed further below.
This clinical scenario warrants investigation and review of the medical regimen 78 — Reprinted from Agiostratidou et al.
Symptoms of hypoglycemia include, but are not limited to, shakiness, irritability, confusion, tachycardia, and hunger.
Hypoglycemia may be inconvenient or frightening to patients with diabetes. Level 3 hypoglycemia may be recognized or unrecognized and can progress to loss of consciousness, seizure, coma, or death. Hypoglycemia is reversed by administration of rapid-acting glucose or glucagon. Hypoglycemia can cause acute harm to the person with diabetes or others, especially if it causes falls, motor vehicle accidents, or other injury.
A large cohort study suggested that among older adults with type 2 diabetes, a history of level 3 hypoglycemia was associated with greater risk of dementia Conversely, in a substudy of the ACCORD trial, cognitive impairment at baseline or decline in cognitive function during the trial was significantly associated with subsequent episodes of level 3 hypoglycemia Studies of rates of level 3 hypoglycemia that rely on claims data for hospitalization, emergency department visits, and ambulance use substantially underestimate rates of level 3 hypoglycemia 89 yet reveal a high burden of hypoglycemia in adults over 60 years of age in the community African Americans are at substantially increased risk of level 3 hypoglycemia 90 , In addition to age and race, other important risk factors found in a community-based epidemiologic cohort of older Black and White adults with type 2 diabetes include insulin use, poor or moderate versus good glycemic control, albuminuria, and poor cognitive function Step 2: Know your diabetes ABCs Step 3: Learn how to live with diabetes Step 4: Get routine care to stay healthy Things to remember My Diabetes Care Record: Page 1 My Diabetes Care Record: Page 2 Self Checks of Blood Sugar This publication has been reviewed by NDEP for plain language principles.
Actions you can take The marks in this booklet show actions you can take to manage your diabetes. Step 1: Learn about diabetes. What is diabetes?
There are three main types of diabetes: Type 1 diabetes — Your body does not make insulin. This is a problem because you need insulin to take the sugar glucose from the foods you eat and turn it into energy for your body. You need to take insulin every day to live. Type 2 diabetes — Your body does not make or use insulin well.
You may need to take pills or insulin to help control your diabetes. Type 2 is the most common type of diabetes. Gestational jest-TAY-shun-al diabetes — Some women get this kind of diabetes when they are pregnant.
Most of the time, it goes away after the baby is born. But even if it goes away, these women and their children have a greater chance of getting diabetes later in life.
You are the most important member of your health care team. Some others who can help are: dentist diabetes doctor diabetes educator dietitian eye doctor foot doctor friends and family mental health counselor nurse nurse practitioner pharmacist social worker How to learn more about diabetes.
Take classes to learn more about living with diabetes. To find a class, check with your health care team, hospital, or area health clinic. You can also search online. Join a support group — in-person or online — to get peer support with managing your diabetes.
Read about diabetes online. Go to National Diabetes Education Program. Take diabetes seriously. Why take care of your diabetes? When your blood sugar glucose is close to normal, you are likely to: have more energy be less tired and thirsty need to pass urine less often heal better have fewer skin or bladder infections You will also have less chance of having health problems caused by diabetes such as: heart attack or stroke eye problems that can lead to trouble seeing or going blind pain, tingling, or numbness in your hands and feet, also called nerve damage kidney problems that can cause your kidneys to stop working teeth and gum problems Actions you can take Ask your health care team what type of diabetes you have.
Step 2: Know your diabetes ABCs. A for the A1C test A-one-C. What is it? Why is it important? What is the A1C goal? B for Blood pressure.
Blood pressure is the force of your blood against the wall of your blood vessels. What is the blood pressure goal? C for Cholesterol ko-LESS-tuh-ruhl. There are two kinds of cholesterol in your blood: LDL and HDL.
What are the LDL and HDL goals? Actions you can take Ask your health care team: what your A1C, blood pressure, and cholesterol numbers are and what they should be. Your ABC goals will depend on how long you have had diabetes, other health problems, and how hard your diabetes is to manage. what you can do to reach your ABC goals Write down your numbers on the record at the back of this booklet to track your progress.
Step 3: Learn how to live with diabetes. Cope with your diabetes. Stress can raise your blood sugar. Learn ways to lower your stress. Try deep breathing, gardening, taking a walk, meditating, working on your hobby, or listening to your favorite music.
Ask for help if you feel down. A mental health counselor, support group, member of the clergy, friend, or family member who will listen to your concerns may help you feel better. Eat well. Make a diabetes meal plan with help from your health care team.
Choose foods that are lower in calories, saturated fat, trans fat, sugar, and salt. Eat foods with more fiber, such as whole grain cereals, breads, crackers, rice, or pasta. Choose foods such as fruits, vegetables, whole grains, bread and cereals, and low-fat or skim milk and cheese.
Drink water instead of juice and regular soda. Your body breaks down the carbs you eat into glucose, which then raises your blood sugar levels. As such, reducing your carb intake can aid blood sugar regulation. Fiber slows carb digestion and sugar absorption, thereby promoting a more gradual rise in blood sugar levels There are two types of fiber — insoluble and soluble.
This could help you better manage type 1 diabetes The recommended daily intake of fiber is about 25 grams for women and 35 grams for men. Eating plenty of fiber can aid blood sugar management. Soluble dietary fiber appears to be more effective than insoluble fiber for this purpose.
In addition to preventing dehydration, it helps your kidneys flush out any excess sugar through urine. One review of observational studies showed that those who drank more water had a lower risk of developing high blood sugar levels Drinking water regularly may rehydrate the blood, lower blood sugar levels, and reduce diabetes risk 20 , Keep in mind that water and other zero-calorie drinks are best.
Avoid sugar-sweetened options, as these can raise blood glucose, drive weight gain, and increase diabetes risk 22 , Staying hydrated can reduce blood sugar levels and diabetes risk.
Choose water and zero-calorie drinks and avoid sugar-sweetened beverages. Portion control can help you regulate your calorie intake and maintain a moderate weight 24 , Consequently, weight management promotes healthy blood sugar levels and has been shown to reduce the risk of developing type 2 diabetes 1 , 26 , Monitoring your serving sizes also helps prevent blood sugar spikes 2.
The glycemic index GI measures how quickly carbs break down during digestion and how rapidly your body absorbs them. This affects how quickly your blood sugar levels rise The GI divides foods into low, medium, and high GI and ranks them on a scale of 0— Low GI foods have a ranking of 55 or less 15 , Both the amount and type of carbs you eat determine how a food affects your blood sugar levels.
Specifically, eating low GI foods has been shown to reduce blood sugar levels in people with diabetes 15 , Furthermore, adding protein or healthy fats helps minimize blood sugar spikes after a meal Stress can affect your blood sugar levels When stressed, your body secretes hormones called glucagon and cortisol, which cause blood sugar levels to rise 29 , One study including a group of students showed that exercise, relaxation, and meditation significantly reduced stress and lowered blood sugar levels Exercises and relaxation methods like yoga and mindfulness-based stress reduction may also help correct insulin secretion problems among people with chronic diabetes 31 , 32 , Managing your stress levels through exercise or relaxation methods like yoga may help you regulate blood sugar levels.
Monitoring blood glucose levels can help you better manage them You can do so at home using a portable blood glucose meter, which is known as a glucometer.
You can discuss this option with your doctor. Keeping track allows you to determine whether you need to adjust your meals or medications.
It also helps you learn how your body reacts to certain foods 2. Try measuring your levels regularly every day and keeping track of the numbers in a log. Also, it may be more helpful to track your blood sugar in pairs — for example, before and after exercise or before and 2 hours after a meal.
This can show you whether you need to make small changes to a meal if it spikes your blood sugar, rather than avoiding your favorite meals altogether. Some adjustments include swapping a starchy side for non-starchy veggies or limiting them to a handful.
Checking your blood glucose and maintaining a daily log enables you to adjust foods and medications when necessary to better manage your blood sugar levels. Getting enough sleep feels excellent and is necessary for good health In fact, poor sleeping habits and a lack of rest can affect blood sugar levels and insulin sensitivity, increasing the risk of developing type 2 diabetes.
They can also increase appetite and promote weight gain 36 , 37 , Additionally, sleep deprivation raises levels of the hormone cortisol, which, as explained, plays an essential role in blood sugar management 29 , Adequate sleep is about both quantity and quality. The National Sleep Foundation recommends that adults get at least 7—8 hours of high quality sleep per night To improve the quality of your sleep , try to:.
Good sleep helps maintain your blood sugar levels and promotes a healthy weight. On the other hand, poor sleep can disrupt critical metabolic hormones. High blood sugar levels and diabetes have been linked to micronutrient deficiencies. Some examples include deficiencies in the minerals chromium and magnesium Chromium is involved in carb and fat metabolism.
It may potentiate the action of insulin, thus aiding blood sugar regulation 41 , 42 , 43 ,
This Curb hunger and reduce calorie intake has been reviewed by NDEP for plain language principles. Learn more about our controll process. The marks bloid this booklet show actions you can take to manage your diabetes. Help your health care team make a diabetes care plan that will work for you. Learn to make wise choices for your diabetes care each day.
American Diabetes Association Professional Contfol Committee; Achkeving. Curb hunger and reduce calorie intake Targets: Standards of Medical Care in Diabetes— Bloov Curb hunger and reduce calorie intake wish to comment on the Mind-body connection in eating of Opptimal are invited to do so at professional. A1C is the metric used to date in clinical trials demonstrating the benefits of improved glycemic control. CGM serves an increasingly important role in the management of the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes. A1C reflects average glycemia over approximately 3 months.
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