Sometimes I disagree with guidelines. Gentle reader, you are no doubt amazed by this, knowing my soft and generous spirit.

At the San Antonio FMX, I heard two lectures on diabetes.

One was a paid drug luncheon. We eat for free, well, eat in exchange for listening to drug company propaganda. At this one, a paid speaker was hammering the wonderful potential of a new drug. I don't remember which one. He pretty much said we should DIAGNOSE diabetes and slap people on a drug IMMEDIATELY and then INCREASE IT IN THREE MONTHS if the hemoglobin A1C is not in control.

Huh. I don't think so.

The hemoglobin A1C (hgbA1C) is a laboratory value that gives us an average three month blood sugar. It measures sugar stuck to hemoglobin. Normal is lab dependent but usually under 6. There is a level that diagnoses diabetes, but that's the least helpful diagnostic test so I don't use it much. Each level corresponds to an average blood sugar. Here:

Another speaker was giving the top ten Really Important New Things, and he is not sponsored by a drug company. He said that if we can keep the hgbA1C between 6 and 8, that is great and better survival. That corresponds with the studies I am skimming. Too tight control is BAD. In the studies with a hgbA1C down in the normal range, under 6, diabetics are MORE likely to die. A bit confusing, but remember, the hgbA1C is an average. Lows are bad.

So what IS the normal range for blood sugar? It depends. Fasting normal is different from postprandial (after you eat) normal. Fasting normal is 70-100. Postprandial is 70-140. So the average should come out somewhere in the 110-130 range, but for diabetics, we'd like the hgbA1C over 6, so an average at 126. I had a diet controlled diabetic in her 90s who kept dropping her blood sugars into the 50s. Ambulance ambulance. The diabetic educator and I cornered her and told her to eat MORE carbs. "Really?" she said. "Oh, yes, really." we said.

The best test for diabetes is the two hour glucose tolerance test. My opinion. The person goes in and has a fasting blood sugar. They are then given a 70 gram glucose drink. Another blood sugar is drawn at one hour and at two hours.

A fasting under 100 is normal. 110-125 is impaired fasting glucose. Over 125, twice, diagnoses diabetes.

Postprandial 70-140 is normal. 141-200 is impaired glucose tolerance. Over 200 is diabetes.

I see different patterns. My caucasians usually have a rising baseline. If their fasting is borderline, often they have impaired glucose tolerance. My hispanic and filipino folks may have a borderline fasting, but then can pop up to 300 or 350 after the sugar load. Diabetes. I don't have enough african american or asian patients here to know any pattern there.

The guidelines say that I should put the person on metformin right away if their kidney function will tolerate it. That's where I disagree. I explain the goals: fasting under 120 or 110 and after eating under 150 and here is a glucometer prescription. I give a basic carbohydrate talk. Keep the carbohydrates at 30 grams for each of three meals and three snacks at 15 grams. Quit any sweetened drinks. Eat fruit and don't drink juice. Soda is evil. I let them loose with a referral to the diabetic educator.

A patient popped to over 300 with the two hour gtt. The diabetic educator calls and scolds me because she is not on metformin yet. I say "Oh, uh huh, yes, guidelines, yes, uh huh." Two weeks later the diabetic educator calls me again. "I don't think she needs metformin after all. She has brought her blood sugars down under 200 after she eats! Don't start her on metformin! She is doing an amazing job!" I do the "Oh, uh huh, wow, thank you so much! Great news!"

But I am not surprised. Setting people loose with a glucometer and telling them the goals is RESPECT. I assume people are SMART. If I stick them on a medicine right away, they never get a chance to play with the glucometer. They never really get a chance to TRY diet control. By catching diabetics really early and giving them power, most of my patients that I diagnose are diet controlled. They may remain diet controlled for years: they may eventually need medicine. But how can they learn diet control if I start by handing them a pill?

This applies to type II diabetes, not type I. Type I has to have insulin or they die. The vast majority of my patients are type II.

And that is my update for 2017.

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