The Ideal A1C in Diabetes: Why the Recommendation Might Be Wrong

A recent New York Times article has generated controversy by suggesting that older people with diabetes don't need to strictly control their blood glucose levels. This recommendation, although endorsed by certain medical societies, might be exposing millions of people to unnecessary risk of diabetic complications. Let's critically analyze these guidelines and the available alternatives.

The Controversial Article and Its Claims

The article titled "Why Older People Might Not Need to Monitor Their Blood Sugar So Closely" suggests that:

Intensive diabetes management offers fewer benefits as patients age
It increases the risk of hypoglycemia (low blood sugar)
Many people haven't received this message

The subtitle states: "Intensive diabetes management yields fewer benefits as patients age and increases the chances of hypoglycemia."

The Case Presented as an Example

The article begins by describing the case of Aurora Larson, a woman who experiences hypoglycemic episodes several times a year, apparently with increasing frequency. Both her endocrinologist and primary care physician have advised her to maintain her A1C above 7.0%.

What is Hypoglycemia and Why is it Concerning?

Hypoglycemia is defined as a blood glucose level below 70 mg/dL, although significant symptoms usually appear below 60 mg/dL. Associated risks include:

Falls and bone fractures
Cardiac arrhythmias
Cognitive damage
In extreme cases, loss of consciousness and death

These risks are real and should be taken seriously, especially in older people.

The Origin of the Recommendations: The ACCORD Study

These guidelines are primarily based on the 2008 ACCORD study, which used:

Intensive insulin therapy
Sulfonylureas (like glibenclamide)
Another medication that was later withdrawn from the market due to adverse effects

The study found that very strict glucose control through these medications increased the risk of severe hypoglycemic episodes without offering proportional benefits in reducing complications.

The Fundamental Problem: The Strategy, Not the Goal

The real problem isn't seeking a normal A1C, but how we try to achieve it. Intensive pharmacological therapy presents inherent risks of hypoglycemia because:

Injected insulin doesn't respond to natural metabolic signals
Sulfonylureas force the pancreas to secrete insulin regardless of glucose levels
These interventions lack the body's natural feedback mechanisms

The Forgotten Paradigm: Dietary Control of Diabetes

Surprisingly, the New York Times article mentions the word "diet" only once, without specifying what dietary approach might be effective. This omission is significant considering that:

The low-carbohydrate diet is the most studied dietary intervention for diabetes control
Millions of people have managed to normalize their A1C levels without medications or with minimal doses
Scientific evidence for this approach continues to accumulate

Questions to ChatGPT: An Interesting Verification

If you ask ChatGPT what is the most studied diet for controlling and reversing diabetes, it will unequivocally answer: the low-carbohydrate or ketogenic diet.

The Two Paths to Control Diabetes

There are fundamentally two approaches to managing type 2 diabetes:

1. The Conventional Pharmacological Approach

Mechanism: Aggressive use of medications to force normal glucose levels
Risks: Frequent hypoglycemic episodes, side effects
Result: The New York Times article suggests giving up and accepting elevated A1C levels

2. The Therapeutic Nutrition Approach

Mechanism: Substantial reduction in carbohydrates to decrease insulin needs
Advantages: Virtually eliminates the risk of hypoglycemia
Result: Allows achieving normal A1C levels without the risks associated with intensive medication

Geriatric Societies' Recommendations: Crucial Context

The article mentions that the American Geriatric Society recommends an A1C target between 7.5% and 8% for older adults. It's important to understand that:

This recommendation assumes the use of the conventional pharmacological model
It's designed to balance the risks of medication-induced hypoglycemia with the risks of diabetic complications
It does not consider the scenario of control through carbohydrate restriction

The Real Impact of Elevated A1C

Maintaining an A1C between 7.5% and 8% (as suggested by the article) implies accepting average glucose levels between 170-180 mg/dL, which significantly increases the risk of:

Diabetic neuropathy (nerve damage)
Retinopathy (vision problems)
Nephropathy (kidney failure)
Cardiovascular disease
Poor healing

The critical question is: why accept these risks when there's an alternative?

Pharmacological De-intensification: A Misunderstood Concept

The article correctly mentions that "de-intensification" can involve:

Stopping medications
Reducing doses
Switching to alternative medications

However, it fails to mention that the most effective de-intensification is the transition to a nutritional approach that naturally reduces the need for medications.

The Evidence-Based Alternative: Low-Carbohydrate Diet

For people with type 2 diabetes:

A very low-carbohydrate diet can normalize glucose levels in days or weeks
Most patients can reduce or completely eliminate their medications
The risk of hypoglycemia becomes practically non-existent when not depending on medications

For people with type 1 diabetes:

They can reduce their insulin needs by 50-80%
They experience much less pronounced glucose fluctuations
They achieve normal A1C with significantly lower risk of hypoglycemia

Media Bias and Its Consequences

The New York Times article represents a concerning pattern in diabetes communication:

It presents a false dilemma: accept elevated A1C or risk severe hypoglycemia
It completely ignores the transformative role of therapeutic nutrition
It indirectly benefits the food and pharmaceutical industry

This type of media coverage perpetuates the paradigm of "diabetes as a progressive disease" when evidence shows that, for many, it is reversible or controllable without medications.

Practical Recommendations: What You Should Do

If you have diabetes or prediabetes:

Seriously consider a nutritional approach: Low-carbohydrate, ketogenic, or carnivore diet can transform your metabolism
Work with informed professionals: Seek doctors familiar with nutritional management of diabetes (there are increasingly more)
Monitor your glucose levels: Continuous or frequent monitoring devices will give you invaluable information
Adjust medications with supervision: As your glucose normalizes, you'll need to reduce doses to avoid hypoglycemia
Set ambitious but safe goals: An A1C below 5.7% is completely achievable without significant risks of hypoglycemia when using a nutritional approach

Conclusion: Reconsidering Standards of Care

The New York Times article, although well-intentioned, promotes a suboptimal standard of care based solely on the pharmacological paradigm. The real solution isn't giving up on elevated A1C levels, but adopting strategies that allow normalizing glucose without the inherent risks of intensive medication.

Age shouldn't be a sentence to inevitable diabetic complications. With the right approach, even older people can achieve excellent metabolic control and preserve their quality of life, regardless of what headlines suggest.