What really is the threshold for being diagnosed as T2 diabetic?

[Sceptical]

My GP has told me categorically that I have T2 diabetes and that I ought to be taking Metformin. My last HbA1C was 48 mmol/mol. I am 59, weigh 11st 1lb and stand 5'7". Scared my this, I paid for a full heart scan that revealed 0 calcification. I am physically fit and experience none of the "traditional" symptoms of T2. There is no known history of diabetes in my family.

Research published in the BMJ in April 2013 (copy attached) says "current guidelines usually recommend a general target HbA1c of 53mmol/mol [7%] or less"

The same paper also says "HbA1c is not a substitute for postprandial measurements or assessment of hypoglycaemia. This surrogate measure has been used to support a treatment strategy that has helped to get drugs licensed, driven guideline development and even determined the amount that GPs get paid (emphasis added). For example, for 2012/13, the primary care Quality and Outcomes Framework (QOF) allocated points for achieving three levels of glucose control in people with type 2 diabetes: HbA1c of IFCC 59mmol/mol [7.5%]i or less, 64mmol/mol [8%] or less, and 75mmol/mol [9%] or less in the preceding 15 months"

All things considered, I am deeply sceptical about my own diagnosis and more importantly wonder how many other people are unnecessarily prescribed powerful chemicals at enormous cost to the NHS.

Is it possible that the "explosion of T2" that we read so much about is partially due to moving the goalposts since 2013? Looks like it to me.

Sceptical

 

[grovesy]

I suspect this is now been reviewed and updated.

 

[rebrascora]

I kind of understand your scepticism but an HbA1c of 48 makes you diabetic by the current guidelines and since the HbA1c is similar to an average of your BG over the past 10-12 weeks, then it indicates that your body is starting to have a problem with carbohydrates. This may be because you are becoming insulin resistant or because your body is not producing enough insulin to remove the glucose from your blood stream. There are different types of diabetes and many of us believe that there is a lot more work to be done on defining them, but the fact that you are not overweight does not preclude you from diabetes by any means... if that is what you are suggesting.

Your reading of 48 certainly does not automatically warrant the commencement of medication and I would certainly be discussing a 3 month hiatus on that with your GP where you undertake dietary changes to try to control it yourself before going down that route. It is likely that reduction in your carbohydrate intake will bring you back into the normal range, but those changes will likely be a lifelong change to maintain it there rather than a short term effort to get things back into line.
Many members of the forum here have pushed their diabetes into remission from much higher HbA1c levels through diet alone. It is just about learning a new way of eating.
There is however the slight possibility that you have a problem with your pancreas becoming less able to produce enough insulin. Cutting back on carbs will give it a bit of a break but these things can be progressive and you may eventually end up requiring insulin at some point in the future despite your best dietary efforts.

 

[Andy HB]

What @rebrascora said.

The last sentence about the progression of diabetes is certainly true. However, don't take it as read that it will definitely be the case. Just take heed of the "can be" and "may" parts of the detail. 🙂

 

[rebrascora]

Yes I realised afterwards it sounded a bit over dramatic. I was just thinking that the OP might possibly be early stages LADA. (Latent Autoimmune Diabetes in Adults) rather than Type 2.

For info of @Sceptical there is no specific testing for Type 2. The number 48 or above just simply gets you a diabetes diagnosis. It is then often just assumed, since you are not a child or young adult, that you must be Type 2 which is what happened to me earlier this year. Type 1 testing is expensive and in the early stages of LADA may prove inconclusive anyway, so might not be beneficial asking for at this stage because if it comes back negative you may be unlikely to get a second test at a later date. Going down the low carb diet route should help regardless of whether it is LADA or Type 2 at this stage.
The good thing about being diagnosed diabetic is that you get free prescriptions and regular testing of eyes and feet and it often gives you motivation to become fitter and eat healthier....ie. less processed foods and more fresh veg etc.

 

[Felinia]

You have one HbA1c reading of 48 mmol/mol which shows you are JUST in the currently recognised UK diabetic range for Diabetes. When my HbA1c shot up from 41 to 57 in 9 months, my GP immediately ordered a 2nd reading, as confirmation (it was confirmed). But her reaction was very different to your GP. She immediately said I was to lose weight, exercise more, follow a low carb diet and be re-tested in 3 months time. She made it clear she did not want to prescribe medication if I could control my blood glucose myself. 3 months later, my HbA1c is at your level of 48 and I was told that my practise would not prescribe Metformin for a level under 52. Speaking to family members in the medical profession I learned 2 things - I need to watch my diet for life, and the longer you can go without taking medication the better. So I control solely with diet and exercise.
You are a healthy weight for your height, but I would hope if you reduce your carbs (bread, pasta, rice, potatoes, and all the usual suspects like cakes, sweets, pastries) and get re-tested in 3 months time, you would see a drop, hopefully to 41 or less. You have shown a tendency towards increased blood glucose levels, but without the usual problem of being overweight, so you will have to watch your diet for the rest of your life. You have been given a very early warning to take charge of your own body and Metformin has some very nasty side effects (constipation will NOT be a problem!!). As someone said to me - you don't crack a peanut with a sledgehammer. If 3 months of dietary care does not bring down your blood glucose, then it's time to re-think. But as rebrascora has said - there are benefits of free prescriptions, flu jabs and regular testing of eyes and feet for life.
Please give your body a chance before going down the drug route, but of course if you develop symptoms or have any concerns, you must go to your doctor - perhaps a more modern thinking one who is not a pill pusher.

 

[Drummer]

Many people with Hba1c levels far higher than yours when diagnosed, have cut back on carbs and in weeks are back below diabetic numbers.
I'd suggest taking a good look at the amount of sugar and starch you eat in a typical day and maybe halving it for a while.
If you want to be more precise you could get a cheap to run glucose meter and test after eating - but you are so close to the edge that it hardly seems necessary.
Just by cutting carbs, avoiding low fat options (protein and fat are the only essential macro nutrients) you should feel some benefit, and if you are a typical type two, and lucky, then your nest test should show improvement, even normality.
I did take Metformin for a while, but it made me feel so dreadful, and combined with Atorvastatin I was in an awful state in just over a month. I'd do anything to avoid it.

 

[Sceptical]

I suspect this is now been reviewed and updated.

Thanks Grovesy - I appreciate that the BMJ publication is 6 years old now but I'm struggling to understand why the threshold has been brought down, if that is indeed the case. It seems to make little sense to me that my last result now means I am diabetic whereas the exact same result no more than 6 years ago would have meant that I was not diabetic. I can get on board with the idea that we should all be wary of developing diabetes and that a better lifestyle / diet can help to reduce the risk. On that basis reducing the threshold to include a larger swathe of the population makes some sort of sense I suppose? However this policy overlooks the fact that many people cannot get on with the default drug Metformin and that you have to disclose to insurers and employers the fact that you have been diagnosed as diabetic thus prejudicing a lot people's lives in other ways.

 

[Sceptical]

Many people with Hba1c levels far higher than yours when diagnosed, have cut back on carbs and in weeks are back below diabetic numbers.
I'd suggest taking a good look at the amount of sugar and starch you eat in a typical day and maybe halving it for a while.
If you want to be more precise you could get a cheap to run glucose meter and test after eating - but you are so close to the edge that it hardly seems necessary.
Just by cutting carbs, avoiding low fat options (protein and fat are the only essential macro nutrients) you should feel some benefit, and if you are a typical type two, and lucky, then your nest test should show improvement, even normality.
I did take Metformin for a while, but it made me feel so dreadful, and combined with Atorvastatin I was in an awful state in just over a month. I'd do anything to avoid it.

 

[Eddy Edson]

Thanks Grovesy - I appreciate that the BMJ publication is 6 years old now but I'm struggling to understand why the threshold has been brought down, if that is indeed the case. It seems to make little sense to me that my last result now means I am diabetic whereas the exact same result no more than 6 years ago would have meant that I was not diabetic. I can get on board with the idea that we should all be wary of developing diabetes and that a better lifestyle / diet can help to reduce the risk. On that basis reducing the threshold to include a larger swathe of the population makes some sort of sense I suppose? However this policy overlooks the fact that many people cannot get on with the default drug Metformin and that you have to disclose to insurers and employers the fact that you have been diagnosed as diabetic thus prejudicing a lot people's lives in other ways.

I think maybe you might be confusing "diagnostic threshold" and "target".

Just about everywhere, the threshold for a D-diagnosis is an HbA1c of 6.5%/48 mmol/mol and as far as I know it has been ever since HbA1c was adopted as a standard metric (I think!).

The recommended HbA1c *target* to aim for, once you have been diagnosed, differs. Eg: In the US, different bodies have different recommendations: some say < 7% / 53 for most diabetics, others say in the range 7%-8%. In the UK, it used to be < 7%/53 for most diabetics, but now it's 6.5% / 48.

 

[Sceptical]

Hi Drummer - thanks so much for your reply - very helpful and encouraging. I'm interested to note that you take atorvastatin. I was prescribed that drug 15 years ago as I had a very high cholesterol / triglyceride result during a routine company medical. I have been taking it ever since, but recently discovered that there is a link between long term use of statins, especially atorvastatin, and otherwise improbable onset of T2. Please see the paper attached - see second point in summary on page 1 and the summarised paper 3 on page 2. You may want to mention this to your GP. Wishing you well.

 

[Sceptical]

I think maybe you might be confusing "diagnostic threshold" and "target".

Just about everywhere, the threshold for a D-diagnosis is an HbA1c of 6.5%/48 mmol/mol and as far as I know it has been ever since HbA1c was adopted as a standard metric (I think!).

The recommended HbA1c *target* to aim for, once you have been diagnosed, differs. Eg: In the US, different bodies have different recommendations: some say < 7% / 53 for most diabetics, others say in the range 7%-8%. In the UK, it used to be < 7%/53 for most diabetics, but now it's 6.5% / 48.

Thanks Eddy - I sort of see what you're getting at but what is the point of a distinction here? You're saying "Level X (the 'diagnostic threshold') = T2 diabetic and Level X+Y (the 'target') still = T2 diabetic?

Surely the only issue that matters is the effect any given BS level it is actually having on the individual which will be different for every one, rendering the simplistic averages approach unhelpful and possibly counterproductive (eg someone who is below the technical threshold / target may still be experiencing micro vascular deterioration but because the immutable number doesn't get them over the line into T2 diagnosis their problem goes un/misdiagnosed). I would much rather GPs tried to find out what is actually going on in an individual than jumped to the default conclusion and prescription based on averages. We're all unique (and special!)

 

[Bruce Stephens]

You're saying "Level X (the 'diagnostic threshold') = T2 diabetic and Level X+Y (the 'target') still = T2 diabetic?

More that X or higher means you have diabetes (actually I think you'd want a couple of tests a few months apart, and to try to exclude other factors such as anaemia), and once you have diabetes there's a target to aim for which may be higher than X. (This target is very much supposed to be an individual one negotiated between patient and healthcare team. As are any treatments to be tried (whether medications or other things).)

Presumably this HbA1c of 48 isn't the only highish one you've had? And looking for harms in particular patients before trying to reduce blood sugar doesn't seem very realistic. The evidence suggests raised blood sugar increases risks of some things over time; even for things that can be measured I suspect once you could see changes that damage would have been done.

 

[Drummer]

Hi Drummer - thanks so much for your reply - very helpful and encouraging. I'm interested to note that you take atorvastatin. I was prescribed that drug 15 years ago as I had a very high cholesterol / triglyceride result during a routine company medical. I have been taking it ever since, but recently discovered that there is a link between long term use of statins, especially atorvastatin, and otherwise improbable onset of T2. Please see the paper attached - see second point in summary on page 1 and the summarised paper 3 on page 2. You may want to mention this to your GP. Wishing you well.

I was only prescribed Atorvastatin after diagnosis - I had a lot of trouble remembering after a few weeks - I have had to relearn over 300 songs which - fortunately I had begn writing down, for posterity - not my own making, but folk songs I knew from decades of singing. Now, after 3 years, I am finally beginning to sing from memory again, but it has shaken my confidence considerably.

 

[Eddy Edson]

Surely the only issue that matters is the effect any given BS level it is actually having on the individual which will be different for every one,

Microvascular & other complications typically develop over long timeframes and particularly in the early stages I don't think there is any good method for directly assessing whether Bad Things are starting to happen. Using avg BG levels as estimated by HbA1c is about the best that can be done to identify those at risk,

EDIT: But should say that with an HbA1c of 48 yr excess complication risk is probably just about sod-all.

I think the best advice is to use the DX as a spur to investigating whether there's anything to change in yr lifestyle to prevent things progressing further & to turn things around.

It's not very useful to resist making changes just because it might seem that lifestyle factors are within generally "healthy" norms - as you say, everybody is different and the norms are applicable to populations, not so much to individuals.

Eg: It's perfectly possible to get a T2D DX with a BMI in a generally "healthy" range and still be able to turn it around by weight loss. Etc etc etc.

On the other hand, if lifestyle changes (and Metformin) don't seem to accomplish much, it may be that you actually have some kind of slow-onset T1, commonly misdiagnosed in adults.

 

[Drummer]

Is it weight loss or fat loss which is important?
I'd say fat loss, as I have been finding that I am becoming stronger and thinner without losing weight, but feel better for it, so much so that I have gone back to working with knitting machines, heaving them around doing servicing, at the age of 68.
I was always quite strong and athletic when younger - something that BMI doesn't seem able to cope with. I was 'overweight' with a waist measurement of 24 inches.

 

[Eddy Edson]

Is it weight loss or fat loss which is important?

Has to be fat. Muscle = good!