A B Cs of DiabetesWritten by Expert Pharmacist
October 24, 2019
Contributor: Dr. Staci-Marie Norman, PharmD, CDE
As I sit writing this article, I can hardly believe we are well into fall and heading into the holiday seasons. Before you start celebrating, I want to remind you that November is Diabetes Awareness Month and a good time to take stock of your health before plunging headlong into a new year!
I’m sure you all know your A, B, C’s, but do you know your A, B, C’s of diabetes?
A is for A1C. This is one number that most people with diabetes have heard of and watch, but do you know what it really is? When I ask patients, they typically tell me it is an average of their blood glucose. This is basically true, but how do we get this “average”? When we measure an A1C, what is being looked at are the red blood cells in our body. Our red blood cells live for 90- 120 days, and as they float through our body over this 3 or 4-month period, they encounter other elements. One such element is glucose. When red blood cells and glucose collide, the glucose permanently attaches to the red blood cell and a “sugar coating” starts to form. I joke that the A1C is the glaze on our red blood cell donuts. The thicker the coating of glucose, the higher our A1C, which means there has been more glucose present in the system. Since the typical life of a red blood cell is approximately three months, by evaluating this coating we are seeing an average of glucose present in the body during that time. This test can not tell us what your blood glucose was exactly at on a specific point in time, and because it is an average it can’t tell us if we have had swings from very high to very low, but it is a good marker to look at over time for trends. We want to see it trending downward and not up!
So, what is your A1C goal? The American Diabetes Association (ADA) says the goal for most people is <7%. This is a great number to be striving for. If you’ve met this goal, the American Association of Clinical Endocrinologists (AACE) has a goal of 6.5% that they set for optimization of management. Because this is a “3-month average” it is recommended that the A1C be done on a quarterly basis, although some physicians will do this twice-yearly if you are very well managed. My one word of caution with the A1C - it is not a replacement for checking blood glucose at home. Checking at home gives a much more accurate picture of what your blood glucose is doing throughout the day, which can be useful in therapy adjustments.
B is for blood pressure. Keeping track of our blood pressure and making sure we are treating hypertension is extremely important in diabetes care. People with diabetes are at an increased risk of cardiovascular disease, and by maintaining our blood pressure, we can reduce this risk. Currently, the ADA goal for blood pressure is <140/90 for people with low 10-year Atherosclerotic Cardiovascular Disease (ASCVD) risk and < 130/80 for those with high 10-year ASCVD risk. This ASCVD risk can be calculated by your physician and is based on things like your age, sex, race, blood pressure, cholesterol, history of diabetes, smoking history, and if you take medications such as antihypertensives, statins or aspirin. If your blood pressure is elevated, it is important to get treatment to lower and maintain it at an acceptable level. This could include lifestyle modifications, like diet and exercise, but medication is typically needed. The ACE inhibitors and ARBs are usually first-line agents for hypertension in people with diabetes due to their ability to protect the kidneys. But calcium channel blockers (CCBs) or thiazide diuretics are also considered first-line agent choices, especially if there is no kidney involvement. Don’t be surprised if a combination of these medications is used. By using two medications that work differently to lower blood pressure in the body, we can use smaller doses and get better results. Smaller doses usually mean fewer side effects, so it is a win-win. Many of the most common medications that are used together come as a combination tablet, so you only take one tablet but are getting the benefit of two medications.
C is for cholesterol. If you've ever looked at your lab work, you have seen that there are many cholesterol components that make up your total cholesterol. Basically, there are three components that we look at, the LDL or lousy cholesterol, HDL or happy cholesterol, and triglycerides.
LDL cholesterol is really the big culprit when it comes to cardiovascular disease. This is the cholesterol that gets into the lining of the blood vessels and can cause hardening, or cause a vessel wall to rupture, leading to a clot formation, which could lead to a heart attack or stroke.
HDL cholesterol acts as the body's "cholesterol vacuum". Its main purpose is to find excess LDL in the blood system, grab onto it, and escort it to the liver to be disposed of. So we like to have good levels of HDL. There are two things you can do to boost your HDL levels - exercise, and smoking cessation.
Triglycerides are the third component of the total cholesterol. These fats fluctuate throughout the day as we eat and fast. They are part of the body's system of processing the fats from our diet. We really worry about triglycerides when their levels are very high, typically when they are greater than 500mg/dL. This puts us at risk of pancreatitis. In the past, the medical community really focused on the "numbers" associated with LDL when setting goals. Over the past ten years, because of research that has solidified the cardiovascular risk reduction benefits that statin therapy provides to patients with ASCVD risk such as diabetes, the focus has moved to making sure patients are not only on statin therapy but also the correct therapy to lower the LDL >50% from baseline. So, if your LDL was 180mg/dL at baseline, the goal would be to lower it to <90mg/dL.
Now that you know what the A, B, Cs of diabetes are, I challenge you to use Diabetes Awareness Month to find out your own numbers.
Dr. Staci-Marie Norman, PharmD, CDE received her bachelor's from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Educator. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.