HbA1c Control

HbA1c provides an excellent tool for assessing overall glycemic status.
Several studies have shown the benefits of reduced HbA1c - the United Kingdom Prospective Diabetes Study showed a 1% reduction in HbA1c produced a 28% decrease in retinopathy and the Wisconsin Epidemiologic Study of Diabetic Retinopathy found retinopathy, nephropathy, neuropathy and cardiovascular disease decreased 20-50% with a 1% decrease in HbA1c.

The American College of Physicians recommended after their review of the available English language guidelines:

The benefits and harm of specific levels of glucose control should be discussed fully between patients and their physicians. Patients should aim for an HbA1c level as low as possible without causing unacceptable or frequent episodes of low blood sugar ('hypoglycemia'), in order to avoid the complications of diabetes. An HbA1c level below 7% is a reasonable goal for many, but not all patients.

2. Individualized evaluation of the risk for complications, additional conditions (comorbidity), life expectancy, and patient preferences should guide the specific target for HbA1c to avoid driving a patient to reach a maybe unattainable target.

Lipids and diabetes
Hyperlipidaemias are common in patients with diabetes and further increase the risk of ischaemic heart disease, especially in type 2 diabetes.
Even when low density lipoprotein (LDL) cholesterol concentration is normal or slightly raised in type 2 diabetes (the major abnormalities being low HDL cholesterol and high triglyceride concentrations), the LDL particles may be qualitatively different and more atherogenic than those in non-diabetic patients.

Screening for dyslipidaemia is an essential aspect of the annual review.
Optimising diabetic control often improves an abnormal lipid profile in patients with type 1 diabetes and sometimes those with type 2 diabetes.

Targets for blood lipid concentrations
Total cholesterol, < 5.0 mmol/l 95
Fasting triglyceride, < 2.0 mmol/l
LDL cholesterol, < 3.0 mmol/l
High density lipoprotein (HDL) cholesterol, > 1.1mmol/l.
The ratio HDL cholesterol/(total cholesterol -HDL cholesterol) should be > 0.25. Alternatively, total cholesterol/HDL cholesterol should be < 3.0.

A high alcohol intake may disturb plasma lipids, and this aspect of treatment must be examined and if necessary modified.

Statins are the first line treatment for hypercholesterolaemia and fibrates for hypertriglyceridaemia. Statins and fibrates can be used alone or together for treating mixed hyperlipidaemia.
Extreme mixed hyperlipidaemias are occasionally associated with uncontrolled diabetes. The plasma has a milky appearance, and xanthomata appear in the skin as bright yellow papules particularly at the elbows, knees, and buttocks. Even the retina assumes the pallor of lipaemia retinalis, described as "peaches and cream." The condition normally resolves when glycaemic control is achieved; lipid concentrations often return to normal, and the xanthomata disappear. Most, but not all, patients have type 2 diabetes. The condition needs to be carefully monitored, and patients should take lipid lowering drugs until it resolves.

Diet.
Energy should come from carbohydrate such as rice, potatoes, pasta, bread 9 (men) 7 (women) 5 (children) portions of vegetables & fruit a day. Pulses, such as lentils, can provide protein, replacing some red meat. Red meat should be lean and in small amounts. Chicken and turkey are acceptable in small amounts.
Meals should be balanced with some carbohydrate (rice, potato etc), vegetables, and protein such as fish or lentils (which may be made into a dahl or stew), many herbs and spices, and fruit. The amount eaten depends on your energy requirements. Active workers require more than those with a sedentary job.

Summary
Lifestyle measures such as smoking, weight reduction, and exercise are important. Patients should be given advice on low fat diets. Hypertension must be treated. Lipid modifying drugs given where appropriate.