Diabetes is a bummer. It increases the risk for all sorts of serious chronic conditions. Patients with diabetes are at increased risk for heart attacks, strokes, kidney problems, vision loss, nerve damage (peripheral neuropathy), and foot and skin problems. There is also an increased risk for dementia.
With such a list of complications, it is hardly any wonder that physicians would want to reduce those risks as much as possible. One approach they have tried over the last several years has been “tight control” of blood sugar. Experts came up with recommendations to keep blood glucose, cholesterol and blood pressure as close to normal as possible. This was accomplished by prescribing multiple medications to reach a target range and was tested in a large study called the ACCORD trials. (ACCORD stands for Action to Control Cardiovascular Risk in Diabetes).
The only trouble with the program was that it didn’t work. Aggressive control of blood sugar, blood pressure and blood fats (including cholesterol) did not keep people with diabetes from dying prematurely of heart attacks and strokes (The New England Journal of Medicine 2008; 358:2545-2559).
As disappointing as these results were, there was another gigantic OOOPS associated with the ACCORD trials. Patients who received the most intensive (tight) control of blood sugar actually did less well than those with more flexible treatment. Patients in the aggressive treatment group died earlier and fared worse than those receiving more moderate treatment (The Lancet 2010; 375:481-495). That appears to be because low blood sugar may be just as bad as high blood sugar. Tight control often leads to dangerous dips in blood glucose.
All that is old news, though. A brand new study in The Lancet suggests that tight blood sugar control doesn’t help prevent dementia either (The Lancet 2011;online Sept. 28, 2011). In this study roughly 3,000 patients with diabetes were randomized to receive either aggressive blood sugar management (below 6 percent on the A1c test) or more flexible treatment (A1c levels between 7 and 7.9 percent). After more than three years of treatment there was no difference in cognitive function between the two groups.
The bottom line conclusion from all this research suggests that people with type 2 diabetes need to be prudent but not obsessive about controlling blood sugar levels. There is a sweet spot that is a little like Goldilocks’ porridge. If you remember, it should not be too hot or too cold. The same can be said for blood sugar…not too high nor too low. People with diabetes need to find a health coach who can help them keep their weight in a good range, exercise regularly, eat sensibly and maintain reasonable blood sugar control.
By the way, next Tuesday (October 4th) we launch a brand new book, Top Screwups Doctors Make and How to Avoid Them (Crown, a division of Random House). In it you will learn that health care harm is one of the top killers in America, rivaling heart attacks and strokes. We discuss the ACCORD trials in much more detail along with the top screwups doctors make for a variety of conditions including diabetes, Alzheimer’s disease, arthritis, asthma, celiac disease, depression, fibromyalgia, heartburn and osteoporosis. Look for it in bookstores, libraries or online. It will be in our shopping cart on Tuesday.
