Diabetes Self-Management Blog

It is standard in diabetes care to recommend practicing reasonably tight blood glucose control — most people, according to the American Diabetes Association, should aim for an HbA1c level around or below 7%. But when it comes to practicing intensive blood glucose control — aiming for an HbA1c level similar to that of people without diabetes, commonly defined as below 6% — controversy abounds. Several studies have aimed to address the question of whether intensive control yields medical benefits, generally without clear-cut results. Now, another report has been added to the mix.

Earlier this summer, a German research institute — the Institute for Quality and Efficiency in Health Care — released a report that examined existing studies on intensive blood glucose control. Described in a recent article at EndocrineWeb, the report examined seven previously published studies that included nearly 28,000 participants, comparing the effect of intensive control versus standard control on overall death, strokes, fatal and nonfatal heart attacks, kidney disease, eye disease, and amputation. Three of these studies took place after the year 2000; the others took place from the 1960’s to the 1990’s. The groups included in all of the studies were not uniform — some had far more men than women, and vice versa, and some had participants who had already experienced heart problems — making comparison difficult. Nevertheless, the report reached several conclusions.

One conclusion is that in each of the seven studies, there was no reduction in overall death from intensive blood glucose control. In one — the ACCORD trial — the intensive-control group experienced a greater death rate than the regular-control group, leading the premature cancellation of that wing of the study. When the results of all studies were combined, only two significant effects of intensive blood glucose control were found: It increased the incidence of severe hypoglycemia, and reduced the incidence of nonfatal heart attacks. However, these effects were not seen on an equal scale. According to the ADVANCE study (one of the seven), 1,823 people would need to aim for intensive blood glucose control for five years to prevent one nonfatal heart attack; within this group, there would be 23 incidents of severe hypoglycemia. According to the ACCORD trial, 104 people would need to aim for intensive control to prevent one nonfatal heart attack, but there would also be one additional death as a result, along with 7–8 cases of hypoglycemia.

There are several grounds on which the report’s position against intensive control could be disputed. First, the ACCORD trial was somewhat unusual in its finding that intensive control caused a higher risk of death. This means the results could be a fluke resulting from a particular condition of the study — although that condition remains a mystery. It appears unlikely, however, that the actual lowering of blood glucose resulted in a higher risk of death, since participants who died were likely to have a higher HbA1c level than other members of the intensive-control group. Setting this risk aside, it may be reasonable to attempt tight control in people with no history of hypoglycemia, especially if they have an elevated risk of heart attack, and if drugs or other treatment methods with a low risk of hypoglycemia are used. Finally, none of the studies included in the report examined a lifestyle-intensive program to lower blood glucose, relying instead primarily on drugs and insulin.

What do you think — have you tried intensive blood glucose control? If so, how has it worked for you? If not, why not? Are mainstream studies on tight control helpful, or do you agree with those who maintain that the methods used to achieve tight control (drugs, insulin, diet) need to be evaluated separately? Leave a comment below!

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Comments
  1. I do practice intensive blood control. I am determined to be the healthiest I can be and this is part of it for me. By doing this and tightening it up over the past few months it has given me more control. My insulin intake is down from 27 at meals to between 5-10 and my night time intake is down from 30-30 down to none. I am also now off of Metformin. It has improved my life but to keep this going I mUST be intese about it to be able to keep to diet and exercise. My goal is to be off the insulin completely

    Posted by Barbara |
  2. At face value, the idea that intensive control is more dangerous is counter-intuitive. If most deaths are associated with hypoglycemia, I can completely understand.
    I’ve been using an insulin pump for a few years, and my A1c was around 8, for a long time, using 40-50, or even more, units of insulin per day. This year, I’ve changed that. I now take around 30-35 units a day, and my A1c is 5.5.
    I’m not new to diabetes. I’ve been Type1 since 1986, and have suffered a few complications along the way. Lately, the only thing that really scares me is hypo episodes. I’m lucky in that I’m still functioning as low as 32, but…
    Frankly, I’d rather see money and energy go more towards finding a cure, than anything else. That’d take care of the complications, wouldn’t it? Since diabetes affects EVERY body system, it’s really the only way.

    Posted by Dana |
  3. Interesting article. My experience indicates that:

    1. Once BG down to 155 and a1c from 13.3 to 6.9, wreckage in my body stopped and started healing on eyes, kidneys, body etc. I am now at 6.4 and a1c at 6.4.

    2. Controlling BG to under a1c of 6 may be desireable but what it gets one I am unclear. My Doctor’s experience indicates that when people’s BG when in hospital at 140 to 180 they heal far faster and death’s are less.

    3. When young and body working correctly, it may be simple and safe to get under 6. When older on organ degeneration or medical complications, it may be more desireable to run with some slop/safety margin considering we can only tweak a few of the body’s levers externally and not all of them.

    4. In my mind, controlling the glucose generation process of the body tightly is in my mind far more important. This help gets insulin resistance back down and get body back to better operating margins. Controlling glucose has to do with controlling any super glycemic grains and carbs that cause large paking of BG. The other aspect is hearty exercise to ensure excess glucose burned out of body. Some folks are lucky in that they can handle far wider operating amounts of glucose in body and get it burnt, stored or kicked out. This is also critical to medically curb leaky livers and any other organ - hormone mis communication that overloads the glucose in body.

    Finally, put me down as not sure what tighter control unser 6 achieves even if desireable.

    Posted by jim snell |
  4. I have used intensive control since my type 1 diagnosis 5 years ago. The first 2 years of being diabetic and controlling the disease with insulin shots was challenging. I would often experience lows when exercising. My family Dr. did not want my A1C to be <6. However, 3 years ago I started using an insulin pump and now see a Joslin doctor who helps me manage my diabetes. My A1C consistantly runs 5.7-5.8, numbers that I am thrilled with. Using a pump makes it easier to control ALL aspects of my diabetes. I can do my daily 70 minute intense cardio workout followed by weight training without experiencing BG lows. I don’t know any other form of diabetic treatment except intensive control and this was my choice from the very beginning. I check my BG 10-15 times daily so that my readings never go high. Diagnosed at 48 years of age and after having this lovely disease for 5 years, I can honestly say that I am in the best shape of my life.

    Posted by Nancy |
  5. I have been practicing intensive control for about 15 years with diet and oral medications. Since switching to the Thiazolidinediones from the tradition insulin production stimulators about 7 years ago first Avandia now Actos I have maintained A1C levels ranging 5.8 to 6.3 (generally 6.0) without an incident of severe (<70) hypoglycemia and only rare < 1/month incidents of mild (<90) hypoglycemia.
    My morning, fasting BG ranges typically from 95 to 115 depending on exercise with occasional excursions to 135 - 150 when taking cortisone or after a late night ice cream binge.
    As far as long term symptoms: “perfect” annual eye examinations, and peripheral neuropathy damage that can only be observed during nerve conductance testing and remains undetectable by tuning fork or sharp stimuli. I would be greatly distressed if Actos follows Avandia and Rezulin from the market as I enjoy the benefits intensive control A1Cs without the fear of debilitating hypoglycemia.

    Posted by Doug Dierdorf |
  6. for me this is very strange. I am a diabetic for1 or 2 reasons-my mother’s mother had diabeties-they did not know what kind etc-this was in the 40s-50s. I am also obese. Both reasons or just 1 can be a contributor. I go to and endocronologis, unlike most diabetics I know. my diabeties 2 is helped with pills-actos, januvia and for some reason-crestor. it keeps me near 7 to halfway between 7 and 8. my doctor is thrilled. no insulin at all. diet is my main thrust alto I lost 40 pounds and am at a plteau. I tell you this for obvious reasons.

    if you took someone like me and suddenly made me think I had to go to 6-I would get stressed. life keeps me stressed enough-the added stress could well cause heart problems. I would then be taken off the actos, ofcourse, and made to do who knows what else and get myself in such a tizzy that between the stress from that and being poor could very well kill me!

    if my dr insisted on this I would _________get a seond opinion!!!!

    Posted by LAURA MUSHKAT |
  7. I was diagnosed with Type 2 diabetes in 1992. In about 2003 I started taking insulin, both fast acting(Novalog) and long acting(Lantus). My A1c’s were running between 7.5 and 9.0 In Nov 2009 I obtained a continuous glucose monitor made by Dexcom. Through the use of the CGM I learned many things about my body that my doctor could not know. For instance, my insulin resistance is high in the morning and decreases during the day. It takes about 30/40 minutes for my Novalog to begin lowering my glucose level. Food begins to raise my glucose level in 25/30 minutes. Using what you call tight control,I was able to reduce my A1c from 9.4 to 7.1 in 5 months with the help of the CGM. The CGM was the difference. I would suppose that none of these studies were conducted with CGMs. I would suggest that people who have diabetes use a CGM. CGMs are not without their difficulties but I for one am willing to deal with them if I can keep my A1cs in the 7 to 7.5 range. I would suggest that the studies be repeated with the new knowledge provided by a CGM.

    Posted by Axel Sjogren |
  8. Experimented with insulin. Have the slow acting one. Diabetes HbA1c kept at about 6.0.

    Had several episodes of hypoglycemia, two required ER treatment and ambulance.

    Found not worth to give insulin in evening when reading was below 199 at bedtime. Made no difference when given insulin at bedtime as morning reading about the same.

    So 200 is the cutoff number for insulin dose at bedtime.

    Posted by BimBam |
  9. I have tried “intensive control” since I developed Type 1 Diabetes in 1952. But, I seem to be a “brittle” diabetic with blood sugars going up and down. and A1C’s from the mid 7’s to 9’s. I have worked with all of the technical updates to diabetes care, now including the pump (since 1993), the CGMS for the past 7/8 years attempting to keep my A1C in the mid 7’s (without a great deal of success).

    I just had my 63 birthday and am doing alright. Although have had complications over the years including eye retinopthia in ‘78, heart attack in ‘94 and epileptic seizures in ‘10 and ‘11. Medication and surgeries have seemed to keep the complications under control.

    I am not sure why I am still alive other than that it is not extremely important to keep the blood sugars too low and I do exercise and eat well, which I do believe does help.

    Posted by Roger Beathard |
  10. folks:

    If you only need small boost on meal bolus; liquid insulin easier and offers better control.

    If you need lots of insulin, STarlix may be answer.

    ALl too often the response to Type 2 is to throw insulin at it. This may not be best answer for all cases.

    AFter years on these insulin enhancers - glyburide, stralix and the super strong stuff - actos more glucose in cells be dammed, I after hearty exercise, 1200 calorie diet, limit the super carbs - grain, corn, rice to small portions; I ended up booting ACtos, STarlix, 75/25 super insulin for an approach of metformin doses spread around clock ( forget the one day wham bamm thank you mamm one super single dose per day) and standard humalog Lispro insulin - 4 units at breakfast, lunch and dinner and after 30 years of nonsense, my numbers are back to stability, a1c is 6.4/BG 140 and under.

    Put me down as fed up with all the stain glass window regimenes that totally ignore the genetic old fashioned hunter gatherer super efficient digestion system on the garlic and onions and old raw grain unprocessed that on super carbs floods the system with glucose and causes insulin resistance and diabetes. And stop using type 1 stratagies to resolve type 2 which is equally as dangerous and problematic as type 1.

    Type 2 should receive the same training and support as type 1 and then some more.

    Posted by jim snell |
  11. Intensive control through the use of drugs in my experience left me feeling weak and drained after a hypoglycemic event due to lack of eating at pre-determined intervals. I now control my type 2 diabetes through diet and exercise with minimal drugs. Low blood sugar now does not leave me feel weak or drained and I don’t have to plan my days around eating. As a result, my A1C numbers have also dropped from 7.4 to 6.8. I believe studies should focus on intensive control through lifesyle changes seperatly from medication to see what added benefits can come from it.

    Posted by Angel A. |
  12. ok i got off my fat behind 2 yrs ago and got moving on my bike and walking fast for 30 mins every day. I refuse to take the Metformin or anything else. I cut out the white flour and sugar, i cut out milk and all pasta, and bread. I eat lots of vegetables and their juices. some nut, seeds and whole grains, especially raw almunds, sunflower seeds, brown rice , whole oats,. A little fish and chicken with out any breading or sauces. Black strap Molasses and raw honey. I use pressure points daily. I take Bitter Melon, Gymnenma, and Dr. Christopher’s Pancreas formula.I drink apple cider vinegar before each meal, and H2O2 food grade in the morning. I have lost 35 lbs and my eye sight is improving. was diagnosed with pretype 2 in 2005, full type 2 in 2007 and in 2010 they said my A1c was now 9 so i needed to take insulin. I refuse and stepped up the exercise, and got more serious about the veggies. I hav lost another 10 lbs. Fell great.Sleep better and longer. The secret is to fet off ur fat behind and stop buying the junk food. And stop the damn drugs, they dont cure . There already is a cure and has been, but the Pharmacedicals dont want u knowing about it.Take care of ur own healthe and body, u hav the best tool ever now called the internet, but years ago i did it without that and used books and info from my local health food store. And the National Health Federation. Check out Homeopathy too.And Accupressure. It is called Wholeistic Medicine, using several remedies, and methods together.This Juvenile Diabetes can be prevented and cured too. The first thing with that is to have a healthy mother who is slim. get in shape before you have a baby. Then nurse the baby for at least a year. Dont give foods till after a year. and dont even bring home the junk food. Give Veggies pureed or juiced. Oatmeal and fertile eggs, some fruit. And Avocadoes!!!! :Pineapple juice is wonderful for children and adults.Bananas are the perfect first food not balogna!!!!!i am tired and hav no more to say right now. thanks, Dot

    Posted by Dotty |
  13. I am a type 1 diabetic for 40 yrs, daignosed at age 13 to parents who were unable to handle the problem and doing what needed to be done. When I finally got hooked up to a good diabetologist nt HgA1C was 21.6. 8 shote a day wouldn’t get it below 13.4. About 20 yrs ago went on pump whuch brought A1c down to 5.5. For years being active and the pump helped me avoid most complications other than those due to my bllod glucose having been so bad for the first 8yrs that I was diabetic, Life became more conplicated when I developed hypoglycemia unawareness. I have a solution now which allows me to keep intensive control and avoid severe hypoglycemia and I wouls never stop my intensive control. Hg A1c rubs aroun 6% most of thr time. I could not do it tho without mt little service dog who alerts me when my blood glucose drops down to 60 or 65. She is incredibly accurate and since I have had her I have only once been low enoigh to havemyliver kick in to break down glycogen which keeps everything more stable since I don’t
    needto take large anoubts of insulin to drop back down after I bounce really high and risk another hypoglycemic episode. That one time I was driving a tractor where she couldn’t reach ne abd as soon as I got off she was pushing at me to tell me I was low. For those of you are worried about hypogkyecmia I would strongly recommend a hypoglycemia alert dog. She is my lifeline. I don’t worry about low BG when she is with me(almost all the time). The law requires you be allowed to take her anywhere ubder the Americans with Disabilties act. They don’t need to be taught to smell just that you need to know when thry smell the hypoglycemia. Google service dogs and diabetes or hypogkycemia and you should be able to find web sites that will tell you how to find an agency that trains alert dogs in your area.

    Posted by Margaret Sheriff DVM |
  14. Am 73 years old, Have had type II diabetes for approx. 23 years, no known or observed complications. Have never had tight control. Exercise vigorously, biking, walking, treadmill quite often (approx 5 days/week) Am on medication, glucophage & Januvia, careful and selective use of glipizide due to hypoglycemia that’s occurred as a result of use. Present A1c 6.6. Was recently taken off of Actos due to evidence in Europe that it potentially causes bladder cancer.

    Posted by Les Grinspoon |
  15. This is my question/comment: What kind of methods were used to control the A1c’s? I have type II and my a1c is always 5.2 to 5.4 with out medication–diet, type of diet and exercise and the loss of 180 pounds and keeping it off for 15 years is what helped me. I did have to use oral medications in the beginning, but have been off of them for some time now. Also, my husband who is 71(I am 60)who has been a diagnosed type II since 1989, and who went from oral meds to insulin and back to oral meds, and now is not on any kind of meds has a normal A1c (5.4), normal EKG. I believe that Doctors and pharmaceutical companies collaborate and do more harm than good. Today’s society has been trained from infancy to rust all that the doctor orders/says, but we have fond that natural means of treating an illness is more beneficial and not dangerous, nor deadly, nor does it have side effects. I think it is time we all start to question the Doctors more and take seriously the side affects listed on the medications print out and find alternative ways that are natural to deal with this and many other diseases.

    Posted by Star Shepherd |
  16. I can easily see why Intensive Control would never receive favorable results with the way diabetes is treated…

    Several years ago I dumped the recommended high carb diet and asked for insulin, which I use before meals and meet my requirements through careful planning. I am LADA (type 1.5) and brittle, but I did learn the patterns and factored it all into my plan which includes testing 7 to 10 times a day.
    In short it worked and I managed to achieve very tight control with most of the nasty complications disappearing in time. It’s a long story but the effort was worth it… you get used to living a couple of hours at a time if the reward is there. I’m over 65 and have maintained the same weight as when I was 30 and I never diet.
    Don’t pig out either :)

    Diabetes is a “grey-scale” disease and the current pattern seems to be to lump everyone into Type 1 or 2 and hope for the best — that was my first mistake.

    How could you possibly control your blood sugar when it is up and down like a yo yo?

    Posted by John_C |
  17. I have practiced tight control several times over the past decade. Each time led to serious hypoglycemic events. Also, having the numbers change each time I reached the “ideal” a1C was very frustratwing. My last attempt led to a quadruple bypass and an MI, though I am sure other things came into play.

    I’ve been rrun through so many drugs. I just want something that works for me with fewer sticks.

    Jim

    Posted by James |
  18. I agree with those who have gotten up and started moving. Was diagnosed with Type 2 13 years ago, at which time I was 225 lbs and had an A1c of over 12. Now I am at 122 with A1c of 5.3. Take Levemir, Byetta, and Metformin. The Byetta has really helped with the weight loss. It’s really worth a try. The important thing is getting active, starting with pushing away from the table. People, you don’t want to go through the trauma of having a major heart attack at 53 like I did. There is a big world out there that needs to be explored!

    Posted by Cathy A. |
  19. Absolutely - exercise, meds, carbs control and for exercise for me is to walk 1 to 2 miles a day.

    Equivalent other forms of exercise acceptable.

    Cathy’s experience is dead on. I had stroke in 2007 and spent 4 years fixing and getting a1c of 13.3 down to 6.4 and BG of 140 average and seeing weight finally drop.

    Always remember that Insulin does not get rid of the glucose - only gate enabler to cell. Exercise
    really gets rid of. Otherwise it gets stored.

    Posted by jim snell |
  20. I was diagnosed with Type I, in 1959. While I have not participated in Intensive Control, like many Type I diabetics, I find that the lower my A1C (mine is in the mid-6 range), the more frequent the hypoglycemia events and the more weight I put on. Use of a pump and CGMS certainly help me know when levels are either too high or too low and I love the freedom they give me.
    I agree with Dana (Aug. 2 post), that finding a cure is more important than studies such as these, but…these studies have taught us how important tight control is to avoiding complications.

    Posted by Trudi Peters |
  21. One mention of CGM in the comments. I just recently received it and within a week I have even tighter control. My A1cs have been upper 6’s and low 7s for several years but with the cgm I know its gonna get even better.

    Posted by John S |
  22. I did practice a tight control. Using two drugs metformin and Januvia I had A1c of 6.1 to 5.3
    But i was constantly tired and having to eat to keep from having hypoglycemia episodes. The results were a B12 insufficiency, a gain of 30 lbs, neuropathic pain to the point I could not do my walking for exercise.
    After they gave me B12 shots for 3 months the hypoglycemia snd eating to avoid it got worse so I cut out the Metformin and Januvia. I do not have the results of my latest A1C but my average blood sugar is 130, 20 points lower than with the drugs.
    I have lost 10 lbs eating more food. I have no neuropathic pain, I stopped wearing my glasses most of the time because I do not need them except to read in a dark area. I do not have the hunger cravings. I am walking again. My lowest blood sugar has been 75. My highest 187. I have started eating nuts to keep it more even. That seems to help but I have only been doing that a week. I have few food cravings and don’t have to eat at the end of my work shift so I can drive. It is usually 95 or higher now.
    I had several bad hypoglycemic episodes, with blood sugars as low as 40. People thought I was drunk, and I was very stupid and confused then. If I had operated a motor vehicle I think I would have certainly had an accident. I have been tested recently for stamina and my lungs. I am normal for my age. That would not have been the case when I was getting no exercise.
    Thanks, -DAN-

    Posted by Daniel Arnold |
  23. There is another issue which has not been addressed: Not everyone glycates at the same rate, so some people can achieve a lower A1c than others, even with the same average BGs. Even when I was eating carbs freely, and always peaking over 200, and sometimes over 250, my A1c was never out of the 6’s, except last year, when I was depressed, bingeing on carbs (but still taking insulin, albeit not enough), and had BGs of 400 and up for a couple of months before I finally went into a coma. And even then, my A1c was only 10.7. After that near-death experience, I have limited carbs to those foods which have other reasons to recommend them — vegetables for fiber and phytonutrients, meat, cheese, eggs for protein, and a little bit of dairy for calcium. My last A1c was 5.8, but I NEED to have an A1c that low, or lower, because I just don’t glycate very much. And that may have to do with the fact that I don’t have any complications after almost 20 years with diabetes and less than spectacular control.

    Posted by Natalie Sera |
  24. natalie Sera:

    Great comments - thank you.

    Obviously every one wants there average to be back to “normal” as much as possible.

    Getting a1c under 7 and back to 140 and under does seem to cut damage back dramatically.

    My evidence bears that out and in spades.

    Whether a body suffering from age degredtaion can be fine tuned back all the way to normal is I think a question with current technology and safety margins necessary to stop hypoglycema events and damage.

    Evidence today suggests no major benefits today and sets up goals that are a Bridge too Far - Arnheim for most folks and causes more harm than good on balance.

    Posted by jim snell |
  25. I do practice intensive blood control. I am determined to be the healthiest I can be and this is part of it for meI’ve been using an insulin pump for a few years, and my A1c was around 8, for a long time, using 40-50, or even more, units of insulin per day.My morning, fasting BG ranges typically from 95 to 115 depending on exercise with occasional excursions to 135 - 150 when taking cortisone or after a late night ice cream binge.I am not sure why I am still alive other than that it is not extremely important to keep the blood sugars too low and I do exercise and eat well, which I do believe does help.

    Posted by Service dog |

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