Updated June 16, 2006

Tight Control

Based on this and other powerful evidence, aggressive blood glucose control as practiced in the DCCT and UKPDS has become the goal of self-care for most people with diabetes, and they should expect their doctors to help them achieve tight control.

To reach the target HbA1c of less than 7% (goals of less than 6% are considered for some individuals), the ADA recommends aiming for the following blood glucose levels:

• Average blood glucose levels before meals should be 80–120 mg/dl on meters that give whole blood values. On meters that measure plasma glucose, the levels before meals should be 90–130 mg/dl.
• At bedtime, average whole blood glucose levels should be 100–140 mg/dl, and plasma glucose values should be 110–150 mg/dl.

If premeal blood sugar levels are consistently within the target range but the HbA1c level is still high, the ADA also suggests monitoring one or two hours after meals and treating out-of-range numbers appropriately. Striving for postmeal plasma glucose values of less than 180 mg/dl may help lower HbA1c.

Ultimately, however, these blood glucose targets must be tailored to the individual, and tight control is not for everyone. All of the studies demonstrating the value of tight blood glucose control have also shown that it is associated with an increased risk of hypoglycemia. Those who are especially prone to hypoglycemia may need somewhat higher target values. In particular, elderly adults, who can experience stroke or heart attack from episodes of hypoglycemia, and who may have a harder time recognizing symptoms of hypoglycemia, may be advised not to attempt tight control. Some people who already have severe complications (particularly end-stage kidney disease) may also be advised against tight control. Work with a health-care professional before starting a regimen of tight control.

Tight control has also been associated with weight gain, but such weight gain can be prevented or reversed. The weight gain associated with improved blood glucose control usually comes from absorbing calories that previously were eliminated in urine, overtreating hypoglycemia, and consuming more food after learning to match carbohydrate grams with insulin. Consuming fewer calories and learning to treat hypoglycemia without overtreating it can remedy the situation.

This article was written by Robert S. Dinsmoor, a Contributing Editor of Diabetes Self-Management.

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