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Tight Control OK if You Want It

David Spero

June 24, 2009

Surprise! I — and various other diabetes bloggers — were right. Ever since results from the ACCORD study were released last year, some in the media and the medical establishment have been reporting that strict blood glucose control is bad for people with diabetes.

ACCORD stands for Action to Control Cardiovascular Risk in Diabetes. The study found that people assigned to the intensive blood glucose control group had more deaths from cardiovascular causes than those in the standard control group. The researchers and much of the media presented the results with stories that blared: “Low blood sugar causes heart deaths! The Diabetes Control and Complications Trial (DCCT) and United Kingdom Diabetes Prevention Study (UKPDS) were wrong! We need to be much looser about glucose control and more aggressive in treating hypertension and cholesterol!”

Since then, at least two more major studies have come out making similar claims. The Veterans Affairs Diabetes Trial (VADT) and the ADVANCE trial both found that lowering HbA1c to 6.5% didn’t reduce cardiovascular risk or risk of certain complications or death as compared to an A1C of 8% or so. A possible conclusion to draw from these studies: tight control doesn’t help.

But as I keep pointing out, the means of tight control in all these trials was the same — piling on more drugs. And as Drs. Victor M. Montori, MD, MSc, and Mercè Fernández-Balsells, MD, wrote in a recent Annals of Internal Medicine article, these drugs put the burdens of costs, side effects, management, and hypoglycemia on patients.

In some critics’ views, the drugs, not the low A1C numbers, were causing the extra deaths. Now a study out of the American Diabetes Association’s 69th Scientific Sessions begins to confirm some of these suspicions.

The original researchers went back through the ACCORD patient records to determine the causes of death. According to an article in Reuters, Dr. Denise Bonds, one of the ACCORD investigators, told reporters that hypoglycemia was likely not the cause. “Now,” says the article, “researchers are looking to other factors, such as drug combinations or age, as potential reasons for the deaths.”

Gee, you think? I mean, some of the drugs used in these studies for tight control, such as Avandia (rosiglitazone), are known to increase the risk of certain heart problems. So how come they blamed the tight control instead? Are some “experts” starting to realize that drugs aren’t the answer to everything in diabetes? That maybe we shouldn’t be loading older, sicker people down with intensive treatments, and should focus instead on well being and self-management?

I like what Drs. Montori and Balsells wrote: (Apologies — scientific language coming…) “Clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction… Given that patients with diabetes often have [other] conditions, clinicians should avoid glycemic control interventions that overwhelm the patients’ capacity to cope clinically, psychologically, and financially…”

“Keeping the HbA1c level between 7% and 7.5% seems reasonable and feasible for many patients… Glycemic targets can be adjusted up or down according to the burden of treatment; side effects; and the patient’s context, values, and preferences. Given the possibility that tighter control may be beneficial, some patients who are less concerned about downsides, and are ready to do whatever may possibly help, may choose tighter control.”

What do you think? Does this approach make sense to you? Remember, there are other ways besides drugs of achieving control — things like stress reduction, physical activity, better eating, and emotional and spiritual healing. And changing from overdoing drugs for blood glucose to overdoing drugs for cholesterol or blood pressure is not likely to help. Does any of this change your thinking, your plans, or your goals for self-management? Please let us know by commenting here.

And Now for Something Completely Different
Diabetes alert dogs are becoming all the rage. Apparently, dogs can differentiate the smell of a person with low, normal, or high blood glucose. They can be trained to warn their owners if their glucose is too high or too low.

A report on some Illinois television stations told about a nine-year-old girl with Type 1 named Allison. Her service poodle Keony has prevented the seizures Allison used to suffer when her glucose got low. “He will eat my hair if I’m high,” says Allison, “and either paw at me or lick me if I’m low.”

Couldn’t we all use a dog like that? If you’re interested, contact the Delta Society or look up “diabetes service dogs” on an Internet search engine such as Google.

High Glucose = Low Testosterone
The Endocrine Society’s 2009 meeting in Washington, DC, reported on the results of a study of 74 men, some with normal blood glucose and some with prediabetes or newly diagnosed Type 2 diabetes. Each man drank a glucose solution, then had his testosterone levels tested. Whether the men had diabetes or not, their testosterone level dropped as much as 25% after they drank the glucose, and it stayed down for more than two hours. So if you’re having problems with sex drive or function, one thing to consider is getting glucose levels down.



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