The treatment guidelines for diabetes, from the American Diabetes Association, recommend a baseline level of blood glucose control for almost everyone. After that, it’s up to doctors and patients to decide when it makes sense to work toward tight blood glucose control — trying to achieve levels near what a person without diabetes would have. While tight control might sound great in theory, its potential benefits have to be weighed against the risk of hypoglycemia (low blood glucose) that often comes with aggressive diabetes management.
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There are no hard and fast rules about who should try to achieve tight blood glucose control, but it’s assumed that younger, healthier people have the most to gain from its long-term benefits — and usually a lower risk for hypoglycemia. Many older people, on the other hand, have little to gain from tight blood glucose control, and potentially a lot to lose from hypoglycemia. In a healthcare system that’s well tailored to individual patients’ needs, you’d expect to see more tight control in younger and healthier people with diabetes, and less in older and sicker people.
Unfortunately, that’s not the healthcare system we live in, according to the findings of a new study. Published in the journal BMJ Open Diabetes Research & Care, it involved researchers from the Mayo Clinic looking at medical records from nearly 200,000 people with type 2 diabetes. They examined HbA1c levels (a measure of long-term blood glucose control), use of insulin and sulfonylurea drugs (both of which can lead to hypoglycemia), and whether people had 16 other health conditions that the American Diabetes Association says should prompt consideration of more relaxed blood glucose targets.
The researchers found that overall, the highest HbA1c levels — with an average level of 7.7% — were seen in the age group of 18 to 44, while the lowest average HbA1c level, 6.9%, was in the age group of 75 and older. People with none of the 16 other health conditions also had the highest average HbA1c on this spectrum, 7.4%, while those with the most serious conditions for reconsidering blood glucose control — such as dementia, cancer, and end-stage kidney disease — had the lowest average HbA1c, at 7.0%. Each of these results is the opposite of what you’d expect to see under the treatment guidelines.
It’s important to note that the reported HbA1c levels are what people actually achieved, rather than what their targets were — so it’s possible that younger, healthier people simply weren’t taking their diabetes management as seriously as other groups, or that older, sicker people experienced unexpected hypoglycemia that brought their HbA1c down. But no matter what, the outcomes show that there’s a lot of room for improvement when it comes to personalizing diabetes treatment goals, and making sure patients have the ability to achieve them.
Doctors “should continue to engage their patients in shared and informed decision-making, weighing the risks and benefits of glucose-lowering treatment regimens in the specific context of each patient, carefully considering the patient’s comorbidity burden, age, and goals and preferences for care,” the researchers write.
If you have any questions or ongoing problems related to your diabetes treatment plan or goals, talk to your doctor about the possible risks and benefits of changing your treatment.