Aggressive Control of Diabetes Reviewed

A report in the medical journal Diabetes Care says that people with type 2 diabetes who have more difficulty lowering their blood sugar levels are at greater risk for death than those who are better able maintain lower levels.

The new report looked at an earlier clinical trial halted in 2008 after researchers noticed an increase in deaths in the group of people with type 2 diabetes. This group was being intensively treated to bring their blood sugar levels down to near-normal levels.

Dr. Matthew Riddle, a professor at Oregon Health and Science University and lead author of the new study, says a new look at the data from that study has found that a rapid lowering of blood sugar (glucose) levels was not the cause of the increased risk of death.

Some deaths in the earlier ACCORD study (Action to Control Cardiovascular Risk in Diabetes) can be attributed to the fact that some of the participants had been diagnosed with diabetes years earlier and were already suffering from diabetic problems, says Dr. Riddle.

However, even though the research team excluded intensive diabetes control as a concern, they still are not clear what factors may have played a role.

A1C Key Test in Understanding Diabetes

In the previous study, the A1C test was reviewed in order to estimate two to three months of blood sugar control. The American Diabetes Association recommends that most people with diabetes try to maintain an A1C of 7 percent or less. This translates to an average blood sugar reading of about 154 milligrams per deciliter.

The hemoglobin A1C test (also called HbA1C test, or A1C) shows the average amount of sugar in the blood over the last three months. The result will indicate if the blood sugar level is under control.

Dr. Riddle emphasizes that people who rapidly lowered their A1C did not have excess deaths, and, in fact, it was the ones who could not bring their A1C level down that had risk for death.

In the ACCORD clinical trial, which included more than 10,000 people with type 2 diabetes, one group was trying to achieve an A1C level of less than 6 percent, which is a normal level. Most people with type 2 diabetes have significantly higher A1C levels.

The reason lowering A1C is important is that other studies have shown that for each 1 percent increase in A1C levels, there is a 15 percent to 20 percent higher risk of cardiovascular disease. And, as A1C levels rise, so do the risks of kidney disease, eye disease, and nerve damage.

To achieve A1C levels of less than 6 percent, most people with type 2 diabetes would need medications and aggressive lifestyle changes, such as losing weight and exercising more often.

Progress, But Better Understanding Needed

Dr. Riddle says, "We need to know what it is about those who couldn't lower their glucose levels that puts them at greater risk. We need to find more specific red flags for clinicians to look for."

He adds that although most people would like a standard set of goals and advice for everyone with type 2 diabetes, there is no one-size-fits-all approach. There are different treatments for different groups.

The study shows that many people can safely achieve good glucose control, says Dr. David Kendall, chief scientific and medical officer for the .

He says it appears that some people with diabetes may have a more challenging situation or there may be other barriers that experts are not aware of yet.

The bottom line, says Dr. Kendall, is that there is no reason to change treatment targets for glucose control for most people.

Always consult your physician for more information.