Diabetes Health Goes Beyond Blood Sugar

The startling findings of a major study on the effects of lowering blood
sugar are unlikely to change the way most people with Type 2 diabetes manage
their illness, doctors said.
The study, showed that an intensive program to lower blood sugar actually
increased risk of death. The findings were so surprising that the study was
stopped early, and they seemed to undercut the accepted wisdom that people
with diabetes should do everything possible to get their blood sugar down to
normal.
But the methods used in the study, called Accord (for Action to Control
Cardiovascular Risk in Diabetes), bear little resemblance to the techniques
most doctors and patients use to manage blood sugar levels. And the patients
in the study were typically far sicker than many people with diabetes today.
"The intensity of what we did is done virtually nowhere on the planet," said
Dr. John Buse, vice chairman of the study's steering committee and the
president of medicine and science at the American Diabetes Association. "It'
s far beyond what's common in clinical practice." Dr. Buse called the study'
s regimen to lower blood sugar a "brutal program."
Still, doctors are likely to reconsider their emphasis on lowering blood
sugar at all costs, because it is becoming clear that other factors
influence the overall health of patients with diabetes.
The New England Journal of Medicine published a study this week showing that
a three-pronged approach of managing sugar, blood pressure and cholesterol -
combined with low doses of aspirin - prolonged the lives of people with
diabetes. The patients who did best in that study did not reach the nearly
normal sugar levels that were the aim of the Accord study. Instead, their
levels were just slightly higher than normal.
In the Accord study, the group of patients who were randomly assigned to
lower their blood sugar levels to nearly normal had 54 more deaths than the
group whose levels were less rigidly controlled. The patients were in the
study for an average of four years when investigators stopped the intense
regimen and put all of them on the less intense one.
"When we look at mortality in patients with Type 2 diabetes, it's not only
the blood sugar," said Dr. Joel Zonszein, director of the Clinical Diabetes
Center. "What the study shows is that just lowering blood sugar is not
protecting you from dying sooner. Blood sugar is important, but so is blood
pressure and cholesterol."
Patients with newly diagnosed diabetes still appear to have much to gain by
keeping their blood sugar levels as close to normal as possible through
healthful eating and exercise. But patients who have had a heart attack and
have other risk factors need not feel guilty if they cannot get their blood
sugar to normal levels, Dr. Buse said.
"The most important thing is get your blood pressure controlled, cholesterol
controlled, and do a reasonable job on your diabetes, but don't go wild," he
said. "We are backing away from notion that we always have to push, push,
push to get blood sugar lower."
Today, many patients with diabetes take two or three drugs to manage their
blood sugar levels. In the Accord study, many patients took multiple drugs
and insulin shots, adhered to strict diets and regularly met with counselors
and doctors who monitored them. No single drug treatment was prescribed;
doctors used whatever combination of various treatments that appeared to
work best in each patients.
The researchers still have to sift through the data on those who died to
find out whether there was any pattern that might help explain why patients
in the intense treatment group fared worse. It may be that they were simply
sicker to begin with. It may have been the number of drugs they used or the
pace at which their blood sugar dropped.
Dr. Buse said one little-discussed issue was the sheer stress of the
treatment program itself. He noted that the program demanded a lot of effort
from patients but that it was still exceedingly difficult for any of them to
achieve the blood sugar levels that had been set for them. Many patients
with diabetes feel stressed when they fail to meet blood sugar goals set by
their doctors.
"At some level I just wonder if some of them were just overwhelmed by this
psychologically," Dr. Buse said. "Could it be the stress of 'I'm trying so
hard, but I can't get it done'?" [NYT]