Important new guidance for those with type 2 diabetes
From FB: Consumer Reports / Hallie Levine / March 5 2018
People with type 2 diabetes are typically advised to
aim for levels of blood sugar, or glucose—the energy from food that fuels our
cells and organs—that are close to those for people without diabetes. But
just how near-normal these levels should go has long been a matter of
disagreement.
Often,
doctors encourage them to strive for an HbA1c of 6.5, which can require high
doses of multiple medications. (Normal is less than 5.7, while 5.7 to 6.4
is considered prediabetes—and anything higher is diabetes.)
But
when the ACP analyzed the evidence behind the guidelines, they found that
bringing blood sugar levels down to between 7 and 8 was enough to reduce the
risks of major diabetes complications such as heart attack, stroke, and damage to eyes, nerves, kidneys,
and feet.
“Going lower than that didn’t provide any more
benefit, and, in fact, in some cases caused harm by causing blood sugar to drop
too low,” explains Jack Ende, M.D., president of the ACP. And left untreated
for long enough, low blood sugar, or hypoglycemia, can cause seizures, heart
attack, or stroke.
The ACP recommendations are in line with what
Consumer Reports and some other organizations have been saying for several
years. “It’s much more consistent with what current evidence suggests:
Aggressive treatment isn’t just unnecessary for many people but is potentially
harmful,” says endocrinologist Marvin M. Lipman, M.D., Consumer Reports’ chief
medical adviser.
Not everyone agrees. The American Diabetes
Association (ADA), for example, considers an HbA1c of less than 7 percent
suitable for the majority of those with type 2 diabetes.
“By lumping ‘most’ people with type 2 diabetes
into a 7 percent to 8 percent target range, ACP’s new guidance may cause
potential harm to those who may safely benefit from lower evidence-based
targets,” says William Cefalu, M.D., chief scientific medical and mission
officer at the ADA.
If you’re currently being treated for type 2 diabetes, here’s what
you need to know to make sure that your blood sugar is at the level that’s
right for you.
The New Recommendations
To develop its new advice, the ACP reviewed six
sets of blood sugar guidelines—from organizations such as the ADA and the
American Association of Clinical Endocrinologists—and the evidence behind them.
Four of the six recommend a target of 7 percent or lower, and two
guidelines suggest a range and advise that doctors take factors such as age and
other health issues into consideration.
All the guidelines are based primarily on the
findings from five major clinical trials. Some of the trials determined that
lowering HbA1c to less than 7 slightly reduced the risk of eye and kidney
damage, and others did not.
And, the ACP found, the trials didn’t
consistently show that maintaining very low HbA1c numbers helped reduce heart
attack, stroke, or deaths overall.
In addition, the evidence suggested that such tight
blood sugar control seemed to lead to much higher rates of hypoglycemia—and
resulting hospitalizations.
“Based on our analysis, we felt that the evidence
showed that going below 7 percent didn’t reduce deaths or macrovascular
complications such as heart attack or stroke, but it did cause harms such as
low blood sugar,” Ende says.
In fact, some research found that people who
lowered their HbA1c levels to less than 6.5 had a higher risk of death
from heart disease than
those who were generally between 7 and 8.
The ACCORD study, for example, found that people on intensive drug
treatment who got their HbA1c lower than 6 were more than 20 percent more
likely to die of any cause, 35 percent more likely to die from heart disease,
and almost twice as likely to gain more than 22 pounds.
“When people’s blood sugar gets too low, their body responds as if it’s under
major stress: Their heart rate increases and they sweat, both of which increase
risk of a cardiac event,” Ende says.
What Should You Do?
The ACP now not only recommends aiming for an
HbA1c level of between 7 and 8 percent but also advises that people who dip
below 6.5 percent have their diabetes medication doses lowered.
“In these patients it’s reasonable to scale back
on dosage and instead encourage them to get their numbers even lower through
lifestyle changes such as losing weight and exercising, which carry the same
risk-reduction benefits without the potential harm of drugs,” Ende says.
That said, if you have type 2 diabetes, and are
younger than 65 and in good health, it’s reasonable to aim for an HbA1c between
6.5 and 7, Lipman says. “And if you’re slightly above the 7 mark—say at 7.1 or
7.2—there’s no reason to push yourself to go any lower. By doing so, you begin
to flirt with episodes of low blood sugar,” he says.
If you’re older, and have co-existing health
conditions such as heart or lung disease, an HbA1c between 7 and 8 is fine. “In
this group, especially if life expectancy is less than a decade, it doesn’t pay
to be too strict about it,” Lipman says. That’s because the main purpose
of treatment for this group is to prevent symptoms that occur from high
blood sugar, such as increased urination, dehydration, and unwanted weight
loss, he adds.
Whether you use diabetes medication or not, it’s
important to focus on lifestyle changes—even if your blood sugar is under
control.
“Many times, type 2 diabetes can be completely
reversed by getting down to a normal weight,”
says Michael Hochman, M.D., M.P.H., assistant professor of clinical medicine at
the Keck School of Medicine at the University of Southern California and
director of the USC Gehr Family Center for Health Systems Science.
One study published in the medical journal The Lancet
this past December, for instance, found that about half of people with type 2
diabetes who underwent an intensive weight-management program went into complete
remission.
“It’s important for patients to realize that if they are proactive
enough about lifestyle, they may not need to be on medication at all,” Hochman
says.
