How Low Should Your Blood Sugar Go?

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.

Today, after reviewing the current guidelines, the American College of Physicians (ACP) advised that most people with type 2 diabetes not go below 7 percent on the HbA1c test, which measures long-term blood sugar control.

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.

C. Diff: Deadly Infection on the Rise in U.S. Hospitals

Consumer Reports' new Ratings show many teaching hospitals fail to prevent this deadly disease

By Hallie Levine
Last updated: March 04, 2016
consumerreports.org

A life-threatening bacterial infection is gaining ground in America’s hospitals, according to a new report from the Centers for Disease Control and Prevention. And a Consumer Reports analysis finds that even some of the nation’s largest and most prestigious medical institutions are having a hard time getting it under control.

The infection, called C. diff (Clostridium difficile) sickened 101,074 hospital patients in 2014, the most recent data available, according to a March report from the CDC. Other research shows that overall about 450,000 people a year, inside and out of hospitals, are sickened by the infection, and it contributes to the death of about 29,000 people.

"New data show that far too many patients are getting infected with dangerous bacteria in healthcare settings,” said CDC director Tom Frieden, M.D. “Doctors and healthcare facilities have the power to protect patients—no one should get sick while trying to get well," he said.

While several serious hospital-acquired infections, such as those caused by central-line catheters, have declined in recent years, C. diff. rates increased by 4 percent between 2013 and 2014, according to the CDC.

And Consumer Reports’ updated Ratings of more than 3,200 hospitals across the country show that many are doing a poor job of reining in the infection. Overall, about a third of them received a low Rating in combating the infection. That means they have C. diff infection rates that are worse than the national benchmark.

That includes 24 of the nation’s largest teaching hospitals, including familiar ones such as Baylor University Medical Center in Dallas, the Cleveland Clinic in Cleveland, Cedars-Sinai Medical Center in Los Angeles, Johns Hopkins Hospital in Baltimore, and Mount Sinai Hospital in New York City. “Teaching hospitals are supposed to be places where we identify the best practices and put them to work,” said Lisa McGiffert, director of Consumer Reports' Safe Patient Project. “But even they seem to be struggling against this infection,” she said.

While about 28 percent of hospitals nationwide earned one of our top two scores in preventing the infection, only four of them were large teaching hospitals: Harris Health System in Houston, Maine Medical Center in Portland, Maimonedes Medical Center in Brooklyn, N.Y., and Mount Sinai St. Luke’s - Mount Sinai West in New York City.

(See the chart below for a complete list of low-scoring large teaching hospitals. And check our free hospital Ratings to see how your local hospitals score on infection prevention for five different types of infections and other key safety measures.)

How C. Diff Spreads

There are two important reasons why C. diff is hard to control in U.S. hospitals.  

First is the misuse of antibiotics in hospitals, said Erik Dubberke, M.D., associate professor of medicine in the Division of Infectious Diseases at Washington University in St. Louis and a spokesman for the Infectious Diseases Society of America. “Those drugs are obviously lifesaving when used appropriately, but they can also make you vulnerable to C. diff,” he said. That’s because those drugs can kill off the “good” bacteria that normally grow in your stomach, allowing bad bacteria, including C. diff, to spread.

About half of all hospitalized patients receive antibiotics during their stay—even though up to 50 percent of such prescriptions are unnecessary or inappropriate, according to the CDC. Particularly worrisome is when patients are given powerful “broad-spectrum” antibiotics, such as ciprofloxacin (Cipro and generic) and levofloxacin (Levaquin and generic), which are meant to act against a variety of disease-causing bacteria at once, instead of drugs that target specific bacteria. That increases the chance of developing C. diff, because those drugs are more likely to kill off the body’s good bacteria along with the bad.

The second reason is poor hygiene. C. diff, which is found in fecal matter, is easily passed from person to person on the hands of healthcare workers—and can survive on door knobs, bed rails, and other surfaces for weeks.

Proper hygiene—including washing hands and, especially, wearing gloves—can cut the spread of the disease. But less than a third of healthcare workers in intensive care units always wash their hands, according to a 2014 University of Iowa study. And a Consumer Reports survey of 1,200 recently hospitalized people found that only about half always saw their doctor or nurse wash their hands.

“Doctors and nurses get busy, and they sometimes simply forget to rewash their hands every time they walk into a new patient’s room,” said Louise-Marie Dembry, M.D., professor of medicine and epidemiology at Yale University and president of the Society for Healthcare Epidemiology of America.

What Hospitals Say

Representatives of some of the low-scoring teaching hospitals in our Ratings say that institutions like theirs face special challenges in combating C. diff.

For example, they may see sicker patients than non-teaching hospitals, said Craig Civale, a spokesman for Baylor University Medical Center. “As a major academic hospital in an urban setting, BUMC routinely admits very complex patients with multiple conditions,” he said. A spokeswoman for Cedars-Sinai Medical Center offered a similar explanation for its hospital's C. diff infection rate, and also notes that it sees an unusually large number of older patients, who are at increased risk of the infection.

Another factor may simply be that teaching hospitals detect more cases of the disease than do other hospitals, because they test and report more carefully, said Lisa Maragakis, M.D., senior director of health care epidemiology and infection control for the Johns Hopkins Health System.

Still, hospital officials acknowledge that C. diff. is a serious problem, and that they are responding by changing their practices. “The results reported by Consumer Reports are disappointing to us,” said a spokeswoman for Mount Sinai Hospital in a statement. Mount Sinai also said that it has recently established a task force to look into the hospital’s infection rates, and is investigating “evidence-based practices targeted to reduce all healthcare-associated infections.”

At Baylor, the hospital is developing new protocols to ensure that antibiotics are prescribed appropriately, Civale said. Johns Hopkins is taking similar steps, and is also instituting “rigorous hand hygiene and environmental cleaning initiatives,” Maragakis said. In addition to to those steps, Cedars-Sinai now tests all patients with diarrhea for C. diff, a spokeswoman for the hospital said. And in a statement to Consumer Reports, the Cleveland Clinic noted that the hospital is “committed to continuous improvement in quality and safety.”

What You Can Do

If you (or family members or friends) are in the hospital, here’s what you can do to reduce your risk of developing a C. diff infection:

• Make sure you really need that antibiotic. If your doctor wants to give you an antibiotic, ask why. If he suspects an infection, he should do a rapid culture, if possible, to quickly pinpoint the possible bacteria so that he can prescribe the most effective antibiotic at the lowest dose. 
• Watch out for heartburn drugs. Hospital patients are sometimes prescribed heartburn drugs called proton-pump inhibitors such as omeprazole (Prilosec and generic) and esomeprazole (Nexium and generic) to ease stomach pain. But those medications can also increase the risk of C. diff infections taking hold in your stomach. So if your doctor suggests you take one of those drugs while in the hospital, ask why. 
• Insist on hand-washing and gloves. Ask everyone who walks into your room whether they’ve washed their hands—if they’re doing it at your sink, make sure they scrub for 40 to 60 seconds. Also check that they are wearing gloves. Rubbing on alcohol-based hand sanitizer is not strong enough to destroy C. diff, Dembry said. 
• Ask about the hospital’s protective measure: Hospitals should order a C. diff test for any patient who has diarrhea (three loose stools within 24 hours), said the CDC. Anyone with diagnosed C. diff should be put in a single room, and healthcare providers should wear gloves and gowns when treating that patient.