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How Low Should You Go?
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By John McIntosh
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Diabetes Focus Spring 2009
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 | Judith Fradkin, M.D., is a member of the NDEP executive committee and director of the Division of Diabetes, Endocrinology and Metabolic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
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National Diabetes Education Program (NDEP) spokesperson and executive committee member Judith Fradkin, M.D., is dedicated to helping people understand the latest information about how to manage type 2 diabetes. She shares her insights.
We want to help people with type 2 diabetes understand the benefits and potential risks of aiming for tight glucose control. Recent studies offer new insights into both.
Let’s start with the benefits.
Basically it breaks down like this: If you are newly diagnosed with type 2 diabetes and still relatively healthy, you can reap lifelong benefits from tight control of your glucose levels through lifestyle changes, oral medications and perhaps insulin. The UK Prospective Diabetes Study (UKPDS) has shown that early, intensive control reduced the risk for heart disease and death a decade after the participants followed a regimen of tight glucose control. Follow-up of participants in an earlier study, the Diabetes Complications and Control Trial, also found that long after they practiced tight control, they reaped the benefits.
Something called metabolic memory appears to be at work. The body continues to benefit from a period of lower glucose levels and tight control for years after the tight control is stopped. It seems to reduce problems such as heart disease as well as complications of the eyes and kidneys.
The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trials showed that very tight control (aiming for an A1C of 6) may be risky for folks who have had type 2 diabetes for 10 years and also have diagnosed heart disease or are at high risk for heart disease. In those people, researchers saw an increased risk of death, as well as other problems such as low blood sugar reactions. So people with longstanding diabetes and heart disease or those with health problems that limit life expectancy probably shouldn’t go for tight control. Early on, those in good health can aim for tight control at or below an A1C of 7.
The NDEP has a “Control Your Diabetes for Life” campaign emphasizing comprehensive control of glucose, blood pressure and cholesterol, as well as getting physical activity, eating a healthy diet and not smoking. There are general goals for A1C, blood pressure and cholesterol, but they must be tailored to the individual. People with heart disease and long-standing diabetes might have lower cholesterol goals and less strict A1C goals, for example, and those with kidney disease should find optimal ways to control blood pressure. The only way to assess your needs is to sit down with your health-care provider and find out what’s best for you.
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