Diabetes conundrum: Can control be too tight?

Intensive management is increasingly the focus of care guidelines, but it doesn't come easy.

By Victoria Stagg Elliott — Posted June 7, 2004

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Robert M. Cohen, MD, an associate professor of endocrinology at the University of Cincinnati College of Medicine, has long been sold on the notion that fewer complications result when diabetics keep their blood sugar numbers as close as possible to those who do not have the illness.

The approach is known as tight control, and Dr. Cohen always considered it the optimum course. But recently, two of his patients were involved in separate car accidents. In each crash, his patients' low blood sugar was possibly to blame. Now, though he still believes that tight control is a good populationwide recommendation, he's no longer quite as sure that it works for everyone.

"What I've learned recently has made me a little more moderate in my goals," Dr. Cohen said.

Many doctors now find themselves seeking a balance between aggressive diabetes treatment plans and real-life forces. Sometimes the answer emerges from the saying: Don't let the perfect be the enemy of the good.

Since the release of the results from the Diabetes Control and Complications trial in 1993 and the United Kingdom's Prospective Diabetes Study in 1998, guidelines have emphasized aggressive disease management to reduce amputations, blindness and other common complications. For instance, the most recent American Diabetes Assn. directives issued in January recommended that hemoglobin A1c levels should be less than 7% in most patients, although less than 6% could be considered a goal for some.

Like most guidelines, these allow for customization based on such factors as age, work or school schedule, or personality. "The guideline is a goal, and all goals will not be achieved, but the closer you get to the goal the better," said Nathaniel Clark, MD, a registered dietitian and the ADA's national vice president for clinical affairs.

Physicians say, however, that this message can get lost in the pursuit of lower numbers. The burden on patients can be significant.

Sources of strain

"Sometimes people who don't need a complicated insulin regimen get prescribed it anyway," said David Dugdale, MD, associate professor in the division of general internal medicine at the University of Washington. "That's a hazard of tight control."

There are the incidents of hypoglycemia, a known risk. It can cause situations ranging from the unpleasant to the tragic -- particularly for elderly patients.

"Hypoglycemia can be devastating if you fall and break your hip," said John W. Williams Jr., MD, a general internist with the Veterans Affairs Medical Center in Durham, N.C. He is also an associate professor at Duke University.

Tight control also can place significant burdens on patient lifestyles, especially regarding cost. Two studies in the February Diabetes Care found that about 20% of diabetes patients skipped medications because they could not afford them. The result was poorer disease control.

Then there's the matter of time. The most recent ADA guidelines recommend that those with type 1 self-test at least three times a day and those with type 2 test often enough to maintain tight control. The exact number is not specified, but there is evidence that many might not be doing due diligence. According to data from the Centers for Disease Control and Prevention's Diabetes Surveillance System, only 57% of those with diabetes monitor their blood sugar daily, although this is an increase from only 36% in 1994.

"It's incredibly hard," Dr. Williams said. "You have to strike a balance. Sometimes it's related to work, and they have to make a choice between making an income or doing the things required."

And then there's the mental stress caused both by the disease as well as its management. Physicians find themselves walking a fine line between egging their patients towards better goals without frustrating them.

"It has to be a dialogue," Dr. Dugdale said. "You don't want to give patients a sense of failure if they don't achieve those results. That can cause patients to be less engaged in treatment rather than more."

Sometimes it works. Online diabetes support chat boards are filled with tales of success.

But there are also dispatches from the darker side -- reports of people self-testing 20 times a day, becoming obsessive and housebound.

The upside

Experts suggest, however, that as tight control becomes more common, patients and physicians will become more adept at dealing with possible hypoglycemic episodes and negotiating the burden of both the disease and the treatment for individual patients.

This weight also eventually could become more evenly distributed, with patients gaining access to help from various sources within the health system. Numerous published studies have examined the prospect of changing the diabetes care model so that it includes additional support for patients, including physician group visits or access to online resources.

"An awful lot is expected of the patient in terms of their day-to-day care," said Suzanne Bennett Johnson, PhD, chair of the medical humanities and social sciences at Florida State University College of Medicine who works on patient adherence issues. "They need a lot more support than 15 minutes in the clinic or just being handed a brochure. If we're going to expect tight control from patients, we have to be willing to put in the health care dollars to help these people do it."

Diabetes experts also say that new medications and new forms of insulin in the pipeline will make it easier.

For now, those who have personally experienced the disease say patience is key.

Harold Pillsbury, MD, chair of ENT-head and neck surgery at the University of North Carolina, was diagnosed with type 2 diabetes three years ago. Since then, he's lost weight, started exercising, taken his medications and achieved good control. He's quick to point out that reaching this goal took time, and that just because the process can be a battle, neither patients nor physicians should give up.

"Physicians should keep working with [diabetes patients]. The problem with these guidelines is you take people, many of whom got diabetes because they weren't taking good care of themselves, and you create a threshold for success that is so high that they give up," Dr. Pillsbury said. "It's not going to happen overnight, but it's worth it. As an intern, my big operation was lopping off the legs of people who had diabetes. And there's not one I threw away that the person was glad to be rid of it."

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Maintaining focus

Managing diabetes involves a constant and complicated regimen to which patients sometimes struggle to adhere. Among diabetics:

56% attend diabetes self-management classes

57% monitor their blood glucose daily

68% receive at least two A1c tests a year

90% have an annual doctor visit

Source: Centers for Disease Control and Prevention's Diabetes Surveillance System

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Cardiovascular risks taking center stage

The goal of diabetes care has always been pinned to controlling blood sugar levels to avoid complications such as blindness, kidney problems and amputations. But physicians now are increasingly turning their attention to addressing the cardiovascular risk factors of those with the type 2 form of the disease, too.

"Most diabetics die of heart disease before they develop the complications, so that's what I focus on," said Michael J. Ryan, MD, of the cardiovascular reversal and prevention center at Main Line Health Center in Philadelphia. "Diabetes is not just a problem of blood sugar. It's also a problem of lipids, blood pressure and clotting."

Recent guidelines also take this focus into account. Last year, the American College of Physicians urged more aggressive blood pressure control for this patient group. Other new recommendations released in April advocated upping their use of statins.

Doctors say the shift is necessary not just to improve diabetics' outcomes but also to prioritize their clinical efforts and limited resources as well as that of their patients. Anecdotally, many say they are choosing blood pressure for their first line of attack before moving on to other risk factors.

"[Blood sugar control] is not nearly as important as good blood pressure control," said John W. Williams Jr., MD, a general internist with the Veterans Affairs Medical Center in Durham, N.C., and an associate professor at Duke University. "That's the message I share with patients, and if we had to choose one thing in terms of the thing that's going to have the most effect on how long they live and how well they live, it would be blood pressure."

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External links

American Diabetes Assn. 2004 Clinical Practice Recommendations (link)

Data and trend information from the Centers for Disease Control and Prevention's Diabetes Surveillance System (link)

The United Kingdom Prospective Diabetes Study (link)

National Institute of Diabetes and Digestive and Kidney Diseases' Diabetes Control and Complications Trial (link)

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