There has been an accepted wisdom in the management of diabetes. Diabetes, as you probably know is a disease which presents with abnormally high levels of sugar in the blood. It’s actually a complex disease and involves much more than sugar levels but doctors, dietiticians and other experts have always worked on the premise that if you can “normalise” the patient’s blood sugar level, then you’ll reduce the risks they have of the serious harms that come with this disease. One of the most serious potential harms is death from heart disease. Now a study which has run for four years has come up with a totally surprising result.
Researchers took people who have “Type 2” diabetes (by far the commonest form of diabetes, and not the kind that usually required insulin treatment – that’s the kind that affects younger people mainly) and they randomly assigned them to different groups. The study is looking at management of sugar, cholesterol and blood pressure. The groups studied for sugar control were divided into an “intensive” control group and a “less intense” control group. The former group has had diet and drugs to try to maintain a blood sugar level the same as that found in people who don’t have diabetes. Everyone expected that the less well controlled group would suffer more heart disease but the study has just been stopped because so many more people in the “intensive” control group have died from heart disease than in the less well controlled group. This is totally contrary to expectations, and, so far, nobody has come up with an explanation.
The researchers are at pains to say that diabetics shouldn’t give up their drugs because we don’t yet understand what’s going on here and there is still clear evidence that blood sugar levels which go sky high pose a serious immediate risk to health.
Here’s the statement which really struck me though –
Clearly, people without diabetes are different from people who have diabetes and get their blood sugar low.
I suspect the answer to this puzzle will be found when that conclusion is taken on board. Human beings are just not like machines, and the idea that health can be achieved by managing to control the level of a single particular component of the body within an artificially set of “norms” is misguided. You don’t cure diabetes by assuming the only difference between a diabetic and a person without diabetes is the level of the blood sugar.
This is an excellent example of why we need to understand health and disease from a complexity perspective rather than a simplistic, reductionist one.
Heroes Not Zombies 
Clearly, the study referenced in this post will cause many medical professionals and the public in general to question the approach of some clinicians in managing diabetic patients. The news reports thusfar released do NOT contain sufficient information to analyse why a presumably similar group of diabetics would have a higher rate of mortality when treated with “intensive management”.
Intensive management is meant to describe a management plan that is geared toward pushing the patient’s blood sugar to as close as normal as possible (90-110). The “standard treatment” takes a more liberal approach and did not, as I read the news report, aggressively try to “normalize” a diabetic patient’s blood sugar.
Intensive vs standard management refers to manner by which the patient’s blood sugar was handled, not how the cholesterol or blood pressure was managed.
“Normalization” of a diabetic’s blood sugar carries with it a number of risks that may be accentuated by the aggressive use of medications. Factors affecting risk include but are not limited to the following:
1. the risk of hypoglycemic episodes
Hypoglycemia (low blood sugar) is a potentially serious and even life-threatening situation. As the blood sugar drops below 60 or so (depends on the patient) any of the following situations can occur: general malaise, acute diaphoresis (breaking out ina cold sweat), confusion, disorientation, hallucinations, unconsciousness, and death. Blood sugars less than 40 are a life threatening emergency and require a 911 response)
Blood sugar levels are quite dynamic (change quickly) and are affected by a number of factors the most important of which are: DIET, LEVEL of EXERCISE, CONCURRENT DISEASES, USE OF STEROIDS (such as prednisone), UNUSUAL STRESS, to mention only the most common.
Another factor, which is often left out of this type of discussion, is at least as critical in some patients:
TIMING of medication AND the TIMING of meals in relation to when the medication is taken.
Even the most dutiful, compliant, conscientious patient must take care to watch the number of calories taken and the timimg of meals and the level (intensity) of exercise in relation to when medications are dosed.
Taking a dose of insulin and then forgetting to eat is a sure ticket to a hypoglycemic episode.
Since blood sugar levels are very dynamic (especially in a diabetic) one must be cautious in making adjustments to dosages of medications such as insulin to assure that the medication will not push the blood sugar too low. LOW BLOOD SUGAR IS ACUTELY FAR MORE DANGEROUS THAN HIGH BLOOD SUGAR in the type 2 diabetic.
I’ve made much of hypoglycemia because in situations of “intensive management” the risk of or significance of low blood sugar does not, i believe, always receive adequate attention. A blood sugar of 70 is NOT “ok” and it is NOT NORMAL. It is a signal that one of two situations may exist:
1. the patient is not taking enough calories, is skipping meals, is not eating regularly timed meals, has changed level or intensity of exercise, etc.
OR
2. the patient is TAKING TOO MUCH MEDICATION.
Whether hypoglycemic episodes were a more frequent occurrence in the “intensively” managed group was not included in the report.
2. Another issue of significance involves the adverse effects that might be particular to a specific medication being used.
(ALL medications whether over the counter or by Rx, herbal supplements, vitamins, etc can cause adverse effects when used inappropriately and some of those adverse effects can be quite serious or even fatal)
Before drawing conclusions from the limited information provided it is very important to have answers to these and a number of other questions.
As a clinician I would strongly advise any diabetic patient to make no drastic changes to their diabetic management plan without having a serious discussion with their physician about the implications of this study.
And, by the way, your physician should TALK WITH you (as opposed to TO YOU). You should ask questions and are entitled to have answers to your questions in terms that you can understand. If doing so takes more than 5 minutes of your physician’s time, well, that’s his/her job. “I’m too busy” is not an adequate or acceptable response. Afterall, it’s YOUR life that on the line.
Comprehensive Michael! Thank you! I would endorse everything you’ve said here.
It will certainly be interesting to find out what the explanation is for the results of this study.
Oh, I particularly like your last paragraph. What excellent advice! In fact that’s ALWAYS good advice. It’s quite astonishing really that any health care system includes 5 or 6 minute appointments as a default or norm. I’ve often thought one of the best things we could do to improve patient care would be abolish such short appointment times.
Thanks again for this very informed and wonderfully clearly written comment.
I saw this study too, and agree with all written here, especially Dr. Bob’s last comment in his original post and the thoughts on appointment times that are too short . All good.
Dr. B