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Sunday, December 20, 2009

Benefits to Tight Blood Glucose Control?


Keeping Blood Sugar Low May Not Help

In a classic 'if a little is good, more is better' manner, the medical establishment has for years touted tight blood sugar, or glucose, control as the best means of avoiding the complications of diabetes. Surprise! Now it's turning out that like so many areas of medicine, this one size fits all approach doesn't work. A study in this issue of Annals of Internal Medicine, Comorbidity Affects the Relationship Between Glycemic Control and Cardiovascular Outcomes in Diabetes, concludes that whether tight glucose control is effective or not depends on the presence of other health issues, so-called 'comorbidities.'

Let's talk about 'comorbidities' first. This is medicalese for the constellation of health problems or conditions in a single individual. As everyone knows, those who develop type 2 diabetes often are overweight or obese, may also have high blood pressure, existing heart disease, or almost any other compromising health condition. When tight blood glucose control is imposed on this background, it doesn't work as well, and in fact may actually compromise overall health, as has been shown in previous studies.

What defines tight blood glucose control? The standard for assessing this is hemoglobin A1c, often abbreviated HbA1c. What is being measured here is how many sugar molecules are attached to hemoglobin, the oxygen carrying compound in red blood cells. When blood sugar is high, some of these sugar molecules become attached to this compound, and since red blood cells are in circulation for a couple of months, this measurement provides an average of how high the blood sugar has been during that time period.

Many diabetes experts aim for an HbA1c measurement of 6.5 or so. But this study demonstrates that for those with other conditions, such a goal doesn't reduce cardiovascular complications in those with comorbidities, suggesting that more modest goals may be more appropriate in people who are already dealing with a host of health issues.

Rick and I both seize this opportunity in the podcast to reiterate once again that old public health message that by far the easiest course is prevention. In terms of diabetes, heart disease, high blood pressure and obesity, exercise, weight control, and a good diet will help most people avoid developing these conditions in the first place.

Other topics this week include asthma and COPD and a genetic mutation in this week's NEJM, cancer and CT scans in Archives of Internal Medicine, and two studies on Alzheimer's disease in this issue of JAMA. Until next week, y'all live well.

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