Diabetes Control

• In people with diabetes, managing elevated blood sugar is crucial for preventing microvascular complications such as nephropathy (kidney damage), retinopathy (eye damage leading to blindness), and neuropathy (nerve damage leading to loss of sensation and ulcers especially in the foot). However the benefit of glucose lowering is much less for preventing macrovascular complications such as heart attack and stroke.

• A healthy lifestyle, especially diet and exercise, combined with diligent monitoring of blood glucose levels and adherence to medication helps control diabetes, reduces risk of complications, and increases longevity. Conversely, individuals who don’t take prescribed medications, do not monitor what they eat, and get little exercise are much more likely to develop complications and severe diseases as they age.

• Several professional organizations have made recommendations for blood sugar targets. In general, an A1C goal of 7% is considered appropriate; however, it is emphasized that goals need to be individualized for patients.

• A more intensive goal (A1C<7%) could be appropriate for a young patient with no cardiovascular disease (CVD), whereas less intensive goals are appropriate for the elderly or for those with established CVD in whom the risk associated with hypoglycemia (low blood sugar) could be significant. In support of this approach, a recent observational study concluded that better glycemic control is associated with better CVD outcomes in diabetic subjects with less comorbidity.¹

• A tight control of blood sugar would be beneficial provided it can be achieved with agents that do not produce low blood sugar. However, control of blood sugar is only one aspect of the management of diabetes.²

• Randomized clinical trial data to date suggest that statin treatment and hypertension management will have a more profound effect on reducing the CVD event rate than management of blood sugar in people with diabetes.^3-7

• In the Steno-2 trial, a multifactorial approach including lipid, blood pressure, and glucose control in diabetic patients reduced CVD death by >50%  (at 13 years of follow-up). ⁷ Subsequent analysis of these results suggested statins and antihypertensive treatment provided the largest benefit, greater than that achieved with glucose control.⁸  Other studies also support this conclusion.

• It is well established that reducing risk factors like smoking, blood pressure, and cholesterol was primarily responsible for reducing the CVD mortality in developed countries.⁹  Control of these three factors appears to be even more important among people with diabetes to reduce CVD and its complications. ³

• There are many missed opportunities to reduce the burden of diabetes through improved control of blood glucose levels and improved diagnosis and treatment of hypertension and high cholesterol. A substantial proportion of individuals with diabetes remain undiagnosed and untreated, both in developed and developing countries. The figures range from 24% of the women in Scotland and the USA to 62% of the men in Thailand. ¹⁰

• The proportion of individuals with diabetes reaching treatment targets for blood glucose, blood pressure, and serum cholesterol was very low, ranging from 1% of male patients in Mexico to about 12% in the United States.¹⁰

• In the three countries with available data insurance status was a strong predictor of diagnosis and effective management, especially in the United States.

• Financial access to care is a strong predictor of diagnosis and management especially in poor and developing countries.¹⁰

• The blood pressure goal is <130/80 mmHg and the LDL-C goal is <100mg/dl for people with diabetes─ considerably lower than the goals for people without diabetes.¹¹

Sources

1. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: a cohort study. Annals of internal medicine. Dec 15 2009;151(12):854-860.

2. Simpson SH, Majumdar SR, Tsuyuki RT, Eurich DT, Johnson JA. Dose-response relation between sulfonylurea drugs and mortality in type 2 diabetes mellitus: a population-based cohort study. CMAJ. Jan 17 2006;174(2):169-174.

3. Mazzone T. Intensive glucose lowering and cardiovascular disease prevention in diabetes: reconciling the recent clinical trial data. Circulation. Nov 23 2010;122(21):2201-2211.

4. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. Aug 21 2004;364(9435):685-696.

5. Heart Protection Study Collaborative Group. Cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet. Jul 6 2002;360(9326):7-22.

6. Turnbull F, Neal B, Algert C, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med. Jun 27 2005;165(12):1410-1419.

7. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. Feb 7 2008;358(6):580-591.

8.  Gaede P, Pedersen O. Intensive integrated therapy of type 2 diabetes: implications for long-term prognosis. Diabetes. Dec 2004;53 Suppl 3:S39-47.

9. Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. Feb 12 2011;377(9765):529-532.

10.Gakidou E, Mallinger L, Abbott-Klafter J, et al. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Bull World Health Organ. Mar 1 2011;89(3):172-183.

11. Handelsman Y. Diabetes and hypertension: a comprehensive report on management and the prevention of cardiovascular and renal complications. J Clin Hypertens (Greenwich). Apr 2011;13(4):221-223.