Maybe doctors could take a lesson from Goldilocks. In this nursery tale, Goldilocks didn’t like porridge that was too hot or too cold. She wanted it “just right.”
People usually relate to this fable because moderation seems to make sense. But many physicians believe in driving lab values down as much as possible, no matter what. A cardiologist friend likes to proclaim that no one can have too low a golf score or cholesterol level.
Diabetes doctors were disappointed recently when three studies showed that aggressive blood sugar control did not protect people with diabetes from heart attacks and other cardiovascular complications. In fact, one well-designed study (ACCORD) showed more heart attacks and deaths among patients who kept their blood sugar near normal (New England Journal of Medicine, June 12, 2008).
Such results defy conventional wisdom. Diabetologists expected that “tight” control of blood sugar would improve survival. The idea that it might lead to the very complications treatment is supposed to prevent is hard to accept.
And yet some previous studies have produced similar results. In 1970 the results of the University Group Diabetes Program shocked physicians. This study was the most ambitious diabetes trial at the time, but patients who received the oral diabetes medication tolbutamide (Orinase) had a higher rate of cardiovascular death than patients on placebo or insulin.
Soon after that, British researchers recruited thousands of diabetic subjects to a ten-year study. Those who received “intensive” drug therapy to lower blood sugar did not have fewer heart attacks, strokes or deaths (Lancet, Sept. 12, 1998).
When doctors treat numbers instead of patients, they may overlook complications of the therapy. In the ACCORD trial, many of the subjects treated aggressively gained weight, some as much as 20 pounds. Others experienced symptoms associated with lowering blood sugar too much (hypoglycemia). These can include dizziness, weakness, anxiety, sweating, shakiness, palpitations and confusion. Severe hypoglycemia can be life threatening.
Where does this new research leave patients with type 2 diabetes and their physicians? If this disease is left untreated, it increases the risk for many serious health problems including kidney disease, blindness, nerve damage, heart attacks and strokes. Clearly, doing nothing is unacceptable.
But aggressive treatment may have the unexpected outcome of causing some of the very cardiovascular complications it is intended to prevent, which leads us back to the story of Goldilocks. Getting the porridge just right takes some effort.
Keeping blood sugar neither too high nor too low requires careful management. The role of exercise, diet, blood pressure and cholesterol control must not be overlooked.
