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, AMNews staff. June 7, 2004.

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.