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Breaking down diabetes: New controversy on blood sugar lowering

In this final installment of the "Breaking down diabetes" series, physician-researcher Randall Stafford weighs in on a debate about blood sugar levels that relates to drug prices.

Inside the community of diabetes experts and organizations, a heated debate is raging. The debate centers around blood sugar levels, but, like so many divisions in our society, it is really about much more. In my view, this debate reveals an unfortunate tendency to take complex chronic medical conditions and simplify them so that drug therapy becomes the only logical solution.

The current uproar began when the American College of Physicians (ACP) released a guidance statement this month that suggests that lowering the long-term blood sugar levels of people with Type 2 diabetes (a measurement known as A1C) below 7 percent (the current recommendation) may not be such a good idea (less than 5.5 percent is normal). Instead, it recommends a goal of between 7 and 8 percent for most patients.

The organization’s primary rationale is that aiming for lower blood sugar values does not benefit health. More intensive drug treatment puts patients at risk for low blood sugar and past studies have frequently shown harm from aggressive blood sugar lowering. The ACP also points out that such treatment is frequently very expensive. In addition, a focus on treating blood sugar can lead other aspects of care to be neglected.

The ACP position fits with whole-person approach that includes blood sugar lowering drugs, but also focuses on lifestyle health behaviors, especially dietary practices, sleep, physical activity, stress, and weight management. Other medical conditions that occur with diabetes also deserve focused attention, including high blood pressure, a propensity for blood clotting, cholesterol abnormalities and obesity. Strategies associated with these other goals are frequently less costly.  They also often result in larger health gains per dollar compared to the multiple medications needed to achieve aggressive A1C goals.

Just days later, the American Diabetes Association issued a statement that it is “deeply concerned” about the proposed higher blood sugar levels.

In my view, its response reflects a common bias that blood sugar is the primary problem faced by people with diabetes. The group does not specify the importance of other treatment goals that, in my opinion, should be given priority over aggressive blood sugar lowering. At face value, the ADA argument appears to favor drug companies selling the newest diabetes medications. The statement suggests that low blood sugar (a common side effect of many diabetes medications) is not really a problem as long as the newest medications are used, often at a cost of $500 to $700 per month for each drug.

The ADA statement comes at a time when corporate sponsorship of health-related advocacy organizations is under intense scrutiny. The ADA attracted attention previously for its ties to drug and device manufacturers and I fear those continuing connections may have influenced their current insistence on aggressive lowering of blood sugar, a goal that usually requires multiple medications.

The complexity of diabetes and its many serious complications require complex solutions. While drugs to lower blood sugar are often necessary for good diabetes care, other goals need to be prioritized. Aggressive blood sugar lowering can only make sense clinically and economically if patients have first achieved:

  1. Blood pressure below 130/80 mm Hg.
  2. A weight that is either stable or declining.
  3. Aspirin is being taken to reduce the risk of stroke and heart attack.
  4. Cholesterol problems have been addressed (usually with a statin medication).
  5. Physical activity is a part of the patient’s lifestyle.
  6. Diet emphasizes a largely plant-based diet with reduced intake of simple carbohydrates (like sugary and starchy foods).
  7. Patient self-management skills are being actively used, such as consistent recording of daily blood sugar and blood pressure.

Thank you for joining me in this nine-piece journey through pre-diabetes and diabetes care.

This is the last of a series of nine blog posts discussing prediabetes and Type 2 diabetes. These blogs cover topics ranging from how Type 2 diabetes develops to key goals for people with diabetes to diabetes drugs to the complications of diabetes. 

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, practices primary care internal medicine at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention.

Photo by Smudge 9000

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