Benefits Lasting for Tight Diabetes Control

Early, tight control of blood sugar can have long-lasting benefits for diabetics, a study has found. The new study followed up an earlier, 10-year study. In that study, people had been just diagnosed with diabetes. They were assigned to control blood sugar with diet or medicine. Those who took medicine achieved lower blood sugar. The new study looked at them 10 years after the first one ended. The two groups no longer had different blood sugar levels. But those whose sugar was lower in the earlier study still had a 15 percent lower risk of heart attack. They had a 13 percent lower risk of death. The Associated Press wrote about the study September 10. It was published online by the New England Journal of Medicine.

What is the doctor's reaction?

We are getting closer to the best approach to blood sugar control in type 2 diabetes. The results of this study add an important piece to this approach.

Tight control means trying to keep blood sugar levels as close to normal as possible.

The advantages of tight blood sugar control in type 1 diabetes are clear. But for type 2 diabetes, it is a mixed picture. Tight control does help diminish risk of kidney failure. But a different, recently published study questioned other benefits. The study suggested that very tight blood sugar control might actually increase the risk of heart attack and early death.

A new article on this issue was just published online by the New England Journal of Medicine. This study suggests that tight blood sugar control must start immediately when the diagnosis of type 2 diabetes is made. Although not conclusive, it also suggests that the drugs used to get blood sugar under control should be tailored to the individual.

There has been a big push to get tight blood sugar control in everyone with type 2 diabetes. Health insurance companies often use this as a measure of quality of care. Yes, it makes sense to strive for tight control early. But for people who have already had type 2 diabetes for 10 to 20 years, tight control might not be the best goal.

What changes can I make now?

In the past, doctors usually have told newly diagnosed patients with type 2 diabetes to try diet and exercise first to bring down their blood sugar. Now that should change. They should immediately begin taking medicine. This doesn't mean that diet and exercise are not just as important as before. As blood sugar gets under control, medicine can be tapered. In some cases, it can be discontinued.

For most, metformin should be the first medicine. This is especially true if the person is obese. I personally choose this drug when a patient has a body mass index (BMI) of 25 or more. (Overweight is a BMI of 25 to 29.9. Obese is a BMI of 30 or more.)

There are exceptions. People with impaired kidney function probably should avoid metformin. Caution is advised with heart failure and some types of severe liver disease.

People who have had type 2 diabetes for many years should continue to keep their blood sugar under reasonable control with diet and exercise. Piling on more and more medicines to bring down blood sugar is not the answer.

Whether you were diagnosed with type 2 diabetes yesterday or 20 years ago, you want your blood pressure less than 130/80. Your LDL cholesterol should be less than 100 (preferably closer to 70). Achieving these goals clearly decreases the risks of heart attack and stroke and helps protect the kidneys.

What can I expect looking to the future?

Some doctors already advise their patients to start metformin if they are at high risk for developing diabetes. This would include obese patients with high normal blood sugar who have a strong family history of type 2 diabetes. Research is under way to help answer whether starting medicine even before the onset of diabetes improves results.