I try to stay objective, but sometimes the sheer amount of poorly summarized research that is even more poorly reported in the media makes me want to weep.
I have written at length about the ACCORD study, which is the study doctors cite when they tell patients, many controlling blood sugar with diet, that it is dangerous to lower their A1c below 7%. You can read those posts here:
ACCORD REDUX: It's the High Blood Sugars Stupid
ACCORD Redux: Low A1c Does Not Raise Risk of Death
When the Doc Says Lowering Your A1c is Dangerous
If your doctor tells you that lowering your A1c is dangerous, remind him or her of what the ACCORD study actually found, which was this: People who attempted to lower their A1c to 6.5% using a combination Avandia, insulin, and a high carb diet had a higher risk of death only when they did not actually achieve a lowered A1c..
The people who DID manage to lower their A1cs in the ACCORD "intensive control" group did fine.
Today's study is NOT news. It is an extension of the same poorly designed ACCORD study whose results were deconstructed and debunked--but not until a lot of family doctors got the message that they must stop their patients from lowering their A1cs below 7%--even if they did it with diet alone.
What this latest publication from the ACCORD group is, is a look at the longer term outcomes in the groups involved in the original study. You can read the very uninformative abstract here:
Long-Term Effects of Intensive Glucose Lowering on Cardiovascular Outcomes The ACCORD Study Group. N Engl J Med 2011; 364:818-828March 3, 2011
There is nothing in this study that contradicts the finding that the people in the "intensive control" group who did poorly did poorly because their A1cs dropped.
It is when you look at the news story as dumbed down for the TV audience that you see what a tragedy it is that the ACCORD study group continues to publish these studies without making it clear what they really show.
For example, when I scan Google News I see this headline: "New results from a large government-run trial confirm that very aggressive treatment to lower blood sugar is associated with an increased risk of death in people with type 2 at high risk for heart attack and stroke." And given that doctors have been brainwashed into believing that ALL people with Type 2 diabetes are at high risk for heart attack, this translates into "Don't lower your blood sugar!" or "Low A1cs Kill!"
I have people emailing me all the time now that their doctors have lectured them about how they are risking death when they lower their A1c to 5.8 using diet alone. This is idiotic.
The real headline to describe this latest ACCORD Study should be this:
STARTING INTENSIVE DIABETES TREATMENT 20 YEARS AFTER DIAGNOSIS WILL NOT REVERSE THE DAMAGE CAUSED BY THE HIGH BLOOD SUGARS OF THE PREVIOUS DECADES. LOWER A1CS IMMEDIATELY AFTER DIAGNOSIS TO SEE EXCELLENT RESULTS.
Or perhaps:
PEOPLE WHO CANNOT LOWER THEIR A1CS USING POORLY PRESCRIBED REGIMENS INVOLVING DANGEROUS TZD DRUGS AND INSULIN PRESCRIBED WITHOUT PROPER EDUCATION DO POORLY
But let's get one thing clear: Nothing in the ACCORD study suggests that lowering A1c is harmful when it is done by cutting back on carbohydrate intake, avoiding the cardiotoxic TZD drugs Avandia and Actos that were heavily used in ACCORD, and using insulin only after being given a good explanation about how it works that allows you to adjust and tailor your doses based on what you see with your meter.
If you are not using insulin in a way that is giving you frequent hypos and are achiveing A1cs in the 5% range you will not develop the neuropathy that damages the nerves that control your heart beat or the kidney disease that damages your blood pressure, or for that matter, blindness or amputation.
But I can rant on about this as much as I want. Mostly the world ignores it. You who are reading this now and are educated and can read the detailed analysis of the ACCORD studies you can find in the blog posts linked above. But most people with Type 2 diabetes trust their doctors and will do whatever those doctors tell them. Even though your average family doctor's knowledge of diabetes is often 20 years out of date and dangerously confused. And many of those doctors will tell them that they should NEVER lower their A1c below 7% because ACCORD proved it's "dangerous."
If you know someone with diabetes who isn't the kind of person who Googles things, explain to them what this study really proved--that "lowering A1c" is only dangerous when you do it with a poorly chosen drug cocktail and then don't manage to lower your A1c.
Remind them too, that ACCORD is only one, not very well designed study, and that there is a ton of other research that shows that lowering A1c to 6.5% or below does improve health, most notably the ADVANCE study, which was larger and longer than ACCORD.
10 comments:
This might explain some of the difference:
What other adverse effects were seen from the intensive blood sugar treatment?
There was a greater rate of seriously low blood sugar (called hypoglycemia) events in the intensive group than in the standard group: about 10% of intensive participants and about 3.5% of standard participants had a hypoglycemia event that needed care from a medical professional. There was more fluid retention in the intensive than the standard group: 71% compared with 67%. About 28% of participants in the intensive group gained more than 10 kg (22 pounds) of body weight, compared with about 14% of participants in the standard group.
Ah, Jenny will the ACCORD ever go away. I'm in Michigan working with a diabetes organization and we are, at this moment, writing up a paper to inform Docs and medical workers about what ACCORD actually says.There are so much better studies out there but this thing keeps coming back with the same misinterpretations. I get your frustration. Just keep writing.
Mike
Sara,
Hypoglycemia is much more common in people who autonomic dysfunction, which can be a result of long-term exposure to high blood sugars or, alternatively, a natural product of age.
It may reflect an underlying systemic problem that has little to do with blood sugar control.
The ACCORD data is presented in a way that makes it impossible to tease out the data that might explain what they found.
I would say it's safe to conclude that people who have severe autonomic dysfunction probably won't do well on insulin, but that has no implications for the many tens of thousands of people in their 50s who have been recently diagnosed for whom lowering the A1c is the ticket back to health.
I hear from those people in a steady stream day in and day out. Their A1cs in the 5%s reflect a return to normal health and high function.
Mike,
I am REALLY happy to hear that there is a diabetes organization that is taking steps to counter this damaging development.
I hope you can make a dent.
The whole thing is idiotic. Most doctors tell their diabetics to aim for an A1C of 7 which roughly correlates with an average blood sugar of 154, which is undoubtedly a dangerous level. They then conclude they shouldn't invest the massive effort trying to get a patient's A1C from 9 to 7 if there isn't a big difference in outcomes betweem the two. They fail to understand that there is a huge difference between 5.5 and 7.
"Hypoglycemia is much more common in people who autonomic dysfunction...."
Is this because of delayed gastric emptying?
I also read recently that H. pylori infection and/or gastritis can result in stomach dumping, which can lead to hypoglycemia as well. Something to be aware of.
Helen,
It might be. But damage to the autonomic nerves causes a host of other problems because it leads to dysregulation of all kinds of hormone and signaling systems.
Just saw the APN at my GP's office with an A1c of 6.3 (new at low-carbing and have room to improve), and told her I was aiming for an A1c in the 5's, and she told me it was dangerous for older people (I'm 63). I asked her if she was basing that on ACCORD, and she said, no, it was newer studies. I don't know WHAT studies, though. I'm going to do what I want, anyway, but I hate arguing with professionals!
The "recent" study your doctor was was the ACCORD follow up, but it isn't being reported very clearly.
The only other study was the Veteran's study which I have discussed in previous posts and that study made it clear that it was people who had spent many, many years out of control who fared poorly with tight control, largely because of lost hypo awareness leading to severe hypos.
Don't let your doctor off the hook on this one. Make sure she realizes it is the ACCORD follow up that recently hit the newsletters.
Jenny,
Thank you so much for this excellent site! I am not a diabetic, but my husband is a non-insulin dependent diabetic. He is not particularly good at learning about the "fine" details of his disease, so I have taken it upon myself to gather and sort through the information. For the most part he pays attention to what I have gathered and is making good attempts to get healthier. Your site has been a true blessing for me in this regard. I try to gather information from all the best Paleo/LC/PaNu type blogs that I can find, but it's the "Jenny says" blurps from me that get my husbands attention the most. Thanks again!
Susan
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