Study questions diabetes approach

Two out of three people with diabetes will die from a heart attack or stroke. For years, doctors were unsure if pushing blood sugar down to normal levels could reduce this cardiovascular risk.

A seven-year Veterans Affairs study, appearing in the January issue of the New England Journal of Medicine, suggests there are no benefits for a certain population — namely, older patients who have had diabetes for a long time and have trouble with low blood sugar.

The trial included nearly 1,800 veterans at 20 VA medical centers, including the Ralph H. Johnson Veterans Affairs Medical Center in Charleston.

The study investigated two treatment goals: lowering blood sugar levels to that of a normal person, or maintaining glucose at slightly higher levels. Patients in the study had long-standing diabetes and a high risk of heart disease.

Researchers found intensive glucose control, mainly through higher doses of medication, did reduce blood sugar but did not cut heart risk compared to standard treatment.

"This means the goals for glucose control need to be individualized," said Dr. Jeremy Soule, chief of the endocrinology section at Ralph H. Johnson Veterans Affairs Medical Center and co-researcher in the trial.

Researchers used long-term AC1 levels, which measure a person's blood sugar over a two- to three-month period, in addition to finger prick tests that take a snapshot of current glucose levels.

A healthy person's AC1 level is between 4 percent and 6 percent. The average level of those studied was 9.5 percent when the trial began.

Participants were divided into two groups. The standard group reached 8.4 percent in six months, while the intensive group, which strictly monitored their levels, dropped to 6.9 percent in the same time period. These levels were maintained throughout the trial.

James Jenkins Jr., 60, was diagnosed with diabetes at age 46. The retired Navy senior chief who works as supervisor of medical records at the Charleston VA received the tight controls of the intensive group.

"It was hard to maintain sometimes. It changed the way I eat a lot," he said. While the study did not change how his diabetes is managed, he said, the lifestyle changes improved his day-to-day health.

Researchers attributed the lower-than-expected cardiovascular events in both groups to improved diet and exercise, blood pressure control, lipid control and treatment with aspirin.

Bobby Browne, 59, of Ladson also was in the intensive group and credited the program with improving his health. He was diagnosed with diabetes at age 33 and suffered a mild heart attack in 1995.

The former Marine and commercial Realtor and developer received a letter outlining the study's findings in March. "They found that people like me who are hypoglycemic do not need to keep (our sugar) so low," he said.

One risk of tightly controlling blood sugar is dropping it so low that a person becomes hypoglycemic. These low blood-sugar events are associated with poor outcomes, Soule said.

On the other hand, one benefit of normalizing blood sugar is the prevention of small blood vessel diseases affecting the kidneys and eyes.

All of these factors go into a calculation weighing a patient's risks and benefits. For older patients who have been diabetic for a long time, and have had significant trouble with low blood sugar, tightly controlling glucose may not be beneficial, Soule said.

Two other major studies in 2008, the ADVANCE and ACCORD trials, also brought into question such low AC1 levels for older patients with advanced disease. As a result, the American Diabetes Association changed its position to say that some subgroups may require less stringent control.

Reach Jill Coley at 937-5719 or jcoley@postandcourier.com.