An analysis of the ACCORD trial has shown that African Amercans, insulin users, and patients who have episodes of severe hypoglycaemia are at considerably higher risk of running hba1cs over 8%.
The trial showed that middle aged and elderly patients with an increased cardiovascular risk had a lower total mortality rate if their HbA1c ran between 7 and 8%. The patients enrolled were all getting free drugs and free medical care so that affordability did not impact on results. The idea was to intensify drug treatment if the patient did not get an A1c below 8% and they saw physicians every 4 months to track their progress. It was fully expected that the more normal the glycaemic results the better the outcomes for the patients would be. To the surprise of much of the medical profession, this turned out not to be the case, and near normal blood sugars have now been recognised as not suitable for everyone.
One of the populations that struggled were African Americans. Do they have more insulin resistance problems? Although drugs and medical care were free, we know that food, exercise, education, rest, and mental health affect diabetes control. How were these factors affected? Was poverty a factor?
Insulin users had poorer control too. Did they receive adequate training on how to precision match their meal to their blood sugar goals? Blood sugar control is much easier to achieve with a low carbohydrate diet, the seven unit rule, and using a specific insulin to cover dietary protein. It will be a lot more difficult, if not impossible for good blood sugars to be reached if a high carb diet is eaten or if fixed insulin regimes are used.
Patients who experience severe hypoglycaemia are usually on insulin, but sometimes can be using sulphonylurea drugs. A severe hypo can be life threatening and it would not be surprising that great fear about approaching normal blood sugars could result. Thus patients may decide to circumvent the entire process by deliberately running blood sugars high. Of course frequent hypos tend to end up in frequent over indulgence in correcting blood sugars. This can cause the rollercoaster blood sugars which get people feeling quite hopeless.
Further research into why individuals can’t seem to control their blood sugars is a good idea. But if this is done, then surely the ADA should be looking at ways of fixing the problem? Should they not be putting their financial incentives from low fat food manufacturers aside, and recommend dietary and insulin strategies that enable people to have normal blood sugars with little risk of hypoglycaemia?
Based on an article in Diabetes in Control March 19th 2016
Researched and prepared by Devon Brooks, Doctor of Pharmacy Candidate from LECOM College of Pharmacy, reviewed by Dave Joffe, BSPharm, CDE
Drake TC, Hsu FC, Hire D, et al. “Factors associated with failure to achieve a glycated haemoglobin target of <8.0% in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.” Diabetes, Obesity and Metabolism. 18.1 (2016): 92-95. Print.