Yale scientists try to parse diabetes treatment intensity and age. Potential harm is the message.

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diabetesResearchers from Yale and a few other centers analyzed data from the vast NHANES nutritional and medical survey, done semi-annually on millions of Americans. The research was an attempt to evaluate the effects of more vs. less intense treatment of diabetes on older patients and those with more complex medical histories. They used the data from 1,288 older subjects as the basis of their analysis, and extrapolated their information to the total group. All data were collected over the first decade of the 21st century. The study appeared in JAMA Internal Medicine.

Depending on their health, the participants were put into one of three categories: relatively healthy, those with complex medical histories for whom self-care was difficult, and those with a very significant additional illness and functional impairment, many of whom had limited life expectancy. In the U.S. 65-plus population they represented there were 3.1 million relatively healthy Americans; 1.7 million with intermediate health; and 1.3 million with poor health.

The main result of the analysis was that there was little difference in how intensively their blood sugar was being controlled. More intense control of blood sugar in diabetics is reflected in the glycosylated hemoglobin level (HBA1C); tight control aims for a level below 7 percent, reflecting blood sugars generally under 150 most of the time. The authors, led by Dr. Kasia Lipska at Yale s endocrinology section and a member of their Center for Outcomes Research, found that the same or similar fraction of the seniors in their study group had HBA1C levels low enough to reflect tight control, regardless of the presence of indices of deteriorating or actual major health problems.: about 60 percent of all three groups had levels of less than 7.0 percent HBA1C.

Dr. Lipska published an op-ed in today s New York Times, sounding the alarm against by the guidelines approach to medical care: Ultimately, changing current paradigms requires that doctors partner with their patients in making decisions about treatment. Patients need to understand that there are different options, with different risks. The goal is not to get a perfect score on a report card, but to weigh these risks to make a good decision.

ACSH s Dr. Gil Ross had this comment: I found it most strange indeed, that a group based at the outcomes center said nary a word in their article about outcomes. They simply decided that any senior diabetic whose glyco-hemoglobin level evinced tight sugar control was, a priori, being over-treated, especially so if the patient had serious co-morbidities. I have a major problem with that assumption: many older diabetes patients have several severe illnesses, some diabetes-related, some not. Just to ignore control of their blood sugars does not sound so wise to me.

That being said, I am a definite skeptic on the subject of treating blood sugars per se as a method of preventing the many adverse health outcomes of diabetes. Some deny that Type 2 diabetes (adult onset in bygone days) even exists as an entity. I do not go that far, but I have searched the literature for good evidence that intense, tight control actually reduces outcomes kidney failure, eye diseases, neuropathy, vascular and the data don t ring very loudly. So I would agree, in principle, that over-treating delicate older diabetics is unwise but I wouldn t use this study to prove it. And the insistence on individualized care, where the doctor and patient discuss choices, is or should be a no-brainer.