Serious Issues in Treating Diabetics

Sometimes while reading an article my jaw literally drops as I realize that what I am reading is shocking in its implications. Such was my experience while reading the article below on Howard Brody’s blog Hooked

Read the excerpts below carefully for what he is saying is that most common approach to treating Type 2 diabetes is woefully oversimplified and dangerous. While all of the lay people and most of the physicians believe that the more a diabetic’s blood sugar can be lowered the better, that actually may be the way to seriously harm diabetic patients.

A second major point contained in the blog post is that current guidelines for treating Type 2 diabetics encourages lowering blood sugar to harmful levels and the pay-for-performance system punish those doctors who are treating the diabetics appropriately.

I urge you to follow the link, printout the article and study the points discussed.

..One of the articles Gary and Henry reviewed was by a team out of Cardiff, Wales headed by Craig J. Currie, and interestingly enough including some people from Eli Lilly, in Lancet(subscription required). Basically the article addresses the fact that most diabetes treatment guidelines act as if lowering blood sugar–or lowering the hemoglobin A1C, which measures blood sugar trends over the long haul–is the be-all and end-all of Type 2 diabetes treatment, and the lower the A1c the better. Currie’s team did a retrospective cohort study, which as such is unable to prove cause and effect. But its results jibe with many other controlled trials, all of which showed no outcomes benefit in Type 2 with tighter control of blood sugar, but an added risk when blood sugars are dropped too low by medication.

Currie’s gang plotted all-cause mortality against A1C levels in nearly 50,000 older adults followed over a 20-year period. The graph they should have ended up with if the guidelines are correct would be a straight line downward toward the left, with fewer deaths the lower the A1C. What they actually found was a U-shaped plot, where the best overall A1C was about 7.5%, and death rates went up on either side. One scary feature of their diagram was that if you had a hemoglobin A1C of 6.5, generally considered “excellent blood sugar control,” your death rate was actually higher than if you had a level of 9.5, which today would be viewed as rotten blood sugar control…

My pals Gary and Henry went on to chat at length about the new pay-for-performance systems whereby the amount of money docs get from insurance companies or Medicare depends on how well you meet various “quality indicators” set by current guidelines. A physician who practices according to what Gary, Henry, and I would consider to be the best available evidence on diabetes Type 2 would probably mostly ignore blood sugar anyway, and stress smoking cessation, lifestyle changes (especially exercise), and aggressive management of heart-disease risks (especially blood pressure control). If this evidence-based physician did pay attention to blood sugar, she would aim for a moderate A1C of around 7.5, as indicated by the Currie research. Many pay-for-performance programs, by contrast, would ding the doc for having patients above 7.0 and would pay a bonus only for patient who were below 7.0 A1C. So basically you have physicians being paid a bonus for putting their patients at higher health risk, all in the name of so-called “evidence-based” guidelines.

Two basic take home messages here. First, as we have been ragging about in the Avandia case, how did the basic disease model of “Type 2 diabetes = problems with high blood sugar” continue to gain such a powerful hold over the minds of physicians, biomedical scientists, and policymakers, when the best evidence today says rather that “Type 2 diabetes = increased cardiovascular risk, not necessarily made any better by tight sugar control”? Is it just a coincidence that the first model sells a lot more drugs than the second model? Is it just a coincidence that the marketing juggernaut of Big Pharma sides squarely with the first model and wants us not to hear about or think about the second?

much more via A Side Trip into Diabetes: Selling the Wrong Model


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