EASD

Why ‘Controlling’ Blood Sugar Shouldn’t Be the Goal

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No person with diabetes, no matter how many years they’ve had it, has achieved absolute control of their blood sugar. In fact, I would argue that “control” is not possible at all.

It has to do with the word control itself, but more on that later.

Even people who use the latest technologies – including insulin pumps, continuous glucose monitors (CGM), smart insulin pens, and hybrid closed loops – won’t have perfect levels every day. Most will see an improvement in their time in range, but not control.

I saw this firsthand at the 2023 EASD conference in Hamburg, Germany, where many of my fellow diabetes advocates wearing hybrid systems had their alarms go off frequently.

It may feel disheartening, but understanding that “full control” over blood sugar levels is not possible can be liberating and empowering. If you think of it as a process of managing with the goal of improvement, it can free you from chasing the impossible goal of perfection, easing the stress, frustration, disappointment, guilt, and self-blame that can come from feeling like you failed.

I’ll explain below how to better work with the constant fluctuations of blood sugar and share some of my practices for navigating (as opposed to controlling) it.

The complex science behind blood sugar management

Our heartbeat, blood pressure, gut and brain signaling, digestion, liver processes, nervous system, and more all interact and influence blood sugar levels. So does living in an unpredictable world.

Personally, every morning I deal with the “dawn effect.” I need to take 1 unit of rapid-acting insulin immediately or I’ll go up 30 points in minutes. The stress of presenting at a conference, even though I feel relaxed, releases hormones that raise my blood sugar.

Adam Brown’s 42 Factors that Affect Blood Glucose is always worth sharing to remind us how many factors, biological and environmental, impact blood sugar.

Instead of using the verb “control,” I prefer “manage.” To manage comes from the Italian maneggiare, meaning to handle and train horses. It suggests a mutual adapting to, respecting, and evolving between two complex entities: the horse and rider. Or, in this case, the complex dance between humans, the environment, and blood sugars.

Even after living with type 1 diabetes for 51 years, I cannot, for example, see 142 mg/dL on my CGM, decide I want to be 102 mg/dL, and make it happen. Yes, I’ll take some insulin or go on a walk, but I cannot guarantee exactly where my blood sugar will settle.

This was much to the chagrin of my husband who early in our marriage thought there must be a few root causes I could manipulate and the effect would be absolute control. But one evening, 15 minutes after I’d ordered my meal in a restaurant and pre-bolused, the waiter came back to say, “There’s been an accident in the kitchen, your meal will take another 20 minutes.”

That’s when the husband saw that managing blood sugar is not a cause-and-effect task but a complex one that relies on constant sensemaking. Sensemaking is the act of trying something and seeing what happens. We do it all the time but we don’t recognize it.

You may think what I’m saying is obvious, but the word “control” is used so often in the language of diabetes that on some level we have absorbed it as true and possible. We hold ourselves responsible for our numbers thinking we should be judged on them. This causes a lot of unnecessary suffering.

Why do we believe we can ‘control’ blood sugar?

During the industrial and scientific revolutions, the idea of machine efficiency was brought into medicine. The human body was widely viewed as a machine. This can be useful for acute care but fails miserably for chronic care, as is the case for managing diabetes.

But machine thinking seeped into diabetes care with control-like, statistical formulas: insulin-to-carb ratio, insulin-on-board, pump algorithms, and carb-counting. Don’t get me wrong: these are enormously helpful, but they don’t turn us into machines.

Improving time in range

Success in managing blood sugar and spending more time in range is knowing how to influence your numbers and sensing what to do with any blood sugar number you see.

This requires you to have a general knowledge of how things affect your blood sugar and a familiarity with your patterns. That said, because so many variables are involved, any action may take some trial and error.

Here are steps that help me spend, on average, 90% time in range.

Influencing your blood sugar

  1. Wear a CGM: I recommend wearing a CGM to anyone with diabetes, particularly if you use insulin. You need to be able to see your numbers to know where you are and where you’re going. A CGM is also an easy way to see your patterns: check your blood sugar before and two hours after a meal or physical activity to see its impact on your blood sugar. If you don’t use a CGM, you can check for patterns using a meter. While the 2-hour check is a mechanical rule, it will give you a sense.
  2. Routine: I eat the same breakfast of plain Greek yogurt, a spoonful of tahini and almond butter, and a slice of a flaxseed muffin every morning when I’m home. My lunches and dinners are similar day to day in quantity and carbs, and I follow a low-carb diet. Eating and exercising consistently also helps my numbers be more similar day to day.

Nudging: small pushes back into range

I follow Dr. Richard Bernstein’s “law of small numbers.” If I’m too high, I take a small amount of insulin to nudge my numbers down, wait, watch, and repeat if necessary.

When I need to raise my blood sugar, if it’s not dangerously low, I’ve learned to take one or two glucose tablets and watch what happens rather than eat everything in the refrigerator like I used to.

Practicing patience and forgiveness

Managing blood sugar takes vigilance. You’ll have more energy to do it when you flow with your numbers, rather than fight them. That means staying calm and seeing the big picture. It means knowing that many variables, not just your decisions, affect blood sugar.

That said, I’m far from perfect. I certainly have times I feel overwhelmed or frustrated by my numbers and my mind shouts, “How could I let that happen again? Why didn’t I wait before I took that extra shot?”

But the temptation to think why didn’t I do this instead of that is useless since I can only know which decision was better in hindsight.

To help my nervous system stay calm, I practice this simple exercise – sometimes during the day or when I’m tempted to rage bolus.

I stand with my knees unlocked, feel my feet on the floor, let my arms rest by my side or hold them over my chest, and slow my breathing. I acknowledge this number is not my fault. My actions alone didn’t cause it. Then I reflect as best I can on what might have created it so I might do better in the future. I think, what do I do now, and do it; I don’t dwell on the number.

In closing

It’s important to mention that managing diabetes is not easy. If it was, more than 50-60% of people with diabetes would reach the time in range recommendation, which is 70% of the time (the equivalent of 17 hours a day).

This past summer at Camp Nejeda I presented this myth of “control” to adults who have been living with type 1 diabetes for decades. They all knew it instinctively, but hearing someone say it caused one woman to sob, releasing years of blame she had been carrying.

It’s time we realize that it’s more accurate and helpful to tell people to “manage” their blood sugar instead of “control” it. Our numbers emerge from dozens of factors, some within our sphere of influence, many not. As such, we’re responsible for our efforts but not our outcome.

Rest in this understanding and see if giving up the idea of perfect numbers helps you spend more time in range with less stress.

Joint guideline contains new recommendations for diabetes, CVD.

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New guidelines on diabetes, prediabetes and CVD unveiled at the ESC Congress 2013 recommend diagnosis using HbA1c, less-strict BP targets and optimal use of revascularization.

The guidelines were developed as a collaboration between the ESC and the European Association for the Study of Diabetes (EASD).

“The growing awareness of the strong biological relationship between diabetes and CVD rightly prompted these two large organizations to collaborate to generate guidelines relevant to their joint interests, the first of which were published in 2007,” the statement reads.

Among the notable updates is the recommendation to use HbA1c for the diagnosis of diabetes. If HbA1c is elevated, the patient is diagnosed with diabetes; if not elevated, patients with CVD should receive an oral glucose tolerance test.

“We have simplified diagnosis because many patients may be disclosed with HbA1c, limiting the numbers who need the lengthier test. But a normal HbA1c does not rule out diabetes in high-risk patients, who need to have an oral glucose tolerance test,” ESC chairperson Lars Rydén, MD, PhD, of the cardiology unit at Karolinska Institute, Sweden, stated in a press release.

The guidelines also simplify CV risk assessment and no longer advocate the use of risk engines. “Risk engines which accumulate risk factors and produce a low-, medium- or high-risk score are less useful for patients with diabetes,” EASD chairperson Peter J. Grant, MD, from the division of cardiovascular and diabetes research at University of Leeds, U.K., stated in the release.

Patients with diabetes are considered at high CV risk. Patients with diabetes and CVD, including MI, angina or peripheral vascular disease, are considered at very high risk for recurrent CVD, according to the release.

Recommendations on revascularization have also changed since the previous guidelines. Medical therapy is now recommended before intervention for patients with stable CAD and no complex coronary lesions. “In former days, we were quick to do coronary interventions, but based on new trial data we now do not advocate bypass surgery and coronaryangioplasty until medical therapy has been tried,” Rydén stated.

Another addition is the recommendation that patients with several or complex coronary artery stenoses should be offered bypass surgery before percutaneous coronary dilatation. This change was based on new trial data that show superior morbidity and mortality with bypass surgery as compared with coronary dilatation, according to the release.

The guidelines also individualize targets for BP and glycemic control. The general BP target for patients with diabetes is <140/85 mm Hg; in the 2007 version, the target was 130/80 mm Hg. In patients with diabetes and kidney disease, the target is <130/85 mm Hg. Stricter BP control is also urged for patients at risk for stroke. Younger patients with a recent diagnosis of diabetes and no CVD history have lower recommended glycemic control targets, while those who are older and have longstanding diabetes and CVD have more modest targets.

Other changes in the new guidelines include the prioritization of weight stabilization over reduction, recommendations against drugs to increase HDL levels and aspirin use in patients with diabetes and no CVD, and a new chapter on patient-centered care with emphasis on shared decision-making.

Source: Endocrine Today.

New EASD/ADA Position Paper Shifts Diabetes Treatment Goals?

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A new position statement for the treatment of type 2 diabetes takes an approach much more focused on the individual patient compared with the “one number fits all” target of glycated hemoglobin (HbA1c) used up to now.

These new recommendations from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA), announced here today in a news conference at the European Association for the Study of Diabetes (EASD) 48th Annual Meeting, put the patient’s condition, desires, abilities, and tolerances at the center of the decision-making process about the goals and methods of treatment. “Our recommendations are less prescriptive than and not as algorithmic as prior guidelines,” the authors write.

In light of the increasing complexity of glycemic management in type 2 diabetes and the wide array of antidiabetic agents now available, as well as uncertainties about the benefits of intensive glycemic control on macrovascular complications, a joint task force of the EASD and the ADA sought to develop recommendations for the treatment of nonpregnant patients with type 2 diabetes to help clinicians determine optimal therapies. Their aim was to take into account the benefits and risks of glycemic control, the efficacy and safety of the drugs used to achieve it, and each patient’s situation. The resulting guidelines are published simultaneously in Diabetes Care (2012;35:1364-1379) and Diabetologia (2012;55:1577-1596) by the EASD and the ADA and are available on the EASD Web site.

“What we’re trying to do is encourage people to really engage in a complex world with the patient, given the variety of choices,” said David Matthews, MD, DPhil, from the Oxford Centre for Diabetes, Endocrinology and Metabolism at Churchill Hospital and the National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom, and cochair of the Position Statement Writing Group of the EASD and ADA. “And the algorithmic approach, in our view, has finally had its day. We can’t do that anymore.”

Dr. Matthews said the EASD and ADA writing group decided not to issue guidelines but rather to take positions and issue recommendations. “Published guidelines tend to be algorithmic, yet few clinicians prescribe by algorithms…and so there’s a lot of lip service to explicit guidelines,” he said.

Furthermore, there’s a danger in guidelines in that some payers and regulatory bodies focus on them as an absolute measure of success or failure and pay accordingly, or not. So for this reason, the authors did not put a specific HbA1c number in their position statement, and in addition, they did not want to give the impression that it is all right for the number to drift upward if it is below a certain level.

On the other hand, a lower HbA1c value may not be best for some patients. “We’ve got trial data challenging the simplistic view of the lower-the-better approach to glycemic control…. That tells us we need to be careful about just using numbers, however important they may be, to treat patients,” Dr. Matthews said.

So the plan is to have the physician and patient combine the best available evidence with clinical expertise and patient preferences to determine the course of treatment, which may include lifestyle interventions such as physical activity, dietary advice, and oral or injectable antidiabetic drugs, including insulin.

Main Points to New Approach

The position statement lays out 7 key points:

  • Individualized glycemic targets and glucose-lowering therapies
  • Diet, exercise, and education as the foundation of the treatment program
  • Use of metformin as the optimal first-line drug unless contraindicated
  • After metformin, the use of 1 or 2 additional oral or injectable agents, with a goal of minimizing adverse effects if possible (despite limited data to guide specific therapy)
  • Ultimately, insulin therapy alone or with other agents if needed to maintain blood glucose control
  • Where possible, all treatment decisions should involve the patient, with a focus on “patient preferences, needs and values”
  • A major focus on “comprehensive cardiovascular risk reduction”

The authors highlight several elements that need to be gauged for making decisions about the appropriate levels of effort to reach glycemic targets. Patient attitudes and expected efforts may range from highly motivated with good adherence and self-care abilities to poor motivation, nonadherence, and poor self-care abilities. The potential risks for hypoglycemia and other adverse effects are another element in decision-making.

The recommendations also focus on duration of disease, life expectancy, significant comorbidities, established vascular complications, and the patient’s resources and support system.

The authors make the point that although the recommendations focus on glycemic control, clinicians and patients should also pay attention to other risk factors, and specifically, “aggressive management of cardiovascular risk factors” in light of the increased risk for cardiovascular morbidity and mortality among patients with type 2 diabetes. Physicians should encourage as much physical activity as possible, aiming for a minimum of 150 min/week, consisting of aerobic, resistance, and flexibility training if possible.

If newly diagnosed patients are at or near the HbA1c target of less than 7.5% and they are highly motivated, they should be given a trial of lifestyle changes for 3 to 6 months with a goal of avoiding pharmacotherapy. But for patients with moderate hyperglycemia or for whom lifestyle changes are expected to be unsuccessful, antidiabetic drug therapy, usually with metformin, should be initiated. If lifestyle efforts are eventually successful, drug therapy may be modified or discontinued.

Information to Guide Pharmacotherapy

Many of the drugs to control blood glucose have similar efficacy, said Writing Group cochair Silvio Inzucchi, MD, professor of medicine, clinical director of the Section of Endocrinology, and director of the Yale Diabetes Center at the Yale School of Medicine in New Haven, Connecticut.

Based on an extensive review of more than 500 articles, “all of these drugs work more or less to the same extent,” he said. “In the grand scheme of things, when you’re talking about a patient taking a medication for years, perhaps decades, and being faced with side effects of medications, the differences in hemoglobin A1c may actually pale in comparison to how they experience that medication.”

To guide choices of glucose-lowering agents, the authors provide in tabular form summaries of the cellular mechanisms, physiological actions, advantages, disadvantages, and costs of classes of agents and drugs within the classes. They also show an algorithm for escalating treatment, starting with lifestyle changes and progressing to initial drug monotherapy, 2- and then 3-drug therapy, and finally to basal and then more complex insulin strategies.

The recommendations end with considerations of the effects of age, weight, sex/racial/ethnic/genetic differences, the comorbidities of coronary artery disease, heart failure, chronic kidney disease, liver dysfunction, and concerns about hypoglycemia. The authors also point out several areas where data are insufficient and therefore where research efforts should be aimed.

When asked if the new recommendations are feasible given the time allotted to seeing a patient, Andreas Pfeiffer, MD, DrMed, chief of the Department of Clinical Nutrition at the German Institute of Human Nutrition Potsdam-Rehbruecke in Nuthetal, Germany, and professor of internal medicine and director of the Department of Endocrinology, Diabetes and Nutrition at Charité Universitaetsmedizin Berlin, Germany, was cautious in his answer.

“If you calculate the time a doctor has per patient, it’s something like 7 minutes or so, and most patients are used to the physician telling him what he’s supposed to do,” Dr. Pfeiffer said. “In some ways it’s unrealistic” for a physician to explore a patient’s desires, capabilities, tolerances, and social support systems in that amount of time. On the other hand, patients return to the doctor several times over the course of a year, so there are more chances to expand the discussion.

But Dr. Pfeiffer worries whether diabetes specialists may become lax if they are not trying to treat to a specific goal. “Diabetologists have average HbA1c’s in Germany of around 7%, which is pretty good, actually…. And now if you relax the guidelines and say, ‘You don’t really have to care so much about it,’ so where do they go?” he wondered.

Source: Mescape.com