Controlling Blood Glucose Levels in Patients with Type 2 Diabetes Mellitus An Evidence-Based Policy Statement by the American Academy of Family Physicians and American Diabetes Association
Steven H. Woolf, MD, MPH Mayer B. Davidson, MD Sheldon Greenfield, MD Hanan S. Bell, PhD Theodore G. Ganiats, MD Michael D. Hagen, MD Valerie Anne Palda, MD, MSc Robert A. Rizza, MD Stephen J. Spann, MD Fairfax, Virginia; Los Angeles, California; Boston, Massachusetts; Seattle, Washington;San Diego, California; Lexington, Kentucky; Toronto, Canada; Rochester, Minnesota; and Houston, Texas Submitted, revised, March 6, 2000. From the Department of Family Medicine, Medical College of Virginia-Virginia Commonwealth University, Richmond (S.H.W.); the Clinical Trials Unit, Charles R. Drew University of Medicine and Science, and the Department of Medicine, University of California-Los Angeles School of Medicine (M.B.D.); the Department of Medicine, Tufts University School of Medicine, Medford (S.G.); the American Academy of Family Physicians, Leawood (H.S.B.); the Department of Family and Preventive Medicine, University of California-San Diego School of Medicine (T.G.G.); the Department of Family Practice, University of Kentucky College of Medicine, Lexington (M.D.H.); the Department of Medicine, University of Toronto (V.A.P.); the Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic and Foundation, Rochester (R.A.R.); and the Department of Family and Community Medicine Baylor College of Medicine, Houston (S.J.S.). Reprint requests should be addressed to Steven H. Woolf, Department of Family Practice, Virginia Commonwealth University, Medical College of Virginia Campus, 3712 Charles Stewart Drive, Fairfax, VA 23298-0251. E-mail: SHWoolf@aol.com.
References
Recommendations for clinical practice
For any patient with type 2 diabetes, the better the glycemic control, the lower the probability of chronic microvascular, neuropathic, and possibly cardiovascular complications. However, because of differences in patients’ life expectancies, comorbidities, and preferences, it is inappropriate to set a uniform target glycated hemoglobin level for all patients. Individuals with long life expectancies and few comorbidities may wish to pursue euglycemia, but less vigorous goals may be appropriate for others, such as patients with multiple comorbid conditions or with limited life expectancies.
Whether the magnitude of benefit of a given treatment goal justifies the potential inconvenience, harms, and costs involves value judgments that must be tailored to the individual patient. Patients’ personal risk profiles and capabilities and the relative importance they assign to the potential outcomes and supporting evidence are integral in determining how intensively to treat.
Cardiovascular disease is the most likely cause of death in patients with type 2 diabetes, and attention to glycemic control should not distract clinicians and patients from other interventions that may be more effective in preventing coronary artery disease and stroke. These include smoking cessation, serum lipid management, control of blood pressure, diet, physical activity, and weight management. Guidelines for the control of these risk factors appear elsewhere.54-56 Clinicians should also pursue treatments other than glycemic control for preventing microvascular complications (eg, blood pressure control, angiotensin-converting enzyme inhibitors for diabetic nephropathy, laser treatment for diabetic retinopathy).
Whatever the desired goals and intensity of treatment, patients face considerable barriers in implementing recommendations. Modifying diet and other personal habits; complying with self-monitoring, medication, and home care; and returning for follow-up visits are difficult. Physicians should work with patients to overcome remediable barriers and should use recommended techniques for patient education and counseling to offer the necessary information and motivation for meaningful change.57
Acknowledgments
The systematic review on which this guideline is based was supported in part by funding from the Health Care Financing Administration. We thank Richard D. Kahn, PhD, (American Diabetes Association), and Herbert F. Young, MD, and Bellinda Schoof (American Academy of Family Physicians) for their assistance, as well as the expert panel that externally reviewed the full report: Eugene Barrett, MD; John A. Colwell, MD; Richard C. Eastman, MD; Saul Genuth, MD; Ronald Klein, MD, MPH; Martin Mahoney, MD; James W. Mold, MD; David M. Nathan, MD; Jonathan E. Rodnick, MD; Jeffrey L. Susman, MD; Sandeep Vijan, MD, MS; and Bruce Zimmerman, MD. Their participation in the review process does not necessarily imply endorsement of the report or its recommendations.
