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WHILE maintaining optimal blood sugar levels, or glycemic control, remains a cornerstone of diabetes management, intensive blood-sugar reduction does not trim the risk of the most serious complications of diabetes: heart attack and stroke — in patients at highest risk of these cardiovascular events, lowering blood sugar too much may be dangerous, says the August 2011 issue of the Cleveland Clinic Men’s Health Advisor.

According to a Cleveland Clinic expert, “aggressively treating blood sugar and addressing cardiovascular risk factors earlier rather than later is the best policy.”

Laurence Kennedy, M.D., chairman of Cleveland Clinic’s Department of Endocrinology, Diabetes and Metabolism, says, “...in type 2 diabetes, the time to really be aggressive is as soon as patients are diagnosed. That actually requires a big change in the way treatment of type 2 diabetes is typically delivered.”

The American Diabetes Association (ADA) recommends that most individuals with type 2 diabetes aim for a hemoglobin A1c level (a measure of blood sugar over the preceding two to three months) of less than 7 percent.

An individual without diabetes has an A1c level of less than 6 percent and most of those treated for type 2 diabetes achieve, on average, an A1c level of 7-7.9 percent.

A study published online April 19 in the journal Diabetes Care supports the ADA recommendation.

Researchers found that among more than 71,000 individuals age 60 and older with type 2 diabetes, death rates were higher among participants with A1c levels of less than 6 percent and greater than 8 percent.

Thus, the study authors recommended setting a target A1c of less than 8 percent for older patients, while cautioning against reducing below 6 percent.

In 2008, results of another study, the ACCORD trial, showed that lowering blood sugar level to achieve an A1c level of less than 6 percent in individuals at high cardiovascular risk did not reduce the risk of heart attack and stroke.

Other studies, including the Veterans Affairs Diabetes Trial showed similar conclusions.

Also, ACCORD investigators reported a 22 percent greater overall death rate (35 percent cardiovascular death rate) in those who underwent intensive glycemic control compared to those who received standard treatment (target A1c of 7-7.9 percent).

A follow-up report, published March 3, 2011, in the New England Journal of Medicine, showed a continued negative trend among those in the intensive-treatment arm of the ACCORD study after five years of follow-up, says the health letter.

Dr. Kennedy says, “A careful analysis of these recent studies, like ACCORD, suggests that it’s those patients who seem to be resistant to their hemoglobin A1c falling readily in response to simple add-on treatment who you may be doing a disfavor by trying to force the issue.”

In these patients, he notes, focusing more in controlling other cardiovascular parameters — such as blood pressure, cholesterol and preventive aspirin therapy — may be more sensible “because they affect cardiovascular risk to a greater extent than the blood-sugar control.”

Although your healthcare professional will advise you on your specific diet and exercise regimen (diet, exercise and weight loss — if you’re overweight — are keys to diabetes management), the following self-help measures are offered:

• Minimize your intake of sugary foods and beverages.

• Limit your alcohol consumption to no more than one drink a day.

• Substitute high-fiber fruits, vegetables and whole grains in place of high-carbohydrate, high-sugar and highly processed foods.

• Replace high-fat protein foods (e.g., red or processed meats or whole milk) with leaner protein sources, such as grilled or baked fish and skinless chicken, low-fat or fat-free dairy products and heart-healthy oils, such as olive and canola oils.

• Aim for 30 minutes of aerobic exercise each day on at least five days a week.

• And, if you’re overweight, ask your doctor about hemoglobin A1c and other blood tests to screen for diabetes.

Although Dr. Kennedy notes that the recent research supports the belief that instead of aiming for an A1c target, doctors should tailor glycemic control based on each patient’s unique characteristics and level of risk, he emphasizes that blood-sugar control is still important for all patients to prevent microvascular complications of diabetes, including vision loss, and nerve and kidney damage.

In conclusion, he says, “In most patients with diabetes, microvascular disease doesn’t kill them, but it can certainly make their life unpleasant.”

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