The ACCORD study’s purpose was to evaluate the efficacy of lowering A1C in long term T2’s with poor control through intervention with drug therapy. The study was halted in 2008 before it was completed because subjects were dying at a higher than expected rate.
The initial take on the results was that reducing A1C was dangerous, and some medical professionals started advising their patients against shooting for a too low an A1C. This interpretation was immediately attacked on the grounds that the goal was only to get their A!C’s below 7. Also the only intervention was with drugs known to increase heart disease risk, diet and exercise were not included. Finally the subjects had spent many years with poor control.
Further analysis of the data has honed in on where the problem was located. The subjects that died were disproportionately those for whom the intervention had failed, their A1C’s were still well above the target of 7. Those who achieved the modest goal of an A1C below 7 had better outcomes after all. Here’s a link describing the study and it’s reinterpretation in more detail.
So if you receive advice that trying to get your A1C below 7 is dangerous kindly disregard it. In fact the risk for all complications starts rising at 5.5 and rises exponentially the further above 5.5 you go. The closer you can get to normal the better.
I think that’s great news! I think they are miscontruing the approach though. I think that everyone can benefit from trying to improve. It’s not the end result that gets you the good feelings, it’s to say “I’m going to change” and then changing. You shouldn’t beat yourself up because you change from an A1C of 9 to an 8, you should feel like you’ve slain a huge dragon and start sharpening your sword (needle, lancet, etc…) for the next one. There are a lot of things that go into improving one’s A1C but diabetes is a one test at a time project. It also bothers me a bit that they suggest that it was “easy” for some people. I don’t think diabetes is ever “easy”. It is a ton of work regardless of what your A1C is. People in concentration camps may not have found it “easy” to escape but they consistently fought back whether by shiving Sonderkommandos or ruining proximity fuses or any one of thousands of other small acts of resistance. It’s the small acts that we should focus on. If you get a ■■■■■■ BG test, don’t beat yourself up about it, look at it as an opportunity to do a good job fixing it and figuring out how to do something differently next time to avoid the same result, more insulin, less food, a scintillating blend of food/ diet/ medication/ exercise and trying to feel better about yourself can all work together.
Getting a doctor to prescribe this is probably very difficult but I think that the larger organizations of doctors, not just the JDRF/ADA but the AMA itself and other organizations used in planning by medical institutions need to adopt a more holistic approach to managing diabetes. 24-7-365 doesn’t fit into a 20 minute endo visit.
I agree, everyone should strive to improve. But the thing is you had basically “non compliant” patients, they were not told to diet (and certainly not low carb) and they were not told to exercise. Then, to control blood sugar, they were put on up to triple combination therapy “and” insulin if needed to control their blood sugar. They were overmedicated and still did not reach blood sugar targets and the treatment had side effects (remember almost all the patients took Avandia which has now been removed from the market).
It would be hard to see into the “non-compliant” community to figure out what the motivation is to adopt that approach. I suspect that doctors play a large role in aiding and abetting their non-compliance? Or even if they are compliant but limited in their approach because of some pencil pusher at an insurance company, you have the same problem, “well, this pill is better than that pill but I’m not taking insulin…”.
I can see that endocrinology could be a very frustrating field to get into but if you have a patient who is leery of needles and doesn’t approach the problem with basic scientific methodology like dropping cannonballs and feathers off of the tower of Pisa, combining with a doctor who doesn’t explain clearly enough that they can get on board or feel some reward from moving their A1C from 11 to 10 or 10 to 9 or 5.8 to 5.6 or whatever, you kind of have a recipe for someone having been lost to the disease. We have 19K members here vs. millions of people with diabetes so it’s a pretty sad situation?
Hello badmoonT2:
I have had neither access, nor time to read this study. However once it has been peer reviewed far more deeply, and we can find out who paid for it (ie no gross bias/flaws) with respect, I will remain justly skeptical. Obviously T2 is a different creature than T1, but the DCCT trial was painfully clear as to the dangers of too tight control!
Pushing too hard, keeping ourselves too low is always dangerous stuff. Until the approach is sentient and entirely “closed loop”, folks with control issues are going to push too hard… foolishly.
Respectfully,
Stuart
This study was strictly T2, and in fact T2’s with a history of poor control over a long period of time. I don’t believe any of the drugs used have any application with T1. FYI the original study was paid for by a drug company I forget which one.
I have run into lots of people with D or relatives/ friends with D. I have only run into one T2 trying to maintain tight control. Interestingly he found that the only thing that worked was low carb, as I have. He is a native of New Orleans and had to give up Red Beans and Rice, a major sacrifice. He is well read and computer literate, in fact he was my first computer guru many years ago.
It just burns me up that T2’s who are not computer literate or used to researching things in books, are dependent on the often poor advice they receive from the likes of the ADA, or the misinterpretation of this study.
That’s what has me confused. I’m a type 1, and at my last endo visit (a new endo, I moved last summer and have only seen her twice), my A1C went from 5.9, my lowest ever since I’ve been getting A1C tests, to 6.7 and I was feeling sorry for myself. So the endo said the ACCORD trial proved that tight control doesn’t improve preventing complications, that 6.7 was fine. Granted, it’s below 7 still, but I am always striving for lower A1C’s.
Stuart,
I thought I’d post an explaination of the DCCT study you quote for those who are not familiar with it. If you are interested in more detail follow this link
The goal of the DCCT study was to keep A1C < 6 It ran from 1983 to 1993. All subjects had T1
DCCT Study Findings are Intensive blood glucose control reduces risk of
- eye disease
76% reduced risk
- kidney disease
50% reduced risk
- nerve disease
60% reduced risk
The EDIC study followed the subjects of of the DCCT study when the original study ended.
EDIC Study Findings
Intensive blood glucose control reduces risk of
- any cardiovascular disease event
42% reduced risk
- nonfatal heart attack, stroke, or death from cardiovascular causes
57% reduced risk
The positive effects are balanced by the negative of increased incidence of lows which can be very dangerous.
Even though I’m T2 not on insulin, I have read many posts on this site by insulin users concerning their struggles with lows and respect what ever choices they make regarding balancing lows vs the obvious benefits of a lower A1C
It’s obvious your endo only read the headline of the ACCORD study. In regards to you, the subjects were all T2’s and one of the drugs used used was Avandia which has since been removed from the market because it causes an alarming increase of heart problems, the ACCORD study has absolutely no relevance to a T1 such as yourself.
Here’s a graphic showing the correlation between A1C and complications.
I’ll take the risk of lows all day long! It is hair-raising to feel your knees dissolve and get wobbly as your BG fades into oblivion but at least they are there.
I 2nd that!
Actually, I have to tell you. I hate this qualitative graph which is meant to be suggestive of the DCCT results. But it is flawed, it “rises” for low A1cs, something that was never observed, and the DCCT suggested results far below 7% which have subsequently been affirmed by other stues.
Agreed it’s not a great graph. I don’t remember where I found it. The upward hook at the low end is bogus for sure. I believe studies show a very slow rise until 5.5 and then steadily increasing risk of complications which this graph does a better job of depicting.
I feel where you and acidrock are coming from but… to simply assume that anyone who isn’t getting good control is “non compliant” is not really fair.
It’s also unfair to assume that Accord was telling its participants to be “non compliant” (e.g. “eat all you want and take these drugs”) like so many do (I note you and AR do not go that far but many do.)
There is a big spectrum out there and some who aren’t getting good control could do better if they had better education and medical intervention. And we could all do “better” in some sense or another.
Maybe I’m just not happy with “non compliant” as a term. Like “brittle” is also not a happy term maybe at the other end of the spectrum (or maybe the same end? Hard for me to tell!).
I suspect that doctors play a large role in aiding and abetting their non-compliance?
That’s a really tough nut because the heavy-duty drugs (insulin) are what’s kept me alive for the past 30 years.
There’s a few paragraphs at the end of The Discovery of Insulin which muses on how insulin is viewed (or maybe, actually IS) in many senses as an “enabler” of bad health. It’s disturbing for me to read but it’s harder for me to dismiss Bliss in the same way that I can with Taubes or the militant low-carbers. Bliss wrote that in the early-mid-80’s and predates them all and despite all that has a superior sense of perspective.
Sorry for that however my actual intent was to continue my stream of invective vs. the medical industry since “non-compliant” is one of the diagnosis codes for people with diabetes. Your type and your compliance are both rated by your diagnosis. http://www.icd9data.com/2010/Volume1/240-279/249-259/250/default.htm#250.0. Not so much how I look at people as how their doctors look at them? And I think that many doctors/ teams just give up if the patient doesn’t report they are compliant.
Frankly, I am totally non-compliant because I am sort of my own doctor, since I got the rates for my pump when it was installed.
Hi, bad Moon,
I've just run across your post regarding the ACCORD Study. It's interesting to read the report about the ACCORD study in Diabetes Care. They have lots of advertisings next to the study showing different diabetes drugs. UNLIKE your summary here, Diabetes Care does not put much emphasis on how instead of drugs, diet and exercise can have a powerful impact on lowering blood sugars. You accurately point out that the ACCORD study only looked at the difference between giving diabetics standard amounts of medicine and giving diabetics MORE medicine (The group in the ACCORD study that used MORE medicine is also the group in which more people died). Thank you for providing a good explanation. Now, can you explain why Diabetes Care does not give much mention of diet and lifestyle options, and instead goes straight to pushing more drugs?
I am perhaps a tad cynical but I notice Diabetes Care is associated with the American Diabetes Association. Many of their biggest sponsors are pharmaceutical companies. All you have to do is follow the money.
There is another side to this story and that is that many patients want to just take a pill and have their diabetes go away, without changing their diet or lifestyle. Many of us have found that we would have to accept dangerous A1C's if we were to follow this approach. I understand that many people are unwilling to change but just wish people were presented all their options, including carb restriction. Instead they are told they are doing fine, when in fact their A1C's mean they will deteriorate further and will develop complications which will shorten their life.
Thanks for posting this BadmoonT2. Cheers! :) Joanne