Editorial illustrates shift away from glycemic control in diabetes treatment

This image shows the "lend a hand" illustration: an open palm facing out. The five major forms of diabetes interventions are arranged in descending order of importance from thumb to pinky. The order is smoking cessation, blood pressure control, metformin therapy, lipid reduction, and glucose control, respectively. Credit: Modified by Heather White, Tufts University

An editorial in a February issue of American Family Physician proposes a simple way for physicians to communicate with patients about the best treatments for diabetes. The "lending a hand" illustration reprioritizes treatment goals, based on research on mortality reduction, to convey that glycemic control is no longer the primary intervention.

In order of benefit, to improve length and quality of life, patients with type 2 benefit from these interventions, starting with :

"Glycemic control is stuck in people's minds as the primary goal of treatment, but evidence has existed since the 1970s that other interventions are of greater benefit," said senior author Allen Shaughnessy, Pharm.D., M.Med.Ed., professor of family medicine at Tufts University School of Medicine and fellowship director of the Tufts University Family Medicine Residency Program at Cambridge Health Alliance.

Shaughnessy and colleagues wrote the editorial on their "lending a hand" illustration to demonstrate the paradigm shift in treatment priorities. "Lending a hand" emphasizes interventions that improve length and quality of life for those living with type 2 diabetes, in line with new guidelines from the American Diabetes Association and the European Association for the Study of Diabetes.

The "lending a hand" illustration uses the fingers of an open hand to depict diabetes interventions from thumb to pinky in descending order of benefit, relative to complications and mortality. Smoking cessation is considered the most important intervention (the thumb). Blood pressure control, metformin drug therapy, and lipid reduction follow along the pointer to ring finger. Glycemic control, considered the least important intervention, is relegated to the pinky.

"Some degree of is necessary to prevent symptoms," Shaughnessy said. "It's just that the return on investment is low when we try to push patients with diabetes to get their blood glucose as close as possible to normal."

According to the National Diabetes Information Clearinghouse, approximately 25.8 million Americans have diabetes, and seven million of those may not be diagnosed. The NDIC further estimates that accounts for 90-95 percent of all cases of diabetes. Diabetes is a major cause of heart disease and stroke and the leading cause of new cases of blindness among adults.

"Our aim in proposing "lending a hand" is to communicate the most beneficial interventions patients can make to reduce their symptoms and risk of death from . But this model requires a shift in thinking away from the outdated idea that glucose reduction is most important, which may be a challenge," said first author Deborah Erlich, M.D., M.Med.Ed., assistant professor at TUSM, assistant family medicine clerkship director, and program director of the new Carney Family Medicine Residency, a TUSM affiliate.

"Working to control blood glucose while not addressing the other risk factors first is like rearranging deck chairs on the Titanic. The ship's going down," said author David Slawson, M.D., professor and vice chair of the department of family medicine, director of the Center for Information Mastery, and director of the fellowship at University of Virginia School of Medicine.

More information: Erlich DR, Slawson DC, Shaughnessy AF. "'Lending a hand' to patients with type 2 diabetes: A simple way to communicate treatment goals." American Family Physician (89:4), 256-258. Feb. 15, 2014.

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