Blood Sugar Control in Diabetes Getting Worse: Study

June 9, 2021 — Fewer adults with diabetes in the United States have well-controlled blood sugar or blood pressure now compared with 10 years ago, a trend that should be a “wake-up call,” say the authors of a new study published today in the New England Journal of Medicine

The researchers analyzed data from five large health and nutrition surveys of Americans in the past 20 years, called National Health and Nutrition Examination Surveys.

They aimed to find how many people with diabetes met the three recommended ABCs of good diabetes control:

• A1c, a measure of blood sugar control: less than 7%
• Blood pressure: less than140/90.
• Cholesterol (non-HDL cholesterol, or “bad” cholesterol): less than 130.

From 1999 to 2010, diabetes control was improving, but since then progress has stalled.

In the most recent survey, done from 2015 to 2018, only 22% of people with diabetes had all three measures under good control.

‘Concerning Findings, a Wake-up Call’

“These trends are a wake-up call,” said the study’s lead author, Michael Fang, PhD, of the Johns Hopkins Bloomberg School of Public Health in Baltimore.

“They mean that millions of Americans with diabetes are at higher risk for major complications,” he said in a statement from the university.

Complications of poorly controlled diabetes include foot amputation, kidney disease, and heart attack.

The findings are “concerning,” agreed senior study author Elizabeth Selvin, PhD, a professor in the Bloomberg School’s Department of Epidemiology.

“There has been a real decline in glycemic control from a decade ago, and overall, only a small proportion of people with diabetes are simultaneously meeting the key goals of glycemic control, blood pressure control, and control of high cholesterol,” she summarized.

Selvin suggests that two large clinical trials published in 2008 may partly explain these disturbing new trends.

The trials found that treating patients with diabetes medicines to reach very low blood sugar targets did not lower the risk of outcomes such as heart attacks and strokes.

And some people receiving this intensive treatment were more likely to develop dangerously low blood sugar levels (hypoglycemia).

“As a result of these trials, what we may be seeing is that doctors of people with diabetes may have backed off a bit on glycemic control, with potentially damaging results,” Selvin speculated.

However, many new, safer diabetes drugs have become available since those trials, she noted, although cost is still an issue.

Generic Diabetes Drugs on the Horizon

The researchers analyzed data from 6,653 adults with diabetes who took part in national health surveys done from 1999-2002, 2003-2006, 2007-2010, 2011-2014, and 2015 -2018.

The percentage of people with good blood sugar control increased from 44% in the first survey to 57% in the 2007-2010 survey and then dropped to 51% by the final survey.

Importantly, the proportion of people with good control of all three measures of diabetes care rose from 9% in the first survey to 25% in survey three but then slipped to 22% in the final survey.

The use of other newer second-line medicines for blood sugar control (generally given after trying metformin, the first-line treatment for type 2 diabetes) has increased but is still low, the researchers note.

Many of these newer diabetes drugs will become generic and more affordable over the next several years, they expect, which might help stop this trend of worsening diabetes control.

In the meantime, they say, doctors should prescribe more of the drugs that guidelines recommend be used first to treat high levels of blood sugar, blood pressure, and bad cholesterol.

Only 56% to 60% of the patients with diabetes surveyed were receiving metformin, ACE inhibitors, or angiotensin receptor blockers (ARBs) for high blood pressure, or statins for high cholesterol.