Tight Glycemic control may not be best for Type 2


The risk for nonfatal myocardial infarction might be lowered by about 16% by intensive glycemic control, based on reported findings from all trials, at the expense of doubled or tripled risk for severe hypoglycemia. The incidence of hypoglycemia was also highest in trials with the lowest glycosylated hemoglobin (HbA1c) target levels. In all but the metformin vs conventional comparison in the UKPDS trial, intensive glycemic control was also associated with a 2% weight gain.

“Given that patients with diabetes often have comorbid conditions, clinicians should avoid glycemic control interventions that overwhelm the patients’ capacity to cope clinically, psychologically, and financially,” the review authors write. "Tight disease-centered goals that require highly complex and burdensome treatment programs may promote frustration, nonadherence, and financial stress in some patients. For instance, many patients will not benefit and could reduce or eliminate glucose self-monitoring.

It all sounds perfectly reasonable if you add the word “some” in a few places.

As a very general and broad statement, any study that thinks we are all the same is going to be problematic.

Here is my edit of a few sentences.

Tight glycemic control may not be best in SOME patients with type 2 diabetes, according to the results of a review and critique of recent large randomized trials reported online April 20 in the Annals of Internal Medicine. …

…"Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens SOME patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return…

It’s like all the cheesy stuff you learn in kindergarten gets thrown out the window with these studies. :grinning:



Let’s talk to @Gary about this, after his blood pressure resolves.

1 Like

To further confound the issues, there is this: https://www.mdedge.com/clinicalendocrinologynews/article/111877/diabetes/evidence-doesnt-support-tight-glycemic-control.

I think relying solely on A1C can be misleading. A person may be experiencing episodes of hyper and hypo glycemia and yet achieve acceptable a1c. If my understanding is correct, a1c is more of an average over a 90 day period, so in theory, someone can achieve an a1c of 6.5 and have very different BG profiles from another person with the same a1c, but is 90% WNL of say 80-140. One may be able to achieve a1c of 6.5 with excursions into >180 and <80. I read somewhere that it is the extreme variations that could cause health complications. Has anyone else heard, read, or , perhaps learned from an endo, @Eric, @Sam ?

@lh378 This is true. That is why the standard is moving from A1c to pgi and gvi ( patient glycemic index and glycemic variability index). These standards are not yet universally defined or accepted in everyday use, but in five years will probably supplant the A1c.

A1c is not a perfect measure—- as you describe. But what we do know at this point is that higher A1C is correlated with higher complication risks. At this point I think we’re basically just assuming that bg variability is also detrimental, but I don’t think we can really say that’s been well established at this point. I think now that cgm use is pretty common and the data will be available for use in research going forward we’ll have much better opportunities to understand what the role of blood sugar variability is in complication risk.


Many type 2’s are not eligible for insurance covered CGM (of course, some type 1’s are not covered either). I think that the healthcare system is truly messed up because it would seem that insurance companies would rather address the complications resulting from poor control than to give all of us the tools necessary to maintain good control. What’s wrong with a few extra test strips, and especially of the good kind?

I have yet to hear any of my healthcare providers speak of pgi and gvi.

1 Like

Just read your second link… it’s just frustrating that all of this different “research” can show completely different realities…

I haven’t read any authoritative studies that say that. It may or may not be true, I do not know.

Either extreme highs or extreme lows can cause a problem by themselves. And if you have a normal BG and then either an extreme high or low, that is an “extreme variation”.

On the other hand, staying at 250 for months would mean very limited variation, but we know that staying high for a long time could cause a problem.

So it’s probably hard for someone to make a case that it is only the variation that is the problem. I think it really depends on how they are defining it.

What is going on with Gary? Is he okay?

I’m sure he’s ok. I was just referring to the article giving him high blood pressure.


I have not heard of pgi and gvi before. Do you a link to share with information about this? :doughnut: :smiley_cat:

You can find a description and link in this thread

PGI is basically a string laid over your CGM trace and comparing its length to a straight line and GVI is glucose variability over a time period.

It’s definitely worth a read ( the link in the thread)

1 Like

Doc is correct I did see red for a while but after cooling down for a bit I have come to agree with @Eric, You have to add the word some in to the article.

I have done tight control and I have done lose control, let me say that tight is much better. There might be some that will do just as good, I suspect it is the T2 that can maintain solely on orals that might do well.

Lets face it that T2s do not always take their condition seriously, Thats one of the insidious things about T2. It tricks you into believing that all is well because there are no immediate consequences, Its not till later that you realize that you should have listened to the Doc. I can see how loser control and less demands might be better if it keeps the patient from bolting out the door.

In my mind tight will always be better for me but I am different that the average T2, I have this thing called an insulin pump hanging on my waist. Control is important. I think tight glycemic control would be better for everyone if you can get everyone to buy in. But not everyone will and good enough is better than nothing at all.

I can’t help but believe this is being done to counter the shaming we often see T2 treatment. Is it an attempt to stop some of the harassment some T2’s endure. You know, if you aim for nothing you will hit it every time.


Absolutely agree.

My mom is T2, A1C is 6.9 or so after eating lower carb and less processed foods for a few months while staying with us recently due to a diabetic leg wound that took five months to heal.

We got her a new GP (with a specialty in endocrine issues) in our area, and the moron told her that her diabetes was “too well controlled” because she was going low in the afternoons. Turns out she needed to halve her dose of Glimepiride since she wasn’t eating cake for breakfast. Same doc also said there was no way the leg wound not healing was related to T2. She was in daily wound care for weeks at a hospital outpatient facility and all staff there agreed diabetes was part of the problem. They encouraged her to test once a day. Her new doc? Nope, don’t bother testing.

So, I agree - deal with complications - ignore the underlying causes.