Diabetes Forecast

Taking a Patient-Centered Approach

Heart and diabetes guidelines reflect findings that more isn’t always better

Robert Churchill/Getty Images

Every January the American Diabetes Association (ADA) publishes new updates to its Clinical Practice Recommendations, which are diabetes treatment guidelines used by health care providers. This year, those updates were somewhat overshadowed by revisions to two other important guidelines that affect many people with diabetes. Many readers may already have read something about these new guidelines.

In December, the American College of Cardiology and the American Heart Association published updates to 13-year-old cholesterol guidelines and 10-year-old hypertension (high blood pressure) guidelines. Both sets of guidelines comment on managing patients with diabetes, who often have abnormal cholesterol and high blood pressure. Notably, both guidelines also take a more patient-centered approach to their recommendations. This notion is becoming familiar. The ADA firmly took a similar patient-centered approach to blood glucose control in 2012, and much has been written about it since then. So what is new in these other areas?

Past guidelines have generally incorporated quite a bit of expert opinion into their recommendations. Expert opinion is often based on experience rather than findings from research studies. Until a few years ago, it was easy for experts to conclude that we should be doing more—more lowering of blood sugar, more lowering of blood pressure, and more controlling of blood cholesterol. It was easy to take this view because new trials kept finding more benefit from doing more to improve those important health risk factors.

But in 2009 and 2010, some studies of lowering blood sugar in patients with diabetes taught us that more was not always better. So in 2012, we received recommendations from the ADA to take a more personalized approach to individual patient goals.

At about the same time, we started getting similar results for controlling blood cholesterol and lowering blood pressure. We learned that if “bad” cholesterol (LDL) was well controlled, we didn’t get much benefit from raising “good” cholesterol (HDL). We learned that older patients and patients with diabetes may not need blood pressure lowered any further than what had already been recommended over a decade ago. Putting this into practice is a big shift from the “more is always better” approach. In this way, the new guidelines remind us that what we know is not the same as what we think we know.

It’s also a true success of modern medicine that we are beginning to find the limits of what current medications can do. This reminds us of something we’ve known for a long time: Much of our health does not derive from health care but from our lifestyle choices. Medications offer tremendous benefits, but those benefits have limits. As we continue to find those limits and to revise our guidelines and treatment approaches, it’s helpful to be reminded that we all write our own guidelines for ourselves every day.

So eat well, exercise, take medicines as directed, and feel reassured that the expert most in charge of your health is you.



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