Doctors should study golf more seriously, especially putting. If you are trying to sink a putt, you have to hit the ball just right. Too hard and the ball goes sailing past the hole. Too soft and you fall short.
The same thing seems to hold true in medicine. A large, long trial of diabetes treatments has brought this lesson home loud and clear.
The ACCORD trial stands for Action to Control Cardiovascular Risk in Diabetes. Patients with type 2 diabetes are at particularly high risk for heart attack, stroke and other cardiovascular complications. More than 10,000 people with this condition were recruited and randomly assigned to different treatments.
The investigators were trying to find out whether aggressive treatment of blood sugar, blood pressure and blood lipids (cholesterol and triglycerides) over many years would lead to fewer complications and deaths. Many physicians expected that intensive treatment of these risk factors would yield big benefits.
The results stunned almost everyone. Instead of improving survival, taking extra measures to get blood sugar down to nearly normal resulted in more heart attacks and deaths (New England Journal of Medicine, June 12, 2008).
Intensive treatment of blood pressure to get systolic pressure down to 120 or less did not reduce the rate of heart attack or death significantly (New England Journal of Medicine, April 29, 2010).
In addition, adding fenofibrate to simvastatin to control blood fats lowered lipids but not the risk of heart attack, stroke or death (New England Journal of Medicine, April 29, 2010).
The ACCORD trial results are no fluke. The earliest large study to explore the treatment of type 2 diabetes was the British University Group Diabetes Program in 1970. Patients who took the oral diabetes medicine tolbutamide, which was relatively new at the time, did worse than patients taking placebo or insulin to control their diabetes.
Not long after that, British researchers recruited thousands of diabetic subjects to a ten-year study. Those who received intensive drug therapy to lower blood sugar did not have fewer heart attacks, strokes or deaths (The Lancet, Sept. 12, 1998).
But hope springs eternal, so British investigators tried again. They employed insulin in addition to oral diabetes drugs to get blood sugar close to normal (The Lancet, Feb. 6, 2010). This turned out to be counterproductive. The patients who used insulin in addition to oral drugs had a 49 percent higher risk of dying during the study than those who just used oral medications to manage their diabetes.
Although American doctors like to address risk factors aggressively, these excellent studies of people who are especially vulnerable to cardiovascular problems suggest that hitting hard might not always be the best approach.
Small steps, especially lifestyle changes, can yield big dividends for general health. A British study found that people who exercised regularly, didn't smoke or drink to excess and ate fruits and vegetables were much less likely to die over the next 20 years (Archives of Internal Medicine, April 26, 2010).
If doctors could coach their patients to adopt healthier behaviors, they might not need as much aggressive drug treatment.
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