Disclaimer – The interviewee’s views are entirely his own and may not reflect the views of Abbott Diabetes Care
Can you tell us a little about how you came to specialise in diabetes?
I’ve been interested in diabetes and endocrinology since the early 90s, and found that I liked the challenge of working with diabetes compared to other conditions. Different groups of diabetes patients have to be treated differently, and of course it is a serious condition, with the risk of life-changing complications, so there is the potential to have a real clinical impact.
How did you come to focus on glycaemia (blood glucose levels) in particular?
Unfortunately, 75-80% of people with diabetes die of cardiovascular disease, and my research is focused on reducing mortality from vascular conditions in this population. In particular, I am interested in reducing the risk of blood clot formation and also working on making the clot easier to break down. Both high and low blood glucose levels have an important part to play in blood clotting and this is where I became interested in developing a more comprehensive approach to control glycaemia in diabetes.
What are the key things people with diabetes should know about blood glucose levels?
We tend to focus on high blood sugars, but we forget that very low sugar levels can be worse than hyperglycaemia in the short term. I always tell patients that we measure average glucose levels by HbA1c, and various guidelines advocate strict glycaemic control, particularly in younger people with diabetes. However, an HbA1c of 58mmol/mol (7.5%) with no significant hypoglycaemic events is probably better than an HbA1c of 48mmol/mol (6.5%) with repeated hypoglycaemia.
So it’s important to monitor hypoglycaemia as well as high blood glucose?
Yes. Until recently, hypoglycaemia has been regarded as an inconvenient side-effect of treating hyperglycaemia. But hypoglycaemia can have devastating short-term effects, and recent studies have also shown that hypoglycaemia increases the risk of cardiovascular mortality in the medium term.
But high blood glucose is bad for you too, isn’t it?
Certainly; we know that high sugars are bad for you in the long term – there’s lots of research into that. To further complicate matters, recent evidence has shown that extremes of blood glucose are a risk too. If you think about it, people without diabetes have a pretty tight range of blood glucose levels. People with diabetes have high blood glucose and treating high blood glucose can result in a large fall in levels.
And this can lead to a see-saw effect?
A Yes, sometimes that can be hard to avoid. For example, overtreating high blood glucose will result in hypoglycaemia, which in turn leads to a very uncomfortable feeling. Most patients tend to overtreat these episodes, resulting again in high blood glucose. This variability in glucose levels can be difficult to control and assess, as it depends largely on patients checking their glucose regularly.
So this is how you came up with the three points of the Triangle of Diabetes Care: HbA1c, avoiding hypoglycaemia and limiting variability?
Yes; I felt that a modern glycaemia strategy should involve all three points of this triangle, not just HbA1c. When I first presented it to fellow health care professionals, I thought I was stating the obvious! I was surprised at how positively this was received and how all could clearly see that the three points are inter-linked.
How can people with diabetes put the Triangle of Diabetes Care into practice?
Unlike other vascular risk factors that people with diabetes might have – like high blood pressure or high cholesterol – glucose levels can be difficult to control because they depend so much on the patient testing regularly. Blood glucose testing can be hard to sustain long-term; it’s inconvenient, painful and causes scarring on the fingers. My patients repeatedly tell me they want a break from testing! So it’s great that there are new devices available that can give them all the data they need without routine fingerstick testing.
Do you think that being aware of the Triangle of Diabetes Care will make a real difference to patients?
A I hope it will. Most patients appreciate that high glucose levels can result in various health problems long-term. However, not so many know how serious hypoglycaemia can be, and very few are aware of the risks of glucose variability. So I do hope that more people with diabetes will want to find out more, and use the Triangle of Diabetes Care to help their day-to-day management.
Dr Ajjan is Associate Professor and Consultant in Diabetes and Endocrinology at the University of Leeds Institute of Cardiovascular and Metabolic Medicine.
The Triangle of Diabetes Care and you
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Read more about Dr Ramzi Ajjan