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Metabolic Control Matters: Why Is the Message Lost in the Translation?

The need for realistic goal-setting in diabetes care

¹ Section of Adult Diabetes and the
² Behavioral Research and Mental Health Unit, Joslin Diabetes Center, Boston, Massachusetts

The scientific evidence is clear: metabolic control matters. The question is, why doesn’t this message persuade most patients? In this letter, we address one important consideration: goal-setting and its role in promoting behavioral change and improved glycemic control. The conclusive evidence from the Diabetes Control and Complications Trial (DCCT) (1) and the U.K. Prospective Diabetes Study (UKPDS) (2) that established causality between glycemic control and the microvascular complications of diabetes has highlighted the importance of the glycohemoglobin level as a critical predictor of future health. Inevitably, the focus of diabetes care and the interaction between the patient and clinician has increasingly become directed around self-monitoring of blood glucose (SMBG) records and glycosylated hemoglobin measurements (3). However, despite this evidence for the efficacy of tight glycemic control, as pointed out in a recent article in Diabetes Care by Narayan et al. (4), translation of these goals into clinical practice has generally been unsuccessful.

The Clinical Practice Recommendations of the American Diabetes Association (ADA) suggest a treatment HbA_1c standard of <7% and a blood glucose self-measurement target of 80–120 mg/dl before meals and of 100–140 mg/dl at bedtime in patients who do not have severe or unrecognized hypoglycemia (5). These targets are similar to those recommended by the American Association of Clinical Endocrinologists (6). For the patient in the earlier pathogenic stages of type 2 diabetes who has residual ß-cell function and is focused on exercise and following a diet, these can be attainable and realistic goals (2). However, even the most conscientious type 1 diabetic patient using a complex regimen of multiple injections or the insulin pump can face a frustrating battle in trying to keep their daily blood glucose fluctuations in the prescribed "idealized" target ranges. For the vast majority of patients, especially those with type 1 diabetes, these "standards" are unattainable "goals." The median HbA_1c levels achieved by the intensive treatment cohort in the DCCT were higher than the currently recommended target goals. Furthermore, annual capillary blood glucose measurements drawn from this group also exceeded these targets: postbreakfast measurements were highest at 195 ± 50 mg/dl, and the calculated mean blood glucose level for this intensively treated group was 155 ± 30 mg/dl (7).

As evidence from clinical trials (such as the DCCT and the UKPDS) have clarified the impact of risk factors on the probability of developing long-term diabetes complications, recommended clinical standards, often inappropriately described as "treatment goals," have been specified. As a first step in discussing "goal- setting in diabetes care," we want to sharpen the distinction between standards and goals, terms often used interchangeably.

One of the first steps in clarifying the goal-setting process with our patients is differentiating and reconciling recommended clinical treatment standards and the patient’s own personal goals. Why does the scientific evidence about the importance of metabolic control not persuade most patients? We propose that the current practice of imposing recommended standards, without first working with the patient to incorporate their personal goals, undermines patient motivation and engagement in treatment and thus sabotages "the message" that metabolic control matters. As the originators (8) of the "empowerment paradigm" have emphasized, mutual frustration frequently develops between patient and clinician when externally recommended standards are imposed on patients with diabetes.

In addition to distinguishing standards from goals, we want to clarify two fundamental assumptions about the use of insulin replacement therapy in type 1 diabetes and the more advanced pathogenic stages of type 2 diabetes with severely compromised ß-cell function. First, from our perspective, despite tremendous recent technological innovations, the current tools for managing diabetes with exogenous insulin are imperfect. Second, blood glucose levels are not under the exclusive control of patient behaviors. Taken together, these two assumptions preclude the achievement of consistently ideal blood glucose control, even in the most motivated and conscientious patient with type 1 diabetes or the more advanced pathogenic stages of type 2 diabetes (9,10).

An exclusive focus on clinical treatment standards within diabetes creates a vulnerability to perfectionism in both patients and clinicians. We know from behavioral science research that perfectionism is frequently associated with severe behavior and mood disorders (11). Therefore, in the context of diabetes management, the price of perfectionism is dangerously high. Yet this does not mean promoting unhealthy glycemic goals. Rather, with respect to biological goals, it means we must encourage patients to monitor their own personal progress in terms of individual movement toward improved blood glucose levels, rather than in terms of ideal and often unrealistic clinical standards. Changing behavior does not necessarily result in a commensurate improvement in biological goals. However, behavior change is the only goal realistically in reach of the patient, and keeping this distinction between behavioral and biological goals in focus is a key element in fostering engagement of the patient in their self care. When concerted patient motivation and behavior change does not result in the expected biological (glycemic) change, clinicians need to help patients problem-solve the situation and encourage and reinforce them in their efforts in striving toward improvement.

Having standardized glycosylated hemoglobin treatment targets is important for disease management programs and serves a useful role as trigger points to prompt clinicians to action. As professionals, we must strive for the ideal, and in view of the compelling evidence of the DCCT and UKPDS, we must have in our minds the ideal HbA_1c level of <7% (or even lower). But translating this ideal into reality in the care of the individual with diabetes is complex. For the individual patient, SMBG and HbA_1c levels are more than just objective measures of glycemic control; they translate into a judgment of their performance, competence, and self-worth. By setting goals for the individual patient that are too ambitious and that overlook the complex difficulties of managing diabetes and the realities of life, we may end up tripping up our best intentions; too often the patient will try, fail, and then disengage.

The ultimate goal in diabetes care (as supported by the scientific evidence and outlined in the ADA guidelines) should be tight glycemic control. However, in translating these targets into clinical practice (4), it is important to recognize the critical role that goals can play in the complex process of promoting behavioral change in the patient, thus highlighting the need for incorporating the concept of individualized realistic goal setting into the accepted standards of diabetes care.

FOOTNOTES

Address correspondence to Dr. Howard A. Wolpert, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215. E-mail: howard.wolpert{at}joslin.harvard.edu.

References

1. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993[Abstract/Free Full Text]
   
2. U.K. Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 354:837–853, 1998
   
3. Butler C, Peters J, Stott N: Glycated hemoglobin and metabolic control of diabetes: external versus locally established clinical targets for primary care. BMJ310:784–788, 1995
   
4. Narayan KMV, Gregg EW, Engelbau MM, Moore B, Thompson TJ, Williamson DE, Vinicor F: Translation research for chronic disease: the case of diabetes. Diabetes Care 23:1794–1798, 2000[Free Full Text]
   
5. American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). Diabetes Care24(Suppl. 1):S33–S43, 2001
   
6. American Association of Clinical Endocrinologists: AACE Medical Guidelines for Clinical Practice. Jacksonville, Fl, AACE, 2000
   
7. Diabetes Control and Complications Trial Research Group: Implementation of treatment protocols in the diabetes control and complications trial. Diabetes Care18:361–376, 1995
   
8. Anderson RM, Funnell M: The Art of Empowerment: Stories and Strategies for Diabetes Educators. Alexandria, VA, American Diabetes Association, 2000
   
9. American Diabetes Association: Implications of the diabetes control and complications trial (Position Statement). Diabetes Care24(Suppl. 1):S25–S27, 2001
   
10. American Diabetes Association: Implications of the United Kingdom Prospective Diabetes Study (Position Statement). Diabetes Care 24 (Suppl. 1): S28–S32, 2001
    
11. Burns DD: The Feeling Good Handbook. New York, Plume, 1990
    

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