NICE recommends tighter blood sugar control in diabetes to reduce risk of complicationsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4612 (Published 26 August 2015) Cite this as: BMJ 2015;351:h4612
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I agree with Professor Stephanie Amiel's view that there is a need to recommend a target goal in blood sugar control which is evidence based without compromising the message for fear of "hurting someone's feeling" or giving those who cannot achieve this a "sense of failure".
We are not handing out prizes for "participating" or "I tried" or "I was there" unlike some of our progressive schools seemed to be doing. We are dealing with preventing complications from poor diabetic control which has life-long health consequences and impact upon life-style and independence on individuals with diabetes. We should not aim lower and accept more complication and suffering simply because we may hurt the feeling of some people who are not able or willing to maintain good blood sugar control.
After all our goal is "first do no harm", not " first do no harm but don't worry if you tried your best"
Competing interests: No competing interests
The BMJ rightly points out that the newly-updated NICE guidelines for the management of type 1 diabetes is recommending a tighter target for glycated haemoglobin than previously. Concerns have been expressed that this may be aspirational or create feelings of failure – or even blame – for patients (and diabetes services) who cannot achieve this. This is misunderstanding the concept of a target as something for which to aim, as in the Oxford Dictionary definition “An objective or result towards which efforts are directed”1. The value of 48 mmol/mol (6.5%) or lower may be considered the bullseye. Landing the arrow in a ring close to the bullseye achieves a score and is not a failure. In the Diabetes Control and Complications Trial (DCCT), the target was 6.05% and the mean achieved value was 1% higher. In the UK, with the previous target of under 7.5%, the mean HbA1c is likewise about 1% higher. We recognised this by stating an audit target for services of the proportion of people achieving 53 mmol/mol (7%) or lower. We agree we do not want to set people up for failure but we do want people to know what optimal is and achieve something that has real clinical benefit. And to provide enough support for those who can achieve near-normality to do it.
To clarify, we only recommend basal-bolus insulin regimens for adults with newly-diagnosed diabetes. The new recommendation “Do not offer non-basal–bolus insulin regimens for treating adults newly diagnosed with type 1 diabetes” is based on evidence that tight control from diagnosis is beneficial, and because of the barriers to basal-bolus regimens encountered when people have become accustomed to twice daily injection regimens. We will expand the recommendation in the guideline to clarify the double negative in the original text.
Stephanie Amiel, on behalf of the guideline development group
Competing interests: Chair of the type 1 diabetes in adults guideline development group. See uploaded file for full details.