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

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 HbA1c 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 …