Dear Dr. Roach: I read about a follow-up study on the ACCORD population that showed that after a few years of follow-up, people in the tight blood-sugar-control arm had fewer heart attacks and need for stents. Can you comment on this? I want to know if I should keep my A1c lower.
Dear S.B.: In an important topic like heart disease with Type 2 diabetes, there are many studies, and it can be hard to make sense out of them all. Let me give you my personal understanding, having read many of them and consulted with experts in the field.
For people at relatively high risk for heart disease, “tight” control (meaning a goal A1c level of 6 percent or less) leads to increased deaths in the first six months to a year or so after changing to tight control. That was the original ACCORD study, which was stopped early. However, subsequent studies on the same population showed that if you survive the first year, your ongoing risk is lower than it would be with a less-stringent goal (such as around 7 percent).
Unfortunately, “relatively high risk” isn’t easily defined. People who are older, who have had diabetes for 10 or more years, especially if was not tightly controlled to begin with, and people with other risks for heart disease, such as smoking, a family history of heart trouble or very high cholesterol, certainly are at higher risk. This is the group that is at risk for worse outcomes with tight control, and I don’t recommend an A1c goal of 6 percent for those people. One study showed that the more calcium in the arteries (this can be measured by a CT scan), the greater the risk with tight control.
On the other hand, people with newly diagnosed diabetes who don’t have additional risk factors are likely to have better outcomes with relatively tight control. There is always the danger of hypoglycemia with very tight control, so management requires an experienced clinician who individualizes therapy (medication, diet, exercise) for optimum results. Clinicians with more experience in managing diabetes are likely to have better outcomes. In my practice, we have two outstanding nurse practitioners who are expert at managing diabetes, but internists and endocrinologists who make diabetes a big part of their practice also are excellent choices. Your diabetes doctor should be working with you to make this decision.
Dear Dr. Roach: I heard that letting vinegar touch your skin causes arthritis. Is there any danger in using vinegar as a cleaning agent?
Dear N.J.A.: I often get asked whether apple cider vinegar cures arthritis (it doesn’t) or can help relieve symptoms (it might, but there is no good evidence that it does), but I have never heard anyone ask about vinegar touching the skin causing internal problems. Vinegar is a mild acid (most are about 5 percent acetic acid), which normally isn’t particularly irritating to the skin, and shouldn’t be absorbed. Even if it were, acetic acid is found in the body (it’s an important molecule in several metabolic pathways), and your body can use it as an energy source. There is no reason to be concerned about being exposed to household vinegar.
Email questions to ToYourGoodHealth@med.cornell.edu.