One of 2008's most interesting developments was the change in one long-standing recommendation for treating diabetes in people who have had the disease for a long time: Work intensely on getting blood sugar levels as low as possible. 

But now experts are increasingly questioning that approach, suggesting that long-time diabetics might be better off working on lowering their blood pressure and cholesterol rather than trying to achieve an A1c of 7% and lower.

That thinking challenges a long-held assumption that one of the first necessities in managing diabetes is to bring blood glucose levels down as low as possible. Excessive glucose in the bloodstream causes inflammation that eventually leads to such organ damage as retinal and renal complications and a much higher susceptibility to heart attack.

In people who do not have diabetes, A1c's typically run in the 4.3% to 4.6% range. For people with diabetes, the American Diabetes Association recommends a minimum goal of 7% and a diabetes "ideal" of 6.5% or even 6%. 

Most people who have been newly or recently diagnosed with type 2 can reach the ADA-suggested A1c numbers fairly easily through a combination of diet, exercise, and medication. But for people who have had diabetes for years and are facing the consequences of long-term damage such as heart disease, getting to 7%-or even 8% or 9%-can be a struggle. 

Recent studies, including one by William Duckworth, MD, in the January 8, 2009, issue of the New England Journal of Medicine, and another by Jay S. Skyler, MD, associate director for academic programs at the University of Miami's Diabetes Research Institute, in the January 2009 issue of Diabetes Care, suggest that although low BG levels are still an ideal to be pursued, they actually offer little benefit to older, longer-term diabetics. 

Not only are such patients typically dealing with high blood pressure and cholesterol levels, as well as increased blood lipids (fats), but they could also be made more susceptible to hypoglycemic episodes, as well as stroke or heart attack, by too intensively controlled BG levels. 

The emerging consensus is to have older people with diabetes focus more on the issues that they can effectively control than on pursuit of a hard-to-achieve ideal that may confer little benefit. That's why you're seeing a shift in emphasis when it comes to discussing low blood sugar levels in the treatment of long-term diabetes patients.