Glycaemic control, glucose variability and the Triangle of Diabetes Care


  • Gerry Rayman Diabetes Foot Clinic and Diabetes Research Unit, Ipswich Hospital, Suffolk, UK



Glucose monitoring, glucose variability, glycosylated haemoglobin, diabetes complications, hypoglycaemia


The discovery of insulin turned a diagnosis of type 1 diabetes from a terminal condition to one that can be managed in a way that allows a full and fulfilling life. Optimal management of glycaemia plays a key role within the long-term management of diabetes. Indeed, the Diabetes Control and Complications Trial and the UK Prospective Diabetes Study established beyond doubt that intensive management of blood glucose (HbA1c) reduced the risk of long-term (especially microvascular) complications of the disease in type 1 and type 2 diabetes, respectively. Long-term observational follow up years or decades beyond these trials revealed a longer-term macrovascular benefit from these interventions. There is more to glycaemic control than the prevailing level of HbA1c, however. Variability of blood glucose within and between days promotes hypoglycaemic and hyperglycaemic episodes that may increase the risk of diabetes complications or adverse clinical outcomes and which certainly impair patients' quality of life and confidence in managing their insulin regimen. The Triangle of Diabetes Care has emerged as a useful concept here, bringing together the need to improve glucose levels, but also to avoid hypoglycaemia and to reduce glucose variability. Continuous glucose monitoring is a particularly valuable tool for addressing glycaemic variability, but patients and healthcare professionals can be swamped by the large amount of data that it generates. Advanced glucose profiling provides a means of producing a straightforward, visual representation of daily glucose profiles over a number of days that can help to pinpoint the changes in the insulin regimen needed to optimise blood glucose control.


Bliss M. The Discovery of Insulin. University of Chicago Press, p. 152.

Ainsberg A. Breakthrough – the story of Elizabeth Hughes and the making of a medical miracle. Available at (accessed December 2015).

Gebel E. The start of something good: the discovery of HbA(1c) and the American Diabetes Association Samuel Rahbar Outstanding Discovery Award. Diabetes Care 2012;35:2429-31.

Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2015; 58:429-42.

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 1993;329:977-86.

UK 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 1998;352:837-53.

Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89.

Nathan DM; DCCT/EDIC Research Group. The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. Diabetes Care 2014;37:9-16.

Cefalu WT, Ratner RE. The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: the "gift" that keeps on giving! Diabetes Care 2014;37:5-7.

Frier BM, Jensen MM, Chubb BD. Hypoglycaemia in adults with insulin-treated diabetes in the UK: self-reported frequency and effects. Diabet Med 2015 (advance online,

Ceriello A, Kilpatrick ES. Glycemic variability: both sides of the story. Diabetes Care 2013;36 Suppl 2:S272-5.

Lachin JM, Genuth S, Nathan DM, Zinman B, Rutledge BN; DCCT/EDIC Research Group. The effect of glycemic exposure on the risk of microvascular complications in the diabetes control and complications trial–revisited. Diabetes 2008;57:995-1001.

Frontoni S, Di Bartolo P, Avogaro A, et al. Glucose variability: An emerging target for the treatment of diabetes mellitus. Diabetes Res Clin Pract 2013;102:86-95.

Ceriello A, Novials A, Ortega E, et al. Hyperglycemia following recovery from hypoglycemia worsens endothelial damage and thrombosis activation in type 1 diabetes and in healthy controls. Nutr Metab Cardiovasc Dis 2014;24:116-23.

Almaatouq MA, Al-Arouj M, Amod A, et al. Barriers to the delivery of optimal antidiabetic therapy in the Middle East and Africa. Int J Clin Pract 2014;68:503-11.

Frier BM. Hypoglycaemia in diabetes mellitus: epidemiology and clinical implications. Nat Rev Endocrinol 2014;10:711-22.

Paty BW. The role of hypoglycemia in cardiovascular outcomes in diabetes. Can J Diabetes 2015;39 Suppl 5:S155-S159.

Cryer PE. Severe hypoglycemia predicts mortality in diabetes. Diabetes Care 2012;35:1814-6.

Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes 1997;46:271-86.

Bergenstal RM, Klonoff DC, Garg SK, et al. Threshold-based insulin-pump interruption for reduction of hypoglycemia. N Engl J Med 2013; 369:224-32.