Dr. Roach: ‘Brittle’ diabetes encompasses harder-to-control blood sugar

Dear Dr. Roach: I am 74 years old and have been a brittle Type 1 diabetic for 50 years. I have no history of heart disease. My doctor of 40 years recently retired and had me control my hemoglobin A1C to a range of 5.9-6.2. My new doctor, who is in her mid-30s, wants me to elevate my hemoglobin A1C to 8.0. Is this the new way of controlling blood sugar? I am confused! Can you please explain the difference in opinion?

— E.S.

Dear E.S.: “Brittle” diabetes is when it is hard to control too-high and too-low blood sugars.

The A1C is a blood test that looks at average blood sugar over the past few months. A normal A1C is between 4 and 5.6%. People with normal A1C levels are at very low risk of complications from diabetes, especially of the kidneys (leading to dialysis), eyes (which ultimately leads to blindness) and nerves (diabetic neuropathy is painful and predisposes to injury).

On the other hand, low A1C levels put people at higher risk for low blood sugar (hypoglycemia), which can be very dangerous. People with Type 2 diabetes and blockages in blood vessels (or at very high risk) were shown to have higher risk of heart attack. For this reason, recent guidelines for older adults with Type 2 diabetes have had more relaxed goals, in the range of 7 to 8, although these do need to be individualized. For Type 1 diabetes, most guidelines still recommend an A1C goal of less than 7%. However, for a person with Type 1 diabetes who also has other medical problems that are likely to impact mortality, and for those at high risk for severe hypoglycemia, a more relaxed goal is not unreasonable.

Hypoglycemia is too-low blood sugar, with risk of confusion. This is a big problem in people with brittle diabetes.

A lower A1C is associated with a lower risk of damage to small blood vessels, which is what is responsible for nerve damage, eye disease and most diabetic kidney disease. If you have been able to keep your A1C in the range of 5.9 to 6.2, which is not an easy feat, and have not had any serious episodes of low blood sugar recently, I would wonder why your new doctor feels your blood sugar needs to be substantially higher than it is.

Finding the right balance between good control and freedom from hypoglycemia isn’t always easy, but these are the risks and benefits your doctors have been considering.

Dear Dr. Roach: I’m going to be 90 years young, and my doctor says I’m considered a prediabetic. I now live in a senior-living home, and my new doctor is great — and gives me printouts of my labs. My glucose level is 120 (it should be 65-99). I was told to watch my diet. What do you suggest?

T.S.

Dear T.S.: A blood glucose level between 100 and 125 does indicate prediabetes, a risk factor for developing Type 2 diabetes. Risk for diabetes increases with age.

I agree with your doctor that a good diet can reduce your risk of developing overt diabetes, and this means limiting the amounts of simple sugars while consuming plenty of vegetables. There are many different dietary styles that are healthy, and you should eat what you enjoy, as long as you stay away from too many sweets.

I am sure there are nutrition experts at your senior-living home — hopefully a highly trained one, a registered dietitian nutritionist — who can work with you to help you choose a healthy diet plan. At age 90, I think you should eat what you enjoy, but I bet you can find ways to do so while still reducing your risk of diabetes.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.