ASK THE DOCTOR

by Wesley W. Wilson, MD

NOTE:� If you have any questions for "Ask the Doctor,"

please send them to the VOICE editorial office.� The only

questions Dr. Wilson will be able to answer are the ones

used in this column.

Wesley W. Wilson, MD has retired as an Internal

Medicine practitioner at the Western Montana Clinic in

Missoula, Montana.� Dr. Wilson was diagnosed with type 1

diabetes in 1956, during his second year of medical school.

He remains interested and involved in diabetes education for

patients and professionals.

Q:�� My doctor and I are arguing about my A1c numbers.

He says an ideal A1c is below 7, but my sugar fluctuates.

I'm worried about hypos if I fight to keep it that low.� If

I keep it CLOSE to 7, and give myself a little safety room

against "lows," isn't that better?

A:�� I'm pleased you and your doctor are discussing

your hemoglobin A1c values.� Medical advice must be a two-

way street, with each willing to listen to the other.

Ideally, the A1c should be in the normal range--below 6.2%,

but in real life, the concerns you mention prevent such

tight control for many individuals.

I find it interesting to review the research studies

that have attempted to demonstrate the benefits of tight

control versus "conventional" control.� In all studies,

particularly in the Diabetes Control and Complications Trial

(DCCT), even with very careful supervision of the tight

control group, the average A1c was very close to 7%.� The

target was under 6.2% at the start of the study, but the

increased risk of hypoglycemia posed by such low numbers

required a bit less intensive blood sugar control.� The

treatment team and the patients decided that the risk of low

blood sugars required a reduction in insulin dose.� Similar

results were found in the recently-reported United Kingdom

Prospective Diabetes Study (UKPDS), for persons with type 2

diabetes.� The Kumamoto study, in which type 2 persons were

treated with insulin, showed the same result.� All studies

were able to achieve a hemoglobin A1c of about 7%.� Today,

treatment of diabetes with insulin, or with any of the other

agents used to control blood sugar, is just not precise

enough to allow "perfect" blood sugar control, but we should

attempt to achieve the best possible A1c.

Most individuals in the DCCT could not achieve a

"normal," (non-diabetic) A1c (below 6.2%), but 5% of the

intensively-treated type 1 persons were able to maintain a

normal A1c for the 9 1/2 years of the study.� We wish we

could bottle what it was they had to allow such tight

control!� Many persons balance high sugars with too low

sugars to achieve their low A1c's, but hypoglycemia is

dangerous and risky.� Most diabetes professionals know of

patients who have been involved in auto accidents while

"low."

The current ADA recommendations are a compromise--the

target A1c is described as "7% or lower," and if the test

results are 8% or higher, "a change in treatment is

suggested."� It is recognized that each person is different,

and each achievable A1c is different, and there is agreement

that an 8% HbA1c is too high.

Your situation may be unique:� Do you have hypoglycemia

unawareness?� If you can't "feel" the onset of hypoglycemia,

your first sign of low blood sugar may be passing out or

falling down.� Do you always check your sugar before

beginning a hazardous activity (like driving)?� It is really

dangerous to drive while low.� How careful are you with the

routine things required to maintain ideal blood sugar, such

as counting carbs and giving just the right amount of

insulin with each meal?� A visit to your dietitian or nurse

educator may be helpful.

The bottom line is that insulin and some other

lifesaving drugs are very powerful, and therefore very

dangerous.� We need better ways of treating diabetes.� We

need to support research into better techniques for

treatment of diabetes.� We know that the closer to normal

your A1c, the less the risk of microvascular complications

(neuropathy, retinopathy, nephropathy,...)� It's hard to be

perfect, but even though we cannot achieve "normal"

hemoglobin A1c values in most persons with diabetes, getting

that value down to 7% clearly reduces the risk of

microvascular disease.��