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: What is brittle diabetes, and what makes someone "brittle?" If you are brittle, can you become not brittle?

A: Brittle diabetes is hard to define. Often physicians label a person as a "brittle diabetic" when attempts to achieve control of the blood sugar result in wildly fluctuating blood sugar levels. Persons who have such unstable blood sugar levels almost always have type 1 diabetes, are often slender (and very likely to have variable activity), and of course, are more likely to have a variable diet—items that certainly lead to fluctuations in blood sugar levels.

Some authorities state that if everyone with diabetes practiced good, tight control, no one would be "brittle," and they are partly right; many people's symptoms would be improved by tighter control. Sometimes, despite our best efforts, we are unable to reduce the blood sugar variations—some folks do everything right and still experience wild, out-of proportion swoops and rises in their blood sugars—and these are the truly "brittle." Luckily there are not many.

I wish I could tell you how to be less brittle. Often the usual methods of diabetes management can improve blood sugar control and even out the blood sugar fluctuations. Frequent tests and careful attention to diet and meticulous efforts to keep exercise the same from day to day act to stabilize blood sugar levels. Oftentimes, if a person is very slender, an effort to gain a modest amount of weight does help smooth out blood sugar levels. Most persons with the symptoms of brittle diabetes show a significant improvement when they work with a nurse educator, dietician, and physician in a team effort to smooth out blood sugar control.

Q: My Hemoglobin A1c has almost always run between 11 and 13.5, and I need to get them down to single digits. How do I do this, and what is a good range for hemoglobin A1c?

A: The Hemoglobin A1c test is used to estimate what your blood sugar has been during the 6-8 weeks prior to the blood sample drawn for the test. Perhaps the best way to demonstrate the importance of knowing your Hemoglobin A1c is to inspect the results of the Diabetes Control and Complications Trial (DCCT). In that study, the conventionally treated (one or two tests a day, one or two insulin injections a day) group's Hemoglobin A1c averaged a little over 9%, and that of the intensively treated group averaged slightly over 7%. The importance, of course, is that the intensively treated group developed far fewer complications than the conventionally treated group after six and a half years. After nine years, the differences between the two groups were even more pronounced.

The rest of your question is harder to answer, namely, how should you attempt to reduce the Hemoglobin A1c level? It is the same answer as usual in diabetes: frequent blood sugar tests, careful attention to diet and exercise, and careful teamwork with your care giver, nurse educator, and dietician are all important in order to achieve careful control of your blood sugar. The tighter the control, the lower the A1c.

Your next question, what should the A1c be ideally? Clearly, a normal, non-diabetic Hemoglobin A1c of 3.5 to 6.5 would be best. The problem with THAT target is the risk of hypoglycemia, particularly in insulin-treated persons. Most diabetics opt for a slightly higher A1c target, about 7, to give them a margin of safety. The target range of A1c must be decided by the person with the diabetes, and the health-care team, since the dangers of severely low blood sugar levels are very real. Severe hypoglycemia was three times greater in the intensively-treated group in the DCCT. Very tight blood sugar control with fasting sugars 120 or less and post-prandial (after meal) sugars 180 or less requires hard work by the person with diabetes, and by the treating team. This offers the best chance to minimize micro vascular diabetes complications (kidney, eye, and nerve diseases).