Sorting out diabetes complications
DEAR DR. ROACH: I’m 85 years old and a Type 2 diabetic. My fasting blood sugars are usually below 100. My physicians seem to worry about low blood sugars, and I am more concerned about slightly elevated blood sugars causing damage to my cardiovascular system and my kidneys. I’ve had three close relatives die from complications of diabetes, and I know they were not able to control their blood sugars. Is it true that death due to low blood sugars is very rare? Is there evidence that there is an increase in strokes and cardiovascular events with every elevation of the A1c above 5. Was the ACCORD trial that recommended an A1c of 7 performed on a group of patients who were in the hospital and not in great health. Since all medications have some side effects, do you know if the multiple use of medications were the cause of the excessive numbers of deaths in the tight control group of patients? — C.R.H.
ANSWER: I would like to congratulate you on your desire to take the best care of your diabetes, but let me correct a few of your misapprehensions. Most important, death from hypoglycemia is unfortunately not rare. While it is more frequent in Type 1 diabetes (where it accounts for approximately 6 percent of deaths), it is also frequent in Type 2.
When considering complications from diabetes, we separate them into microvascular complications — of the small vessels, especially in the kidneys, nerves and eyes — and macrovascular disease — of the large blood vessels to the heart and brain, and the great vessels of the body, like the aorta and femoral arteries.
It is microvascular disease in which A1c levels above 5 showed an increase, but most of the increase occurs over an A1c of 7 percent. For people with diabetic disease of the eye (retinopathy) and kidney (nephropathy), keeping the A1c as low as possible keeps the disease from advancing (although in the first year of changing to excellent control, the retinopathy paradoxically gets worse).
On the other hand, the ACCORD trial (which was of generally healthy people age 40-79 with Type 2 diabetes, not hospitalized people) showed that there were more deaths from macrovascular disease in the group with an A1c goal of less than 6 percent, compared with the group with an A1c goal of 77.9 percent. The difference was large enough that the study was halted and all participants were switched to a goal of about 7 percent. While it is possible that the increased use of diabetes medications was responsible for the deaths, most experts feel that the goal of lower than 6 percent is too risky from the standpoint of macrovascular disease. The risk/benefit ratio for lower A1c is even less for older adults like you.
Every person with diabetes needs an individualized plan made by his or her doctor, who must negotiate the risks of microvascular disease from too high blood sugars with hypoglycemia and increased macrovascular disease from too low blood sugar. For most older Type 2 diabetics, the optimum level seems to be an A1c near 7.
DEAR DR. ROACH: We care for our elderly dad, who has early stages of dementia. When church friends and acquaintances greet him, at least half of them ask him, "Do you remember me?" or "What’s my name?" Please, people, no one enjoys being put on the spot! Greet the person, and tell them your name and maybe someone they can associate with you. — A.D.
ANSWER: This is great advice. Being constantly reminded that your memory is failing can be very painful for people with dementia and for their families. A friendly introduction to remind the person of your name can make social events much smoother and less painful for everybody.