Sort­ing out di­a­betes com­pli­ca­tions

Cape Breton Post - - IN MEMORIAM / HEALTH / ADVICE - Keith Roach Dr. Roach re­grets that he is un­able to an­swer in­di­vid­ual letters, but will in­corpo rate them in the col­umn when­ever pos­si­ble. Read­ers may email ques­tions to ToYourGoodHealth@med.cor­nell.edu or re­quest an or­der form of avail­able health newslet

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.

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