Type 2 di­a­betes di­ag­no­sis and drug ques­tioned

Times Colonist - - Life - DR. KEITH ROACH Your Good Health

Dear Dr. Roach: My re­cent fast­ing blood test showed my glu­cose num­ber as 99, but the A1C said seven per cent. My doc­tor im­me­di­ately wanted to put me on met­formin, but I re­fused for two rea­sons:

1. I am a se­nior, 69 years old, and I heard this medicine’s side­ef­fects could be dan­ger­ous; 2. I am not con­vinced I have Type 2 di­a­betes, be­cause I don’t ex­hibit any of the symp­toms. I am five feet, two inches tall and weigh 130 pounds, and I am full of energy. I eat healthily and get ad­e­quate ex­er­cise. How­ever, I am un­der a lot of stress be­cause I take care of my mom, who has de­men­tia. It’s been nine years. Can stress cause a rise in blood sugar? I have taken Lip­i­tor since 2008, and that’s when the trou­ble started. Do I re­ally need treat­ment?

M.B.

The A1C level mea­sures the amount of sugar mol­e­cules at­tached to he­mo­glo­bin, the pro­tein in red blood cells that car­ries oxy­gen. In peo­ple with nor­mal he­mo­glo­bin, the A1C is an ac­cu­rate rep­re­sen­ta­tion of the per­son’s av­er­age blood sugar over the past cou­ple of months. A re­peated A1C of over 6.5 per cent makes the di­ag­no­sis of di­a­betes.

There are two caveats. The first is that the A1C is un­re­li­able for peo­ple with ab­nor­mal he­mo­glo­bin or those who have med­i­cal con­di­tions caus­ing red blood cells to be bro­ken up too quickly (es­pe­cially hemolytic ane­mias) or bro­ken up too slowly (such as iron, B12 or folic acid de­fi­ciency). The second is that the level should be con­firmed on a dif­fer­ent day. Since you don’t have symp­toms, con­firm­ing the re­sult is par­tic­u­larly im­por­tant. A glu­cose tol­er­ance test re­mains the most ac­cu­rate way of con­firm­ing the di­ag­no­sis of Type 2 di­a­betes.

Most peo­ple with an A1C of seven per cent do have di­a­betes. You have at least one risk factor for di­a­betes, and that is the ator­vas­tatin (Lip­i­tor) you are tak­ing. Statins can pre­cip­i­tate di­a­betes in those pre­dis­posed to get­ting it. It is worth dis­cussing with your doc­tor your risk for heart dis­ease and re­con­sid­er­ing the need for con­tin­ued statin use. Chronic stress, which can cause el­e­vated lev­els of cor­ti­sone, does have a small ef­fect on blood sugar, but sel­dom enough to cause overt di­a­betes.

Your BMI is 24, which is nor­mal, but in­di­vid­ual body com­po­si­tion has an im­pact on di­a­betes as well. Peo­ple with large waist cir­cum­fer­ence for their height are more pre­dis­posed. Most peo­ple have room to im­prove their diet and ex­er­cise. It might be worth con­sult­ing with a di­a­betes ed­u­ca­tor or di­eti­tian nu­tri­tion­ist, as treat­ment with lifestyle is pre­ferred over med­i­ca­tions.

Not ev­ery­one with an A1C of seven per cent needs med­i­ca­tion. Many ex­perts ad­vise against pre­scrib­ing blood sugar low­er­ing med­i­ca­tions for peo­ple in their 60s and older un­less the A1C is higher than yours. The ex­act num­ber re­mains con­tro­ver­sial, but an A1C of seven per cent is rea­son­able as long as it is not head­ing up. If you do re­quire med­i­ca­tion, met­formin is the usual first-line choice, although there are other op­tions.

Dr. Roach re­grets that he is un­able to an­swer in­di­vid­ual let­ters, but will in­cor­po­rate them in the col­umn when­ever pos­si­ble. Read­ers can email ques­tions to ToYourGood­Health@ med.cor­nell.edu.

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