I have had diabetes for almost two years and use an insulin pump. I’m also in nursing school. On several occasions, I’ve had professors ask me if I were “brittle” just because I had a low blood sugar. They know I use an insulin pump and test my blood sugar frequently. I know the term brittle isn’t really used any more, and even if it were, I maintain tight control and have an excellent A1c, so I know it wouldn’t describe me. I don’t know how to respond to this question and I have been asked it several times now. I don’t want to sound condescending to my professors by telling them the term isn’t commonly used anymore, but at the same time, I feel slightly offended by their remarks that I must be brittle if I have a glucose excursion below or above the limits. I know that no matter what I do, those are inevitable. Am I incorrect in feeling this term is outdated? How should I respond?

Brittle diabetes is a subjective term and may refer to different things. Nowadays, the most common definition, when referred to by experienced diabetes clinicians, would include a person whose life is constantly disrupted by hypoglycemia and hyperglycemia, including repeated hospitalizations, emergency room visits, etc. Many times, but not always, the cause of this definition “brittle” diabetes has to do with psychosocial problems and difficulty in taking care of diabetes (missing or taking too much insulin, etc.).

Your question is one that many people with diabetes have experienced from health care professionals who may not have as much knowledge about diabetes as you do. Lay people may also ask the same question, without the term “brittle,” but they are all wondering why you have hypoglycemia and hyperglycemia. I have told my patients that all type 1 diabetes is “brittle” by nature and it is because of your careful and relentless excellent self-care that you keep the normal swings in glucose from becoming problematic ones. Many people just do not understand what diabetes care involves and that the closer you keep yourself to a “good” glucose range, the closer you are to being hypoglycemic. Many people, with good intentions, think that you just take your insulin, eat right and everything should fall into place. They may mistakenly attribute blame to the situation when a person with diabetes has a low glucose.

If the conversation allows, I would explain that although you use an insulin pump and check your glucose many times through the day, we don’t have perfect diabetes tools. You can explain that hypoglycemia DOES happen to all people who use insulin and that in most cases it is NOT a sign of poor self-care, as the pumped or injected insulin just can’t match as well as what the pancreas can do. You can also tell them that the tools we have now are so much better than before and the long-term outlook is so much better, but you are still looking forward to advances in diabetes care that will help you keep your glucose as close to the normal range more easily.

If you need a reference article for a health care professional that would like to read more about hypoglycemia in diabetes, see Hypoglycemia in diabetes.

LM