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February 27, 2002

Tight Control

Question from Venedocia, Ohio, USA:

My 72 year old father, diagnosed with type 2 diabetes 27 years ago, is currently taking several different oral hypoglycemic agents, but his control has not been that good. He watched my 14 year old daughter (who has type�1 in good control) manage her diabetes while we were visiting, and decided to do some extra blood glucose checks to try to get his diabetes back under control, and found that his blood glucose was regularly running well over 300 mg/dl [16.7 mmol/L]. I sent my parents some information, and he had an A1c done, which came back at 9.5%. I told them everything I read said his should be under 7.0%, but yesterday they went to their doctor, who explained to them that the expectations for control in children and older adults are very different. He suggested my father should be satisfied with keeping his blood sugar around 200 mg/dl [11.1 mmol/L], and told him he was in great shape. (He has retinopathy, neuropathy, and had quadruple bypass surgery a couple of years ago). The doctor did order a kidney profile at their request and added yet another oral medication. He suggested they walk 30 minutes a day and ordered another A1c in two weeks. I would like them to seek out an endocrinologist and a diabetes team, but my father is now convinced everything is fine. Is it unrealistic for him to aim for an A1c under 7.0%?

Answer:

I would tend to feel similar to the way you feel about the control of diabetes. A hemoglobin A1c of 9.5% is too high. I would agree sugars need to be decreased.

However, your father’s physician told him what he wanted to hear. That is a problem. The only thing I can say about different thresholds for control is that when a patient already has complications, the risk/benefit for tighter control is different than in a young child. For your child, you will want good control all her life so that she can avoid complications. For your dad, he already has complications. However, there are short-term benefits to good control that cannot be overlooked.

JTL

[Editor’s comment: Improving control will go a long way in abating the effects of the complications your father already has and hopefully help him avoid others. Of course, your dad could not possibly feel well with blood sugars that high all the time. There is a plethora of options these days for treatment of type�2 diabetes, which needs to be individualized, and it sounds like your dad may need insulin at this point, or soon, to improve his control.

I suggest you print out this response and sit down and discuss it with your parents. Keep in mind that the ultimate decision to seek a referral to an endocrinologist and/or improve control is ultimately your father’s.

By the way, I cannot figure out why your father’s doctor wants to recheck an A1c in two weeks, since there will be no change.

SS]

[Editor’s comment: I’d like to cast another vote for continuing with tight control of diabetes whenever feasible. If your dad had a terminal condition that’s likely to cause his death in a few months (which you certainly did not mention!), then sloppy control might be okay. If he has a reasonable chance of another 5 or 10 years of active life, however, he ought to do what’s possible to maintain his health — and tighter control of his blood sugar (avoiding hypoglycemia at all costs, however) would seem very appropriate.

WWQ]