The Roundup -

What is your Diabetes Grade?


Jerome Kessler, MD

When I was in elementary school, the teachers gave us a report card every quarter that we were supposed to show our parents. I dutifully handed this over to my parents, and they would make comments. They were pleased that I got As in Math and Science, but were not happy if I got a D in Conduct and Behavior. . . That is another story, but it is analogous to how "Glycosylated Hemoglobin Testing" is used in diabetes.

You already know that Diabetes mellitus ("sugar diabetes") is a serious medical condition. Uncontrolled diabetes increases your chance of having a heart attack, stroke, kidney failure, blindness, nerve damage and amputations. Adult-onset diabetes (Type 2 DM) affects around 7% of American adults. It is twice as common in Hispanic and African-American populations. About 8 million Americans have undiagnosed diabetes, and another 87 million have "pre-diabetes." Whether diagnosed or not, diabetes can seriously affect your life in many ways.

Diabetes is characterized by elevated blood sugar levels and other metabolic abnormalities. New diabetics will sometimes present to their health care provider with increased thirst, increased urination, and weight loss. When their blood sugar is over 200, the diagnosis of diabetes is obvious. More often than not, however, the symptoms of diabetes are subtle, and blood sugar values go up and down depending on that particular day's food intake and exercise level. It is human nature that diabetic patients want to "look good" when they go to the doctor, so they improve their diet and exercise a few days before going to their health care provider, show him or her their latest blood sugars, and expect to hear that everything is just fine.

Getting a pat on the back is not as important as hearing the truth, and the Glycosylated Hemoglobin (also called a "Hemoglobin A1c") gives us an objective measure as to how your diabetes has actually been doing. You can use a formula (HgbA1c minus 2 times 30) to estimate what your average blood sugar has been over the last 3 months.A normal HgbA1c should be under 6.0%. A formal diagnosis of diabetes is defined as either a HgbA1c over 6.5%, a fasting blood sugar over 125, a random blood sugar over 200 in the presence of diabetes symptoms, or a blood sugar over 200 after ingestion of 75 grams of glucose.

Excellent diabetes control is generally defined as a HgbA1c under 6.5%. Realistically, we usually aim for a HgbA1c under 7.0% in healthy young adults, and adjusted goals (10% of age) in older Americans. Numerous scientific studies have shown that achieving these goals leads to longer and healthier lives. Monitoring HgbA1c (your "grade" for the last 3 months) is essential, and knowing this score helps your health care provider know what treatments to recommend.

All diabetics should eat a healthy diet, lose weight if indicated, and try to exercise 150 minutes per week. There are many medications available to treat this disease. New-onset diabetics (and also "pre-diabetics") are usually put on Metformin therapy. This medication has been around for many years, and is proven to control diabetes and prevent complications. Each class of diabetes drug (MET, SU, DPP4 inhibitors, GLP1 agonists, SGLT2 inhibitors, TZD, Insulin, and others) will lower your HgbA1c by approximately one point.If your HgbA1c is over 7.5%, or remains high after 3 months of therapy, then you will probably need combination therapy. Experts in diabetes treatment (the ADA, AACE, and others) say that you may even need "triple therapy" for uncontrolled diabetes. And if your HgbA1c is over 9.0%, and you have diabetic symptoms, then you should probably go on insulin. Fortunately there are many more diabetes treatment options than there used to be.

In the past, virtually all of the diabetes drugs caused weight gain – which aggravated the association between adult-onset diabetes and obesity. We now have drugs that don't have that side effect. Metformin and the DPP4 inhibitors are "weight neutral." The GLP1 agonists(Byetta and Victoza) and SGLT2 inhibitors (Invokana and Farxiga) actually promote weight loss, and can be prescribed as "add-on" or "stand alone" therapy for type 2 diabetes.

It is highly recommended that uncontrolled diabetics do home blood sugar monitoring, and also get their HgbA1c checked every 3 months. Latest studies have shown that not every diabetic needs to do home blood sugar monitoring, however, providing that their HgbA1c values are checked every 6 to 12 months, and are staying under target levels.

If you are diabetic (or think you might be) get your HgbA1c tested for $25 on Tuesday, March 25th, at the Richland County Fair Event Center from 2 pm to 7 pm during the Community Health Fair. If you are not getting an A or a B on your test, you might need to make some adjustments. You should also visit with your health care provider to discuss old and new treatment options for this serious disease.


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