Diabetic hemoglobin A1C goals may be too low for older diabetics. Here is why and what some doctors think should change.
Because the A1C is so new, doctors are still learning what number is the best goal for diabetes control.
In 1986 the testing program was given to doctors to provide a clearer picture of blood sugar control in diabetics.
They hoped to find that a lower number on the A1C improved diabetic complications.
On the diabetic hemoglobin A1C, non-diabetics test in the 4% to 6% range.
But a type 2 diabetic can test 10% or higher. Studies find that at levels higher than 8%, the complications multiply.
The National Institute of Health says half of type 2 diabetics have poor blood sugar control in the U.S.
So doctors hope the diabetic hemoglobin A1C will become a powerful tool for change. So far it seems to be working. But what is the perfect number for a diabetic?
For a while they thought the perfect number for a diabetic was 7%.
But diabetes doctors want to lower the goal to 6.5% or less. They say this will keep the heart, kidney, retinal and peripheral diseases from getting worse in type 1 and type 2 diabetes.
There is no doubt that a lower diabetic hemoglobin A1C does equal fewer complications.
A lower A1C means you have fewer AGEs, in your body. So you have less damage to your organs - your brain, heart, blood vessels and eyes.
But the A1C cannot tell you how often you have those dangerous low blood sugars.
Diabetic medications are a common cause of hypoglycemia as you attempt to lower the sugar in your blood by artificial means.
Your endocrine system is a complex and sensitive organism. Medications cannot hope to duplicate it.
Hormones regulate your blood sugar with tiny adjustments. If it dips too low your body releases epinephrine, making you feel nervous. Your heart starts pounding.
Your lips, hands and feet may feel numb because hormones restrict the amount of glucose sent to your extremities.
If your blood sugar drops lower you start having neurological symptoms like blurred eyesight, profuse sweating and sleepiness.
The diabetic hemoglobin A1C test cannot warn you or your doctor when or how often diabetic shock is happening to you.
But the worst problem with sugar lows is that if they happen a lot, you become less sensitive to them. This is one danger of aging with diabetes.
Especially at night, hypoglycemia can go unnoticed. Without early warnings your blood sugar may dip low enough to send you into shock.
Another problem is this. Low blood sugar attacks wear down your diabetic heart. They are not good for your brain either. As you age the results appear in heart disease and cognitive decline.
Only constant blood sugar monitoring uncovers when and how often low blood sugars are occurring. The diabetic hemoglobin A1C cannot keep track of them.
Studies performed in older diabetics show that a diabetic hemoglobin A1C over 7.5%
to 8% leads to higher death rates from complications. That is no surprise.
But research showed the same risk of death when the A1C is less
than 6.5%. This result was shocking.
If older diabetics have heart failure
or nephropathy, what doctors call comorbidities, the risk is even higher.
Doctors who work with diabetics in the geriatric range believe that the goals for things like weight, blood pressure and diabetic hemoglobin A1C need to be higher than those for younger, newer diabetics.
They say that an A1C between 7% and 7.8% would be better because pushing for lower numbers raises the chances of dying.
These findings are new, and all doctors do not agree on the conclusions.
But doctors who specialize in treating elderly patients think that pushing for tight blood sugar control leads to multiple hypoglycemic attacks.
They see diabetic shock as the result of over control with medications.
So giving the same goals to young and old patients is a mistake.
For example, doctors know that elderly patients who are a little overweight survive heart attacks and other illnesses better than low weight patients.
Geriatric doctors who treat cholesterol and blood pressure with less medication report improved survival rates. They also report smaller benefits from tight blood sugar control.
Measured against the catastrophic results of hypoglycemia in the elderly, a diabetic hemoglobin A1C of 6.5% or lower is not worth the risk.
That applies most of all to diabetics with a high risk for cardiovascular disease and those who have heart failure or kidney disease.
If you have a diabetic hemoglobin A1C below 7% because you diet and exercise, you can dodge the complications from high blood sugar.
No matter how old we are, we can lower our blood sugar with a sensible diet that does not contain AGEs, and use exercise for weight loss and cardiovascular health.
The less we have to depend on insulin and pills to control type 2 diabetes, the better we will do as we age.
It is exercise and eating healthy food that will improve the quality of our years as we live longer and longer with diabetes.
But as older diabetics, we need to be realistic with our goals. We are not going to live forever, but we can enjoy today and love others while we are here.
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