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Although there are only two major types of diabetes— type 1 and type 2—there are so many variations, particularly in type 2, that a treatment plan that works for one diabetic won’t necessarily work for another. Each plan has to be tailored to the individual.

Part 3 of 4
Although there are only two major types of diabetes— type 1 and type 2—there are so many variations, particularly in type 2, that a treatment plan that works for one diabetic won’t necessarily work for another. Each plan has to be tailored to the individual.

Part 3 continued

SETTING A BLOOD SUGAR TARGET
Whenever I talk about blood sugars in this book, I’m referring to fingerstick, plasma blood glucose measurements.

In my experience, given the right blood sugar meter, these values will be almost exactly the same as you would get from plasma measurements of venous blood that your doctor would send to a clinical laboratory. I’ve seen finger-stick blood sugars measured on hundreds of nondiabetic, nonobese adults (for example, salespeople who come into the office trying to sell me meters—I insist on demonstrations;* or the nondiabetic spouses, parents, or siblings of patients). It usually is about 83 mg/dl. In order to simplify, I round off and tell my patients that a normal to shoot for is 85 mg/dl, no matter what age. I haven’t had the opportunity to test a great number of nondiabetic children, but the literature shows that normal blood sugars will be about 85 mg/dl, with the potential to be considerably lower.

With respect to hemoglobin A1C, I have a sophisticated machine in my office that I’ve found correlates almost exactly with measures from a clinical laboratory. I therefore check HgbA1C values on every patient at every routine visit, and frequently on nondiabetic relatives. Essentially what I see is that nondiabetics who are not obese have HgbA1C levels in the range of 4.2–4.6 percent. I have a number of diabetic patients who, under treatment, now have HgbA1C readings as low as 4.2percent. This is a considerable deviation from the ADA’s recommendation of under 7 percent—with no intervention unless levels exceed 8 percent. In my opinion, this is yet another example of “the rape of the diabetic.”

* My training program consists essentially of the material covered in this book.
It’s my hope that physicians who have little time to educate patients will use this
book to assist in that purpose.

The ADA recommendation for “tight control” of blood sugars, from its Web site, is as follows:

Ideally, this means levels between 70 and 120 mg/dl before meals and less than 180 mg/dl after meals,with a glycated hemoglobin [HgbA1C] level less than 7 percent.

The recommendations go on to state that tight control (what I advocate) “isn’t for everyone,” which I believe is nonsense. But the ADA’s tight control as defined above isn’t very tight at all. I would call it “out of control.”
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CONVERTING HGBA1C TO BLOOD
SUGAR VALUES

Many years ago, I reviewed dozens of HgbA1C values and thousands of blood sugars from data sheets submitted by my patients and came up with a formula for converting HgbA1C to mean (average) blood sugar.

My formula does not jibe with most other formulas, perhaps because others haven’t collected blood sugars throughout the day running into the hundreds or even thousands of patients covering 4-month periods. The formula is very simple. An HgbA1C of 5 percent is equivalent to a blood sugar reading of 100 mg/dl, and every 1 percent above 5 corresponds
to an additional 40 mg/dl increase in blood sugars. So an HgbA1C of 7 percent would correspond to an average blood sugar of 180 mg/dl.

The formula is, in my experience, useless for HgbA1C values of less than 5 percent, and it may not work for average blood sugars greater than 300 mg/dl for the simple reason that for a new patient running blood sugars greater than 300 mg/dl, we rapidly get them down into
the 100s or less. Such new patients don’t come in bringing me hundreds of data points in the 300s for me to compute an accurate formula at these values—nor would I ask them to. Many may not bring me any prior blood sugar data on their initial visit.

So how do we go about setting a target normal value given all these numbers? Let’s take a look at a type 2 diabetic whose disease can be controlled by diet and exercise. Here, we’ll certainly shoot for blood sugars of about 85 mg/dl before, during, and after meals. It will then
be up to both me and the patient jointly—if his blood sugars are, say, in the 90s—to decide whether we want to introduce medications to further lower blood sugar. Many patients these days are hesitant to take any medication that’s been approved by the FDA, despite many
such medications’ being quite benign. If we have a type 2 diabetic who requires the insulin-sensitizing drugs like metformin or the thiazolidinediones, we certainly can shoot for a target blood sugar of 85 mg/dl before, during, and after meals, and indeed, I will work with the patient to juggle the medications, using long- or short-acting versions in order to achieve that target.

____________________
* I used to have some fun with nondiabetic sales reps when they came into the office selling blood sugar meters. They’d be demonstrating a meter, which I would compare to my own meter. I always used their blood because I’ve had enough finger sticks. I’d “guess” their blood sugar. I’d make a show of examining their skin, then give them a number. It was always the same, but they didn’t know that. The number was 83 mg/dl. Inevitably I’d be within ±3 mg/dl. You know, of course, that I didn’t have any special powers—it was just that I’d seen so many random finger-stick readings from nondiabetics, I knew what number the nondiabetic was likely to show.

Type 2 diabetics who require very small amounts of insulin (say, 1–2 units per dose) are at very low risk for hypoglycemia and will usually automatically “turn off” the insulin they make themselves if blood sugars are too low. Such people are also good candidates for a target of
85 mg/dl.

When it comes to type 1 diabetics, where virtually all of the needed insulin is going to be injected, I increase the target to 90 mg/dl, even though we know that the mortality rate—even in the general, nondiabetic population—is slightly greater for those with fasting or postprandial
blood sugars of 90 mg/dl than it is for those with blood sugars of 85. I use 90 as a target for myself because of the greater risk for hypoglycemia with a target of 85. I have to face the reality that my blood sugars are totally determined by what goes into my mouth, what I inject, my level of exercise, and rare extremes of emotional stress. There is no “automatic” control, so I feel it’s wise to throw in this small add-on of 5 mg/dl as a safety factor.

A target may imply corrections to get you to that target. As a rule, if you’re a type 2, your blood sugar goes down eventually—maybe quickly, maybe over many hours. If you’re a type 1 and injecting significant doses of insulin, if you make a mistake on your diet and your blood sugar goes up, you have to inject additional, calibrated doses of fast-acting insulin deliberately to bring down your blood sugar and, if it’s too low, take glucose tablets to raise it.

For a new patient in the very early stages of type 2 diabetes, I may see both hypo- and hyperglycemia. This is probably because one of the early “lesions” of type 2 is difficulty in storing the insulin granules your body makes. So such a person would make insulin for a meal,
then make more after the meal. A nondiabetic would store that additional insulin as it’s being made, but the early type 2 would release some or all of it into the bloodstream as it’s generated, thereby bringing blood sugar too low. This explanation also accounts for attenuated (diminished) phase I insulin response—just not having enough insulin stored to cover a meal adequately (another reason to follow a low-carbohydrate diet). Such an individual could experience blood
sugars in the 70s or even mid-60s from time to time, and these individuals must carry glucose tablets with them to bring blood sugars up to their target, usually 85. They don’t take injected insulin to bring blood sugar down if it goes too high when they make a mistake, because
their bodies will do that for them, probably faster than injected insulin would.

Click for Part 1 and Part 2

Part 4 next: SETTING GOALS OF TREATMENT

We would like to thank the publisher Little Brown and Company and Dr. Richard K. Bernstein, for allowing us to provide excerpts from Diabetes Solution.

Copyright © 2003 by Richard K. Bernstein, M.D.
All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

Author’s Note
This book is not intended as a substitute for professional medical care. The reader should regularly consult a physician for all health-related problems and routine care.

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