Note: he has a visit with his doctor scheduled for next Wednesday.
My husband, a 75-year-ol Japanese man, was diagnosed with Type II diabetes 21 months ago with an A1C reading of 6.6. He was prescribed Metformin, which he takes as prescribed.
Three months ago as part of a routine doctor visit, his A1C had gone up to 8.0. So the doctor doubled his dosage of Metformin and encouraged him to change at least some of his eating habits, and directed him to come back in 3 months. His most recent test results (which our medical practice makes available to us online) is 7.9.
How serious is this? What might the doctor do about it? Note that we had to change doctors last year because our previous PCP retired. The new doctor is part of the same (large) regional practice. My husband’s medical history is in their computer records.
IANAD, but speaking as a T2 diabetic, that’d certainly get my attention if my numbers did that. Assuming that your husband did make the suggested dietary changes as well as upping his metformin dose, that his A1C essentially didn’t budge, and is still rather high, is definitely cause for a conversation with his doctor, IMO.
Approaches might include the addition of other meds, and/or possibly thinking about starting him on insulin, but again, IANAD, and I am not his doctor.
Edit: how physically active is he? Has his activity level changed over the past months, compared to what it was like 21 months ago, when he was first diagnosed? Physical activity, even just regular walking or calisthenics, can help to keep glucose levels lower.
He risks permanent damage to his vision, kidneys, and nervous system, among other things.
If Metformin isn’t working, he may need insulin shots.
A better question is what might he do about it? Things that will help are changing eating habits and being more active (if he’s not in good enough shape to exercise at least move around a lot, or as much as possible).
Diabetes is a one-way trip. The cells in your pancreas that generate insulin get over-stressed and die from trying to regulate such high glucose levels. Unlike many cells in your body, these cells do not regenerate. Once they are gone, they are gone forever. Reducing the stress on these cells is critical to getting your A1C down. Diet and exercise are the two biggest things that can help.
You can’t reverse the damage, but you can reduce the damage that you continue to do to yourself.
Losing weight helps. It is common with Type II diabetes to basically have fat clogging up the insulin receptors in your cells. Lose the fat and it takes less insulin to make the cells work, which reduces the strain on your pancreas,and prevents further damage.
That’s not a panic value, but certainly needs attention in the medium run. Lacking pertinent medical history and exam/lab findings I’m not going to try to lay out all the possible pathways forward, but there are a number of simple interventions/additions that could be added that could help things improve. This could include considering other oral anti-hypoglycemic meds and/or certain injectables, along with diet/exercise reinforcement. I’d not be rushing towards insulin injections unless it was apparent his situation was one of a primary failure of pancreas to produce insulin rather than insulin resistance.
I’d also encourage other posters here to not be too prescriptive in their recommendations; we don’t know enough about this particular individual to make a lot of assertions at this point and we’re finding that in many cases, certain approaches to better control can be quite counter-productive for many patients.
Decade+ very well-controlled diabetic here. One who started with a scary-high A1C: 10.3. Although I’m totally NOT any sort of trained medical expert.
A1Cs like 7.9/8.0 are dangerous in the medium-long term. He’s building in battle damage every single day. At age 75, whether something else gets him before he goes blind & his feet fall off is an open question. But at my age (64) I’d sure as heck be moving heaven and earth to get my A1C down from that elevated level. How long he’s had this problem undiagnosed is another factor. This diagnosis may be new news to him, but if he’s unwittingly had high A1C for a decade, he’s already built in a hefty chunk of irreversible battle damage.
IMO The single most important tool in a diabetic’s arsenal is his/her spoon. If he’s eating simple carbs it’s time to stop that. Nearly completely. If he’s heavy, it’s time to lose a big chunk of that weight. Portion control plus age-appropriate exercise are the way to do this. A bit of good news: Metformin is generally credited as an effective weight loss agent in its own right. I have no doubt it helped me during my own weight loss phase.
By the time somebody is running A1Cs like that, their pancreas is probably pretty weak. If he can avoid overworking it by eating very low carb low glycemic and losing weight he can extend the remaining life of whatever’s left of his pancreas. The alternative is stronger meds and eventually insulin.
One other question for the OP: you mention “a routine doctor visit.” Out of curiosity, is your husband being prescribed metformin by his general practitioner / primary care physician, or is he seeing a specialist (e.g., endocrinologist) for his diabetes?
As far as I’m concerned, he should have never been put on medication with a reading of 6.6. It isn’t that much higher than an acceptable reading, and he should have been given an opportunity to use diet and exercise as a means of lowering it.
Diabetic medication can have really bad negative effects on the body. My uncle gained 35 pounds of water weight with the first medication he was given. After finally getting on a medication that was tolerable, he decided to dedicate himself to a diet that would lose wight and a regular exercise program. Now, he is off the medication entirely!
Maybe so, but maybe not. Depends on the clinical situation. There a plenty of good reasons to start metformin at such a level, and plenty of good reasons to avoid doing so.
I was shitty at changing my eating habits. I was really battling gastroparesis and GERD when I was first diagnoses with T2 so I wasn’t eating much but what I did eat wasn’t low carb. I’m not talking Coke and donuts but still Cheerios and pizza. What worked best for me is a weekly shot of Bydureon (and eventually Trulicity), as well as regular exercise and continuing to at least be mindful of what I eat.
My buddy was diagnosed with T2, got Metformin and maybe Januvia, he stopped drinking Mtn Dew every day, stopped eating massive amounts of food, and cut way back on his drinking. Lost a ton of weight and his A1C is better than mine most months. He doesn’t really exercise, even.
One can manage their A1c via diet and exercise, if one’s pancreas is still working. WILL one manage one’s diet and exercise? That is what he needs to figure out with his doctor.
If he didn’t change his eating and exercise habits and is wondering why his A1c is going up, well…you know why.
I’m on one of the drugs in that class – dulaglutide (aka Trulicity) – plus metformin & glimepiride (aka Amaryl). My A1C has gone from close to 9 to just over 7.
Just observationally, it saddens me to find that so many younger primary care practitioners do not seem to be able to manage diabetics these days. During my career, I managed nearly all my type 2 DM patients myself (being board certified in Family Medicine), and referred only the ones on whom I could not get into good control despite fair compliance. Of course, the type 1 and 1.5 and CFR DMs and other niche diabetics were a different story. I know my endocrine consultants loved me because I relieved them of having to manage so many type 2 folks. They’d lament the seeming increasing inability of primary care physicians to do the job.
Heck, my nephew was dxed as type 2 by an internist, who told him he’d need to see an endocrine specialist as he (the internist) wasn’t all that good at/interested in managing DM 2.
Interesting & unexpected. I’ve been managed by my PCP(s) for all my years of DM2.
I wonder how much of what you report is a difference in physician training, how much it’s about physician productivity, and how much it’s just that DM2 is probably very frustrating to treat when the pts want a magic wand that involves absolutely no dietary changes while diet is the 90% solution to their health issues.
My only relevant experience is my college roommate who went on to become an ED physician. Who said the main thing that drove him to that specialty was his frustrations with generally pitiful pt compliance during his other clinical specialty rotations.
Excellent! Especially with DM so common now, the physicians on the front lines need to be able to deal with it.
It’s a mixed bag, with some of it also coming from the fact that endocrinologists often can bill more from insurance than primary care docs can. Hence many health care systems WANT the patient referred to endocrine.
Thank you all for the responses. To answer a few pertinent questions:
His A1C has been in the regular round of annual blood tests at least since he changed to my doctor, which was after he retired, so 7 or 8 years. His most recent reading previous to 21 months ago was 5.6.
Doctor is our PCP, who started out as a cardiologist but who is now in general practice because he wanted to cut back his hours. He seems competent and concerned.
We have both changed our eating habits to some extent. We no longer eat purely white rice, instead we use a partially-milled brown rice recommended by our doctor. We still eat bread (about half whole wheat, about half white) and potatoes. He does all the cooking. He doesn’t buy as many sweets as he used to, but still a few.
He is less active than he was, I think he is beginning to feel his age. He doesn’t go out in the yard gardening nearly as much as he used to. He has put on weight since Covid.
What I think he needs is to understand and believe the kind of problem this represents, and that the longer it goes on the less it can be reversed (assuming some of the above posts are correct). I don’t know if our doctor is able to explain this so that he can understand it. Partly there is the language problem, I never know for sure whether he has understood some explanation, he hates to admit when he doesn’t understand something in English. He usually doesn’t want to listen to me about things that are hard to understand. I sit in on his doctor visits to make sure instructions are understood and followed. I was hoping to find a Japanese-speaking doctor for him, but there are surprisingly few of them here. There is a Japanese bookstore in town, maybe I can find something there that will help.
Beyond the language problem is the stubbornness problem. I know this doesn’t get a lot of sympathy, but he has never been a particularly practical person in terms of things like planning for the future or taking preventive action.
Thanks for sharing that further info. I’d definitely let your practitioner guide you two as to what ought to come next. A lot of decisions will be based on what meds he’s on, other co-morbid conditions he has, his renal function, his BMI, and whether or not he’s got any complications of diabetes thus far.
Basic rule of thumb: An A1C of 8 is considered “fair control”. Above 9 would be “poor control”. Under 7 is “good control”. So no need to panic. But individual mileage will vary due to individual circumstances.
The highest A1c I ever saw in a patient of mine was 20. He had a lot of issues . . .
One thing I would recommend that has helped me is taking you blood sugar levels several times a day and see how you react to certain foods. Some of those sugar substatutes can actually spike your blood sugar. Some things that you are told are OK to eat in moderation may actually turn out to be something you can’t handle without a long term spike.
At one point I was taking mine 6 to 8 times a day and tracking what I ate. Now I’m down to a reasonable 6.1 A1C and only take my readings 3 times a day.
Based on your husband’s A1c, his average blood sugar over the past 90 days is about 180*. This in itself is not panic-high, but it is too high and the upward trend is deserving of close attention.
Upping the Metformin dose is just one spoke of the wheel. He should be vigilant about what he is eating and would benefit from consulting with a Registered Dietitian if he has not already. He should avoid sugary beverages altogether. He should keep a food log and bring it when meeting with the RD. And he should get some sort of daily exercise, even if it is just walking.
Beyond these basics – which are good pieces of advice for all of us – pretty much any other online input, well-meaning though it may be, is a bit reckless.
Except this: Does he have a Continuous Glucose Monitor? If not, have him look into obtaining a Dexcom G6 (preferable but less likely covered by insurance for a Type 2) or a Libre 3. Both are wonderful devices. His physician’s office can fight/appeal for insurance approval, if necessary.
Good luck!
*The formula for converting Hb A1c to average blood sugar is A1c x 28.7 – 46.7.
