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Sunday, May 19, 2013
Dear Sir, I am 79 years of age and was diagnosed with type 2 diabetes 8 years ago. I took the prognosis seroiusly and changed a rather outrageous dietry lifestyle to a more sensible regime. Initially my positive blood level readings were no more than 14 mmols/litre level and on a daily basis. Over the years, I refined my diet to the extent that weeks can elapse before a positive blood glucose reading happens. My eyesight at each test has proved to be 100% perfect, and so my conclusion is that my diabetes is well under control. However, three years ago it was picked up by the nursing practitioner at my clinic that my fasting glucose levels were high,(around 7mmols/litre) and I was medicated with Metformin (1gram daily). Since recently my fasting reading has not reached the magic level (6 mmol/litre) my medication has been increased to 2grms daily.
My question is that since my diet control has already been so effective,the Metformin medication appears to be a spurious exercise, and even if the 6mmol target is achieved, I feel little improvement will be achieved in terms of the already long periods of negative readings. My feeling is that the fasting readings have been unduly focused upon solely as an academic exercise, and without a balanced consideration of an already excellent level of diabetic control. Your views would be very much appreciated.
I don't fully agree with your reasoning process. I would like to address the issues you raise separate from your age and then put it into the context of how your age might affect any decisions.
Long-term effects of diabetes develop slowly over years. They can get to be quite advanced before they have effects that the individual with the disease can detect. So you may be correct that your vision is perfect and yet still have had progression of eye damage (or kidney or nerve damage or any of the other complications of diabetes) that will have some consequences for you in the future. So the present function of your organs (like eyes) are not the only criterion we use for whether diabetes is being adequately controlled - we look at the control in terms of how fast it may be permitting the complications to advance that may affect the individual in the future.
Now, we put this in the context of your age: Some 79 year olds expect to live many more years and make efforts to keep themselves as healthy as possible for those remaining years. Other 79 year olds - rightly or wrongly - don't think they will live a long time and are less concerned about the future health implications of decisions they make right now. Some people would make such decisions only for themselves while others would involve their family members in decisions like that. So all those factors play in to what decision is reached.
Now we return to more of the specifics of the situation: The longer an individual plans to be around and the more concerned they are about the quality of their remaining life life, the more potential benefit there is from tighter glycemic control. This is the effort that you are describing as academic. That individual needs to consider the trade-off between the potential health benefits and any disadvantages they may foresee from the health care efforts - those trade-offs are not the same for all.
So those are my views. I would be happy to continue the discussion if this raises further questions for you.
Robert M Cohen, MD
Professor of Clinical Medicine
College of Medicine
University of Cincinnati