The Future of Type II Diabetes Care?

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Jackie Wilkinson is a Registered Dietitian and Certified Diabetes Educator at Upland Hills Health. She is the Coordinator of the Diabetes Self Management Program which helps individuals manage diabetes to live long, healthy lives. To learn more, please contact wilkinsonj@uplandhillshealth.org

According to the CDC, nearly 30 million people in the United States have type II diabetes. This is over 9 percent of the entire U.S. population (CDC, 2014). People with type II diabetes become quickly familiar with the HgbA1c test, which averages a person’s blood sugar levels over the past 2 to 3 months. A HgbA1c level that is greater than or equal to 6.5% is diagnostic for diabetes.

Recent studies show that the HbA1c test may be overused in the U.S, leading to over prescribed diabetes medications, which can cause a variety of side effects, including excessively low blood sugars. New standards by the American Diabetes Association state that a HgbA1c less than 7% in a person diagnosed with diabetes is typically correlated with too many low blood sugar episodes (less than 70 mg/dL). Low blood sugars can be very dangerous, sometimes even more dangerous than elevated blood sugars because low blood sugars can cause brain damage and loss of brain cells quickly. Symptoms of a low blood sugar can include feeling dizzy or shaky, sweating, confusion, and even coma or death. A rule of thumb to remember when managing blood sugars is to always “fix lows fast.”

However, having a high HgbA1c can be detrimental as well. Chronic, elevated blood sugars can cause small blood vessel damage, such as those that feed the kidneys, eyes, and nerves; as well as large blood vessel damage, such as those that feed the heart. Elevated blood sugars make the blood thick and sticky, like syrup. The excess sugar in the bloodstream also make red blood cells much more likely to stick together, creating blockages.

So, what is an appropriate HgbA1c goal for someone with type II diabetes? The answer isn’t so black and white; it is individualized based on many factors, such as age, ethnicity, gender, and co-morbidities. The evidence shows that for most people with diabetes, having a HgbA1c between 7%-8% is recommended. It seems that having a HgbA1c within this range is not correlated with many, if any, low blood sugar episodes, and will also help with long term health.

My take? Remember that the HbgA1c test isn’t perfect, it really is just an average of 2-3 months of blood sugar which could mean a person could have large swings in blood sugar (i.e. extreme highs and extreme lows) and the HgbA1c result could come back as “good” control.

Rather, the future of blood sugar monitoring will be looking at the blood sugar “time in range” this is how much of the time an individual’s blood sugar is within a healthy range, between 80-180 mg/dL. Currently, most type II diabetics monitor blood sugar with a glucometer, which checks a blood sugar at one single moment in time and does not show the blood sugar’s time in range. The only way to monitor the blood sugar’s time in range is to use a continuous glucose monitor (CGM). However, most insurance companies do not cover the expense of a CGM for type II diabetics. Freestyle recently came out with a CGM that is being marketed for the type II diabetic population but it may take a while before insurance companies will cover it.

I believe in about 5-10 years insurance companies will cover CGMs for all diabetics, whether type I or type II, and this will be the gold standard for monitoring blood sugars at home; glucometers as we know them may be obsolete.