What does it mean to be a brittle diabetic?

[Debbie Sue]

I've read many posts on this site and see the term brittle diabetic mentioned but not really explained.

[fgummett]

Many of us strive daily to balance our insulin with diet, exercise, stress etc... and become quite skilled at this juggling act... but all know that we can still be surprised by an unexpected result. If that were not the case we would not need to test as we could always predict what our BS would be. Someone who is described as brittle seems unable to strike this balance much more of the time... no matter what they try the BS does not seem to settle into a pattern; so they end up playing catchup correction all the time.

[Debbie Sue]

Ok, I understand now. I feel I fall into that category for now since starting all the testing and Metformin/Actos meds. My numbers are all over the place, no pattern as of yet, but I've
only been doing this for 5 days. Out of those 5 days I've only had 3 below 200 numbers. This mornings fasting bs # was 229. Totally unexpected since last night's post dinner # was 174. It's frustrating!

[xMenace]

A cursory review of the web actually looks quite interesting.

Brittle diabetes definition - Diabetes Mellitus, Type 2 Diabetes, Type 1, and Metabolic Disorders Treatment and Medications on MedicineNet.com (http://www.medterms.com/script/main/art.asp?articlekey=18392)
Definition of Brittle diabetes
Brittle diabetes: A type of diabetes when a person's blood glucose (sugar) level often swings quickly from high to low and from low to high. Also called "unstable diabetes" or "labile diabetes."



"Brittle Diabetes" (http://nfb.org/legacy/vod/vsum9906.htm)
For most diabetics, most of the time, the "rules" work. "If I do this, or do not do that, I can expect this result." But there is a body of individuals for whom the rules do not appear to apply, and to them is often applied the adjective "brittle."

The patient with brittle diabetes mellitus (http://www.uptodate.com/patients/content/topic.do?topicKey=diabetes/6678)
Almost all diabetic patients experience swings in blood glucose levels which are larger and less predictable than in nondiabetics. The point at which these swings become intolerable and cause disruption to the person's daily life (and at which the person is labeled "labile" or "brittle") depends upon the psyche, competence, and confidence of both the patient and his or her provider.

Diabetes Mellitus (DM): Diabetes Mellitus and Disorders of Carbohydrate Metabolism: Merck Manual Professional (http://www.merck.com/mmpe/sec12/ch158/ch158b.html)

Brittle diabetes: The term brittle diabetes refers to patients who have dramatic, recurrent swings in glucose levels that often occur for no apparent reason. Patients experience disabling episodes of hyperglycemia or hypoglycemia that typically lead to recurrent emergency department visits and hospitalizations. Labile plasma glucose levels are more likely to occur in type 1 diabetics because of complete absence of endogenous insulin production but can occur in any diabetic. Known causes include occult infection (eg, osteomyelitis, soft tissue abscess), gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (eg, Addison's disease, hypothyroidism). In most cases, the cause is unknown, and brittle diabetes is attributed to an inappropriate insulin regimen and inadequate patient education or understanding that leads to errors in insulin administration and diet choices or to psychologic distress (eg, anger, depression, anxiety) that expresses itself in erratic patterns of food intake and physical activity, nonadherence to medical recommendations, and inappropriate self-titration of drugs.

Lengthy PDF article (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1418237)

The spectrum of brittle diabetes. (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1294600)

Abstract
A group of 42 severely brittle insulin dependent diabetic patients were studied, and compared with a similar number of 'stable' diabetic patients. Brittle diabetics were predominantly female (86% v 45%, P < 0.01), were of younger age (mean +/- SD 27.9 +/- 12.8 years v 40.1 +/- 13.6 years, P < 0.001), and of shorter duration of diabetes (13.7 +/- 9.4 years v 19.6 +/- 11.2 years, P < 0.01). Control as measured by glycosylated haemoglobin (HbA1) was poorer (13.7 +/- 3.1% v 10.1 +/- 1.5%, P < 0.001), and daily insulin dose higher (98 +/- 81 u v 47 +/- 14 u, P << 0.001). There was no difference in diabetic complication rates, but psychosocial disturbances (74% v 17%) and factitious instability (40% v 2%) were highly significantly more common amongst brittle patients. Examination of patterns of admission revealed most brittle diabetics to have hyperglycaemic problems (70%), mainly due to recurrent ketoacidosis (52%). Recurrent hypoglycaemia accounted for 12% of the group, and only 5/42 patients (12%) had mixed forms of instability. Brittle diabetes is thus characterized by young age and female sex, and usually manifests itself as recurrent ketoacidosis or other forms of hyperglycaemic instability. Psychosocial problems and factitious metabolic decompensation are common.

[xMenace]

Ok, I understand now. I feel I fall into that category for now since starting all the testing and Metformin/Actos meds. My numbers are all over the place, no pattern as of yet, but I've
only been doing this for 5 days. Out of those 5 days I've only had 3 below 200 numbers. This mornings fasting bs # was 229. Totally unexpected since last night's post dinner # was 174. It's frustrating!

No. You are just not yet under control.

[Aurora96]

My father falls into this category. He was diagnosed with type 2 approximately 35 years ago. Was put on sulfonyureas - I believe the only drug at the time - and basically ignored his diabetes. His eyes were ravaged by retinopathy, he required a kidney transplant, and he eventually burned out his beta cells. Now, he can go from 300s to hypos in the blink of an eye. He can eat the same thing two days in a row, take the exact same amount of insulin and end up with two incredibly different results.

[davef]

No. You are just not yet under control.

Ditto

Debbie,

It takes a few weeks (4-5) before Metformin to really kick in, you are still in the very early days, give yourself some time Metformin is not like insulin it doesn't reduce your levels within a short time of taking it. What it actually does is help your body use the insulin your are producing, it does this by reducing your insulin resistance.

I'd recommend a book called "The first year: Type 2 Diabetes" by Gretchen Becker, I found it easy to read and very informative.

Are you watching your Carb intake and testing regularly?

[Debbie Sue]

Are you watching your Carb intake and testing regularly?

Yes I am. I test 4x a day, fasting and 2 hour post meals. I haven't had anymore 300+ readings. Some are 200+ and more are 100+. I did have one that was 141 over the weekend.

I have the Atkins Diet book and making many changes with that. I'm still rattled somewhat about what I can eat, but it's getting better. I will read the book you suggested and better educate myself.

[davef]

Yes I am. I test 4x a day, fasting and 2 hour post meals. I haven't had anymore 300+ readings. Some are 200+ and more are 100+. I did have one that was 141 over the weekend.

Well done, isn't encouraging when you see the numbers coming down! Keep it up and you will gain control.

I have the Atkins Diet book and making many changes with that. I'm still rattled somewhat about what I can eat, but it's getting better. I will read the book you suggested and better educate myself.

Personally, I don't follow Atkins, Bernstein or that style of diet. I have worked to find foods that are friendly to my BG levels and to cut out foods that don't work for me. I don't like the word diet as it has so many negative connotations and "being on a diet" is not something I would be able to continue long term. Instead I have focused on developing new habits, a big part of this is eating better. The way you are testing (2 hours after first bite) will really help you get a handle on what foods work for you. Personally I avoid things like potatoes, rice, pasta and white bread, that has worked for me. I try to keep my carbs to less than 30g per meal. I'm 6 months into my management and have learned a lot about what foods suit me so I don't count carb fanatically, but if I eat something new/different, I will test 2,3,4 hours after first bite to make sure I don't get a delayed spike.

Keep up the good work, you are doing fine.

[HelenM]

I knew a teenager who was said to have 'brittle' diabetes some 10 years ago. She was in and out of hopital with DKA. She was a pupil at a performing arts school. Now I feel that she may well have had diabulimia. (Akin to an eating disorder where not taking insulin results in weight loss)

[sprzepiora]

Yes I am. I test 4x a day, fasting and 2 hour post meals. I haven't had anymore 300+ readings. Some are 200+ and more are 100+. I did have one that was 141 over the weekend.

I have the Atkins Diet book and making many changes with that. I'm still rattled somewhat about what I can eat, but it's getting better. I will read the book you suggested and better educate myself.

Hello Debbie, and welcome aboard, and you are to be congratulated on your testing regime.

[Debbie Sue]

Thank you for the welcome! :)

I remain diligent to it. I have to call in my #'s Wed. to the PA's nurse. I should hear back sometime this week on the lab work and the liver sonogram. I may have fatty liver too.

[princesslinda]

I had fatty liver at diagnosis with elevated LFT's (liver function tests). When blood sugars were under control and I had lost a little weight, these normalized.

[Debbie Sue]

I had fatty liver at diagnosis with elevated LFT's (liver function tests). When blood sugars were under control and I had lost a little weight, these normalized.

Were you taking any med/s for your liver? Good to know the levels will come down with modifications.

[princesslinda]

No meds at all for the liver. Doc told me it was very common in newly-diagnosed diabetics, esp. those who are overweight.

[w5wjp]

"Brittle" diabetic usually refers to an out of control T1.

Us T2 are a different case altogether.

[camjen1]

"Brittle" diabetic usually refers to an out of control T1.

Us T2 are a different case altogether.

Yes, "brittle" diabetes can be referred to as not having control but should go on to clear up that everyone who is "brittle" don't exactly have any fault in it.

I have always been labeled "brittle". If I lived my life the same everyday, ate the same foods everyday and did the same amount of exercise a day you would think I can easily inject this amount of insulin a day and be stable for lets say an entire month.

This doesn't happen. While one week may give me wonderful bg's the next week though following the same regime may have me falling low or having highs. All the while everything is the same.

I find myself consistently changing basal rates in my pump. What seems to work one week completely falls apart the next and so forth.

I also do fall in that category when my blood sugar rises, it rises fast same with going low.