What is Brittle Diabetes: Diagnosis and Treatment

Also referred to as “hard to control” diabetes or “labile” diabetes, brittle diabetes is a term to describe type 1 diabetes that is very difficult to manage.

The term “brittle diabetes” has been long debated in the endocrinology world because anyone with type 1 diabetes knows that just one unit of too much or too little insulin can easily lead to quick swings in your blood sugar.

This can be a controversial issue, as some people believe it’s an outdated label for a condition that’s so hard to manage, some insist that it simply doesn’t exist, and others feel that being diagnosed as “brittle” is accusatory, or an insult that you’re not staying on top of your diabetes. 

However, the category stands, and people with diabetes are regularly diagnosed as being “brittle”. So, what exactly is brittle diabetes? 

In this article, we’ll discuss what brittle diabetes is, the risk factors, how it’s diagnosed, and the best ways to manage it for smoother blood sugar levels.

What is “brittle” diabetes?

Those with brittle diabetes can see blood sugars swing wildly high and low without explanation or logical predictability, often resulting in frequent hospitalization. These swings negatively disrupt their overall quality of life. 

Those with brittle diabetes also typically struggle with hypoglycemia unawareness, which means they’ve experienced so many severe low blood sugars, their body no longer alerts them to oncoming lows with traditional symptoms, such as shakiness, sweating, confusion, and rapid heart rate. 

According to the National Institutes of Health, only a small percentage of people with type 1 diabetes experience these drastic fluctuations in blood sugars that can frequently be described as “brittle”, affecting only 3 out of every 1,000 people with type 1 diabetes. Younger, heavyset women between the ages of 15-30 are most likely to be affected by brittle diabetes. 

Risk factors for brittle diabetes

The most significant risk factor for brittle diabetes is type 1 diabetes, as brittle diabetes is a subset of the disease. Other risk factors include anxiety, depression, and high levels of stress. 

People who frequently find themselves in high-stress situations release more of the hormone cortisol, which increases insulin resistance, spiking blood sugars, and worsening blood sugar fluctuations. 

Some people with type 1 diabetes may produce abnormal and inconsistent amounts of glucagon, a hormone that tells your liver to produce glucose. This can easily lead to rapid swings in blood sugar levels, resulting in a diagnosis of brittle diabetes. 

Additionally, those suffering from gastroparesis or celiac disease may experience brittle diabetes, due to malabsorption of nutrients and carbohydrates, which can result in unpredictable insulin requirements. 

If your meals are being digested inconsistently, it can create sudden spikes or drops in blood sugar because the timing of your insulin dose is impossible to match with the unpredictable digestion of your meal. 

Young women who have a history of eating disorders, such as diabulimia, anorexia nervosa, bulimia, or binge eating disorder are also at a higher risk for brittle diabetes. 

Diagnosis

Getting the correct diagnosis for brittle diabetes can prove difficult. Many times, brittle diabetes is diagnosed concurrently with mental health issues, such as depression. 

For example, a person suffering from depression may forget to pre-bolus for a meal (or bolus at all), which can exacerbate fluctuations in blood sugars, and out of control blood sugar levels can worsen depression and anxiety; oftentimes these conditions feed into each other. 

One study showed that people with brittle diabetes have a greater hormonal response to stress, and release more cortisol (causing more insulin resistance) than those without brittle diabetes.

Treatment options

The treatment of brittle diabetes will often include treating any underlying psychological or mental health issues first, controlling the level of stress (and subsequent hormonal response) one is experiencing.

Behavioral therapy is typically effective in treating those with brittle diabetes and achieving better health outcomes, including improved blood sugar levels and Hba1c results.

Those with brittle diabetes may require a long hospitalization where food intake, insulin dosage exercise routines, and the stress response is monitored closely, to achieve baseline data for more successful long-term treatment protocol and control. 

Some other helpful ways to treat brittle diabetes include:

• Wearing a continuous glucose monitor to track blood sugar trends
• Re-establishing sensitivity to low blood sugars, by working closely with your doctor 
• Using an insulin pump for more precise dosing 
• Reducing carbohydrates, and having a more predictable diet 
• Having a regular, consistent exercise routine
• Getting the proper amount of sleep each night
• Managing stress in healthy ways, such as practicing yoga and meditation 

Living well with brittle diabetes 

Getting an official diagnosis of brittle diabetes is rare and usually accompanies underlying mental health or gastrointestinal disorders.

It’s normal for people with type 1 diabetes to have extreme fluctuations in blood sugar, and for it not to be officially characterized as brittle diabetes. 

Life with diabetes is complicated, and the learning curve is neverending. Long-term success in living with diabetes comes down to a constant effort to study and learn about your blood sugar levels and insulin needs around life’s many variables.

However, if you feel that you may have this rare condition, call your doctor right away. The first step in addressing brittle diabetes comes down to working with an expert Certified Diabetes Educator or diabetes coach and improving how you take your insulin, how you eat, how and when you exercise, and how you manage the variables that impact blood sugar levels the most.

Hospitalizations are much more common in people with brittle diabetes, making school and work attendance more difficult. People with brittle diabetes are also much more vulnerable to experiencing a diabetic coma from lows and diabetic ketoacidosis (DKA) from highs. 

Talking with your doctor can help you get the right diagnosis for this condition, and they can help you make a plan to better manage it, and address any underlying mental health or digestive issues that may be contributing to such wild swings in blood sugar levels. 

Type 1 diabetes is always challenging, but with enough gradual education, you can likely gain more confidence and understanding of how to improve your blood sugar levels, your safety, and your quality of life.