Monday, September 10, 2007

Tight Diabetes Control

Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications of diabetes, giving you extra years of healthy, active life.

But tight control is not for everyone and it involves hard work.

By the Numbers

Good control means getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 90 and 130 mg/dl before meals, and less than 180 two hours after starting a meal, with a glycated hemoglobin level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses.

In real life, you should set your goals with your doctor. Keeping a normal level all the time is not practical. And it's not needed to get results. Every bit you lower your blood glucose level helps to prevent complications.

What Tight Control Does

No one knows why high glucose levels cause complications in people with diabetes. But keeping glucose levels as low as possible prevents or slows some complications.

The Diabetes Control and Complications Trial (DCCT) proved it. Researchers followed 1,441 people with diabetes for several years. Half of the people continued standard diabetes treatment. The other half followed an intensive-control program. Those on intensive control kept their blood glucose levels lower than those on standard treatment, although the average level was still above normal. The results? In the tight-control group, compared with the standard-treatment group,

Diabetic eye disease started in only one-quarter as many people.

Kidney disease started in only half as many people.

Nerve disease started in only one-third as many people.

Far fewer people who already had early forms of these three complications got worse.

Living With Tight Control

To get tight control, you must pay more attention to your diet and exercise. You must measure your blood glucose levels more often. And, if you take insulin, you must change how much you use and your injection schedule.

In intensive therapy, you provide yourself with a low level of insulin at all times and take extra insulin when you eat. This pattern mimics the release of insulin from the normal pancreas.

There are two ways to get more natural levels of insulin: multiple daily injection therapy and an insulin pump. Both are good methods. Your choice should depend on which best fits your lifestyle.

In multiple daily injection therapy, you take three or more insulin shots per day. Usually, you take a shot of short-acting or Regular insulin before each meal and a shot of intermediate- or long-acting insulin at bedtime.

With an insulin pump, you wear a tiny pump that releases insulin into your body through a plastic tube. Usually, it gives you a constant small dose of Regular insulin. You also have the pump release extra insulin when you need it, such as before a meal.

With either method, you must test your blood glucose levels several times a day. You need to test before each shot or extra dose of insulin to know how many units to take and how long before eating to take it. Also, you may want to test 2-3 hours after eating to make sure you took enough insulin. You must adjust your insulin dose for how much you plan to eat and how active you expect to be.

You do not need to figure these things out on your own. Whatever method you choose, your health care team (your doctor, dietitian, diabetes educator, and other health care professionals) should spend a lot of time teaching you about it. Your team will help you make guidelines for how much insulin to take and when. You will also come up with guidelines for eating and exercising. These guidelines may change several times as you test them out.

You shouldn't try tight control on your own. A good health care team is a must. Choose a doctor who understands diabetes well or is willing to learn for your sake. Your doctor should have ties with other health professionals you need, such as dietitians and a mental health worker. If you live in a small town, look at your options carefully. You may be better off driving to a city to see a specialist.

How to Keep Going and Going

Starting a program of tight control is exciting. But it can also be overwhelming. How do you keep from running out of energy?

One way is to start slowly. For example, you might start by checking your blood glucose more times each day. Get used to that first. Then start multiple daily injections. Once you're used to those, add your new exercise program and make the changes in your diet.

If you are newly diagnosed with diabetes, look honestly at yourself. Are you still angry and depressed that you have diabetes? If so, you already have a big challenge facing you. You may want to wait to try tight control until after you've come to terms with the changes in your life.

Keep your goals realistic. No matter how hard you try, your blood glucose readings will not be perfect every time. If they are often too high or too low, you should talk to your doctor about whether your plan needs to be adjusted. But if "wrong" levels happen only sometimes, that's life. With practice, you will become more skilled at choosing the right insulin doses for various situations.

If you need to, take a breather from the new routine. Having some time off may make it easier to stick to your plan when you start again.

Pluses and Minuses

One big reason to try tight control is to prevent complications later. But tight control has effects you can enjoy right now. You will probably feel better and have more energy. Also, because you adjust your insulin dose to your life, and not the other way around, you have more freedom. You can vary your activities more. And you're not locked into having your meals at the same time each day.

Tight control is especially good for pregnant women. It can reduce the risk of birth defects in the baby.

But the DCCT found two major problems with tight control.

First, people had three times as many low blood glucose reactions (hypoglycemia). You will need to be alert to the symptoms of hypoglycemia so that you can treat yourself quickly. Also, you should always check your blood glucose levels before you drive.

If you often have low blood glucose reactions when you try tight control, talk to your doctor. You may need to ease up on your goals or go back on standard therapy for a while.

Second, people on tight control gained more weight than people on standard insulin treatment. The average in the DCCT was 10 pounds. If you are concerned about putting on pounds, work with your dietitian and doctor to devise a meal and exercise plan to prevent it.

You should also consider the cost. You will need to see your health care team more often. Pumps cost about $5000, and pump supplies run $60 to $80 a month. Multiple injection therapy is much cheaper. But you will still use more supplies, like test strips and syringes, than before.

Tight Control and Type 2 Diabetes

The DCCT studied only people with type 1 diabetes. But doctors believe that tight control can also prevent complications in people with type 2 diabetes.

Most people with type 2 diabetes do not take insulin. You may be wondering how you can achieve tight control without it.

One way is to lose weight. Shedding excess pounds may bring your glucose levels down to normal. The key to losing weight and keeping it off is changing your behavior so that you eat less and exercise more. Your doctor should work with you to find an eating and exercise plan you can stick to.

Even if you don't need to lose weight, exercise is helpful in controlling your blood glucose levels. It makes your cells take glucose out of the blood.

You will need to check your blood glucose regularly. You should decide with your doctor how often. Once a day or even once a week may be enough for some people with type 2 diabetes.

If exercise and good eating habits are not enough to keep your glucose under control, you doctor may prescribe pills. And if these don't work, you may need to take insulin.

People with type 2 diabetes should talk to their doctors before starting tight control.

Tight Control Is Not for Everyone

Tight control is not safe for everyone with diabetes.

Children should not be put on a program of tight control. Having enough glucose in the blood is vital to brain development. Some doctors say that tight control should wait until a child reaches 13; others say after the age of 7 is okay.

Elderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years.

Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control. People who have hypoglycemia unawareness probably should not go on tight control