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

Checking Your Blood Glucose

People with diabetes work to keep their blood sugar (glucose) as near to normal as possible. Keeping your blood glucose in your target range can help prevent or delay the start of diabetes complications such as nerve, eye, kidney, and blood vessel damage.

When you learned you had diabetes, you and your health care team worked out a diabetes care plan. The plan aims to balance the foods you eat with your exercise and, possibly, diabetes pills or insulin. You can do two types of checks to help keep track of how your plan is working. These are blood glucose checks and urine ketone checks.

Blood Glucose Monitoring Checks


Blood glucose monitoring is the main tool you have to check your diabetes control. This check tells you your blood glucose level at any one time. Keeping a log of your results is vital. When you bring this record to your health care provider, you have a good picture of your body's response to your diabetes care plan. Blood glucose checks let you see what works and what doesn't. This allows you and your doctor, dietitian, or nurse educator to make needed changes.

Here is a table that lists blood glucose ranges for adults with diabetes:


Glycemic control

A1C
<7.0%

Preprandial plasma glucose (before a meal)
90–130 mg/dl (5.0–7.2 mmol/l)

Postprandial plasma glucose (after a meal)
<180 mg/dl (<10.0 mmol/l)

Blood pressure
<130/80 mmHg

Lipids


LDL
<100 mg/dl (<2.6 mmol/l)

Triglycerides
<150 mg/dl (<1.7 mmol/l)

HDL
>40 mg/dl (>1.1 mmol/l)


Who Should Check?

Experts feel that anyone with diabetes can benefit from checking their blood glucose. The American Diabetes Association recommends blood glucose checks if you have diabetes and are:

taking insulin or diabetes pills on intensive insulin therapy pregnant having a hard time controlling your blood glucose levels having severe low blood glucose levels or ketones from high blood glucose levels having low blood glucose levels without the usual warning signs


Urine Checks

Urine checks for glucose are not as accurate as blood glucose checks. Urine testing for glucose should not be done unless blood testing is impossible.

A urine check for ketones is another matter. This check is important when your diabetes is out of control or when you are sick. You can find moderate or large amounts of ketones in urine when your body is burning fat instead of glucose for fuel. This happens when there is too little insulin at work. Everyone with diabetes needs to know how to check their urine for ketones.

How Blood Checks Work

You stick your finger with a special needle, called a lancet, to get a drop of blood. With some meters, you can also use your forearm, thigh or fleshy part of your hand. There are spring-loaded lancing devices that make sticking yourself less painful. Before using the lancing device, wash your hands or site you chose with soap and water. If you use your fingertip, stick the side of your fingertip by your fingernail to avoid having sore spots on the frequently used part of your finger.

Checking With a Blood Glucose Meter



Blood glucose meters are small computerized machines that "read" your blood glucose. In all types of meters, your blood glucose level shows up as a number on a screen (like that on your pocket calculator). Be sure your doctor or nurse educator shows you the correct way to use your meter. With all the advances in blood glucose meters, use of a meter is better than visual checking.

How to Pick a Meter

There are many meters to choose from. Some meters are made for those with poor eyesight. Others come with memory so you can store your results in the meter itself. The American Diabetes Association does not endorse any products or recommend one meter over another. If you plan to buy a meter, here are some questions to think about:

What meter does your doctor or diabetes educator suggest? They may have meters that they use often and know best.

What will it cost? Some insurance companies will only pay for a certain meter. Call your insurance company before you purchase a meter and ask how to get a meter and supplies. If your insurance company does not pay for blood glucose checking supplies, rebates are often available toward the purchase of your meter. You still have to consider the cost of the matching strips and lancets. Shop around.


How easy is the meter to use? Methods vary. Some have fewer steps than others.

How simple is the meter to maintain? Is it easy to clean? How is the meter calibrated (set correctly for the batch of strips you are using)?

Are meters accurate?

Experts testing meters in the lab setting found them accurate and precise. That's the good news. The bad: meter mistakes most often come from the person doing the blood checks. For good results you need to do each step correctly. Here are other things that can cause your meter to give a poor reading:

a dirty meter

a meter or strip that's not at room temperature

an outdated test strip

a meter not calibrated (set up for) the current box of test strips

a blood drop that is too small
Ask your health care team to check your skills at least once a year. Error can creep in over time.

Logging Your Results

When you finish the blood glucose check, write down your results and use them to see how food, activity and stress affect your blood glucose. Take a close look at your blood glucose record to see if your level is too high or too low several days in a row at about the same time. If the same thing keeps happening, it might be time to change your plan. Work with your doctor or diabetes educator to learn what your results mean for you. This takes time. Ask your doctor or nurse if you should report results out of a certain range at once by phone.

Keep in mind that blood glucose results often trigger strong feelings. Blood glucose numbers can leave you upset, confused, frustrated, angry, or down. It's easy to use the numbers to judge yourself. Remind yourself that your blood glucose level is a way to track how well your diabetes care plan is working. It is not a judgment of you as a person. The results may show you need a change in your diabetes plan.

Checking for Ketones

You may need to check your urine for ketones once in a while. Ketones in the urine is a sign that your body is using fat for energy instead of using glucose because not enough insulin is available to use glucose for energy. Ketones in the urine is more common in type 1 diabetes.

Urine tests are simple, but to get good results, you have to follow directions carefully. Check to be sure that the strip is not outdated. Read the insert that comes with your strips. Go over the correct way to check with your doctor or nurse.

Here's how most urine tests go:

Get a sample of your urine in a clean container.

Place the strip in the sample (you can also pass the strip through the urine stream).

Gently shake excess urine off the strip.

Wait for the strip pad to change color. The directions will tell you how long to wait.

Compare the strip pad to the color chart on the strip bottle. This gives you a range of the amount of ketones in your urine.

Record your results.
What do your results mean? Small or trace amounts of ketones may mean that ketone buildup is starting. You should test again in a few hours. Moderate or large amounts are a danger sign. They upset the chemical balance of your blood and can poison the body. Never exercise when your urine checks show moderate or large amounts of ketones and your blood glucoser is high. These are signs that your diabetes is out of control. Talk to your doctor at once if your urine results show moderate or large amounts of ketones.

Keeping track of your results and related events is important. Your log gives you the data you and your doctor and diabetes educator need to adjust your diabetes care plan.


When to Test

Ask your doctor or nurse when to check for ketones. You may be advised to check for ketones when:

your blood glucose is more than 300 mg/dl

you feel nauseated, are vomiting, or have abdominal pain

you are sick (for example, with a cold or flu)

you feel tired all the time

you are thirsty or have a very dry mouth

your skin is flushed

you have a hard time breathing your breath smells "fruity"

you feel confused or "in a fog"

These can be signs of high ketone levels that need your doctor's help.