By Patty Colombe, R.N.
Diabetes is a condition whose face has changed greatly and often over the years. In the early days, it was recognized as a devastating, body ravaging disease which afflicted children and young adults causing them to literally waste away and starve to death. As the years progressed, it was discovered that a similar condition afflicted adults which also ravaged the body but at a considerably slower rate.
Few older adults were screened for hyperglycemia during the early years of my nursing profession. Little seemed to be understood about Type 1 diabetes and less about Type 2. The past decade has brought about much innovation in the research, screening, education and management of both.
The greatest breakthrough for the frontline management team may possibly be the Diabetes Control and Complications Trial, which sought to prove tighter blood sugar control would result in a decreased incidence of complications which were considered inevitable for those with long term diabetes. Type 1 subjects were to be followed for a ten year period with one group using conventional insulin therapy of 1-2 injections per day while the other group was introduced to an insulin regime similar to a sliding scale. The difference was, however, rather than adjusting insulin to blood sugar readings only, the insulin was adjusted in a more calculated fashion to also deal with daily activity and carbohydrate intake. Blood glucose readings were collected up to eight times daily to allow the team to distinguish patterns. Before the end of the ten year time frame, intensive therapy was proven to be an effective mode of diabetes management. The incidence of complications was lessened paving the way for a longer healthier life for those diagnosed with diabetes.
The most recognized challenge of intensive treatment was, and for the most part still is, frequency of hypoglycemia. All incidences of hypoglycemia were documented and treatment regime was reviewed. A consequence which was not noted in detail or stressed during the Trial but only surfaced once utilization of intensive therapy became more commonplace, is the poor regulation of insulin and carbohydrate intake.
Carbohydrate counting has become the mainstay of diabetes management over the past several years. Its function is best utilized by using a specifically prescribed amount of carbohydrate then determining the amount of insulin needed to maintain blood glucose levels within an appropriate range. This carbohydrate amount is carefully formulated with consideration given to various factors including gender, body type and physical activity. The multiple daily insulin injections mimic the natural response of endogenous insulin to carbohydrate intake. During the DCCT, factors and determinants were fairly controlled. Once findings were collected and evaluated, intensive therapy was incorporated into the everyday lives of the Type 1 diabetes population.
This is where poor regulation of both carbohydrate intake and insulin reared its ugly head. During the research trial strict measurement of blood glucose levels to insulin adjustment was utilized. Participants were followed closely as all diabetes education/management centers would do in a utopian world.
Many, if not most diabetes education centers began the use of intensive therapy and carbohydrate counting shortly after the numbers were in from the DCCT. Physicians and diabetes educators were excited with the prospect of providing their clients with the opportunity to obtain tighter blood sugar control. There is one glitch in the system…many diabetes education centers lack the necessary resources to provide adequate follow up once multiple daily injections are initiated.
Another challenge is proper incorporation of carbohydrate counting. On a basic level, carbohydrate counting is the ability of the client to use the amount of carbohydrate per meal to add variety to his or her meal pattern. Label reading and a good understanding of carbohydrate content per food group is essential. For those utilizing intensive therapy, increases and decreases in carbohydrate intake and activity level is also incorporated. To make this management mode more convenient, insulin pumps are frequently introduced for clients with erratic lifestyles and/or an aversion to injections.
One of the laws of physics states every action has an equal and opposite reaction. This is a point to keep in mind while trying to make lifestyle choices more convenient for the person with an erratic schedule.
Identifying erratic lifestyles is the point where the family physician, diabetes educator or other health care professional should reassess this particular client’s ability to self-manage effectively. Poor or possible non-existent meal patterns are the foundation for the development of insulin resistance. Couple this with increasing insulin dosages to compensate for high carbohydrate intake, and you have a cocktail for increasing risk factors which may in turn increase the incidence of complications.
Persons with Type 1 diabetes, and health care professionals themselves, often ignore the risk associated with the co-existence of obesity and excessive circulating insulin. The effect of insulin on smooth muscle tissue is not well understood but is quite visually evident. Upon initiation and with increases in insulin dosages weight gain of 2-5 kilograms is expected. Mom’s with gestational or pre-existing diabetes who have blood glucose levels higher than 8mmols in their third trimester often have a baby with a birth weight greater than 4.1 kilograms. This is due to increased insulin secretion by the fetus to cope with the excessive sugar load. The increased insulin production causes changes in the cells resulting in weight gain. With prolonged presence of excessive levels of insulin in the body the cells will become less sensitive and ineffective.
After much research and deliberation, it has been concluded that the greatest percentage of persons diagnosed with Type 2 diabetes indeed have insulin resistance. It is also felt the cause of insulin resistance is primarily due to erratic behaviors in lifestyle. Annually, in my clinical setting alone, more clients under the age of 35 are presenting with hyperglycemia due to insulin resistance. Often, there is no family history of diabetes. The common factors are sporadic or minimal activity, irregular meal patterns and abdominal obesity. The obesity may not be overt. The limbs may be quite thin and he or she may fall into an acceptable or near acceptable BMI range. However, a small paunch will be apparent. The distribution of fat is the key rather than the body mass, which of course is more obvious but not always the best marker for insulin resistance. Waist-hip ratio proves to be a better determinant.
This brings us back to the initial query; How will irregular lifestyle behaviors effect our efforts to obtain optimal blood sugar control and ultimately, overall good health?
It’s unrealistic to expect Sally will never oversleep or Billy will never eat a candy bar. However, if continually missing and delaying meals or eating fast food and junk food will cause weight gain, which in turn will cause metabolic problems in people with relatively healthy bodies, how will it affect those who are already metabolically compromised?
It has been discovered that hypertension precedes hyperglycemia in insulin resistance. This illustrates the effect of insulin resistance on blood vessels.
Persons with Type 1 diabetes do not have readily available insulin on an “as needed” basis as metabolically stable persons can. Because of this they have increased insulin circulating. Prolonged hyperinsulinemia will result in some degree of insulin resistance. Those with poor control will obviously have early resistance development. Because of this resistance, early renal insufficiency may be apparent due to premature essential hypertension before any other organs are affected. Meanwhile, blood glucose levels continue to rise as the body’s cells will be insensitive to available insulin. Increasing insulin dosages to compensate for high blood sugar levels persistent insulin resistance will cause blood vessel damage to accelerate and all organs will be affected.
In summary, intensive therapy and the use of the insulin pump are major breakthroughs in the management of diabetes to obtain normal or near normal control. BUT, I firmly believe attitude adjustment is the first step toward this goal. This management regime can’t be viewed as an avenue to do whatever you want. Over the years Lifestyle management has become a mainstay for prevention of disease which places health outcomes back into the hands of the individual. This does not exclude persons with Type 1 diabetes. Quite the contrary; they are more prone to chronic debilitating diseases and should adhere as closely as possible to these healthy lifestyle guidelines. Whether or not they do is their choice to make.
Indeed, there have been numerous changes in the management of diabetes. The greatest to come may be allowing the diabetes population to take ownership of their own health.