Diabetes Mellitus Health Article

TREATMENT

Large, prospective, randomized, controlled clinical trials in both type 1 and type 2 diabetes have demonstrated that normal or near-normal blood glucose control can delay or prevent the development of major birth defects and the development and progression of complications affecting the eyes, kidneys, and nerves. Accordingly, the goals for management for both type 1 and type 2 diabetes are to achieve glucose levels as close to the nondiabetic range as possible while minimizing the side-effects of treatment (hypoglycemia and weight gain).

In nondiabetic subjects, blood glucose levels are between 70 and 90 mg/dl (milligrams per deciliter) in the fasting state and rise to 120 to 140 mg/dl one to two hours after meals. These values reflect normal glucose tolerance. Average glucose levels may be assessed by measurement of glycosylated hemoglobin (hemoglobin A1c), is a measure of the average blood glucose level over the previous two to four months. In nondiabetic subjects, hemoglobin A1c is generally less than 6.1 percent, and in poorly controlled diabetic subjects, it may rise to 12 percent or higher.

In general, the goals of treatment are to achieve blood glucose and hemoglobin A1c levels as close to the nondiabetic range as possible with diet, physical activity, and medications.

Diet. In type 1 diabetes, diet is designed to provide adequate nutrients for growth and development and for the maintenance of ideal body weight. The recommended diet includes approximately 20 percent of daily calories from protein, 30 percent from fat, and 50 percent from complex carbohydrates. Simple sugars are limited to prevent excessive glucose excursions, and carbohydrate content is distributed into regular meals and

Table 3

snacks so that a similar quantity of carbohydrate is consumed at approximately the same time each day.

In type 2 diabetes, caloric content is adjusted to achieve and maintain an ideal body weight or, in those who are obese, to produce gradual weight loss or at least weight maintenance. Dietary composition may also be adjusted in light of intercurrent conditions. For example, sodium may be restricted for patients with hypertension, and both total fat and saturated fat may be restricted for those with high cholesterol.

Exercise. Exercise lowers blood glucose and improves glucose tolerance in diabetics. Other benefits of exercise are reductions in LDL cholesterol and triglycerides levels, and improvements in HDL cholesterol, improvements in blood pressure, improved cardiovascular fitness, and an increased sense of well-being and quality of life. Because exercise may potentiate the hypoglycemic effect of injected insulin and may, paradoxically, result in elevated blood glucose levels and the rapid development of ketosis in type 1 diabetic patients in poor metabolic control, the goal of management in type 1 diabetes is to permit people to enjoy and participate safely in physical and sport activities. In type 2 diabetes, exercise is frequently prescribed as an adjunct to reduced-calorie diets for weight reduction and to improve insulin resistance.

Medications. Because patients with type 1 diabetes are absolutely insulin deficient, treatment requires insulin injections. Although one or two injections per day are often adequate to prevent symptoms of hyperglycemia, intensive therapy employing three or four insulin injections per day, or continuous subcutaneous insulin infusion, may be necessary to achieve near-normal glucose control.

Both oral medications and injected insulin are used for the treatment of type 2 diabetes. Four groups of oral agents are currently available: insulin secretagogues, which enhance nutrient-stimulated insulin secretion; the biguanides, which suppress abnormal glucose production by the liver; the thiazolidinediones, which reduce insulin resistance at the level of muscle and fat; and the alpha-glucosidase inhibitors, which slow the breakdown and absorption of carbohydrates and reduce postprandial glucose excursions. To the extent that these four groups of oral medications have different mechanisms of action, they can be used clinically in combination. When oral agents are ineffective in controlling hyperglycemia or achieving glycemic goals, insulin is added or substituted.