Diabetes management


is a metabolic disease that is characterized by chronic elevated blood glucose levels. Therefore, the main goal of diabetes management is to keep blood glucose levels within normal limits as often as possible. If diabetes is not well controlled, health challenges may develop. People with diabetes can measure blood glucose by various methods, such as with a glucose meter or a continuous glucose monitor, which monitors over several days. Long-term glucose levels can also be measured by analysis of a blood sample. In addition to lifestyle modification, some individuals with type 2 diabetes may require medication to adequately control their blood glucose levels. Other goals of diabetes management are prevention or treatment of complications that can result from the disease itself and from its treatment.

Description

Diabetes is a well known chronic disease that affects many individuals of all ages worldwide. There are many subtypes including Type 1, Type 2, gestational diabetes, maturity-onset diabetes of the young, neonatal diabetes, etc., with Type 1 and Type 2 being the most common. All types of diabetes should be controlled as uncontrolled diabetes can cause many complications. Blood glucose levels that are too low or too high can cause both acute and chronic problems.
Uncontrolled diabetes can harm the inner lining of blood vessels, which affects the ability of blood to deliver nutrients and oxygen to organs throughout the body. By causing damage to blood vessels, diabetes is associated with an increased risk of macrovascular conditions such as stroke and heart disease. Diabetes is also associated with microvascular complications to organs such as the eyes and the kidneys.
In addition to maintaining adequate blood sugar levels in the body, control of other risk factors that contribute to complications such as smoking, alcohol use, excessive weight, high blood pressure, and high cholesterol are also very important. Often, the recommended treatment for diabetes mellitus is a combination of lifestyle changes such as increasing exercise and healthy eating, along with medications to help control the blood glucose levels in the long term. In addition to management of the diabetes, it is recommended to have routine follow up with a primary care physician or endocrinologist in addition to a variety of specialists who assist in managing possible common complications such as foot ulcers, vision changes, and hearing loss.

Glucose Measurement

There are several methods in which blood sugar is measured including with a glucose meter, continuous glucose monitor, and routine bloodwork.
The glucose meter, also known as a glucometer, is a common and simple method using a portable electronic device to measure glucose levels either at home or in a clinical setting. The glucose meter works by taking a small sample of blood using a lancet to prick a fingertip, usually the index or middle finger. The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter. The drop of blood is drawn into the meter and can directly measure the glucose in the sample. The units of blood sugar level from a glucose meter, will result in either mg/dL or mmol/L of blood. Proper user technique and environmental conditions are important in obtaining reliable readings and accurate glucose measurements. Control of diabetes may be improved using home glucose meters to regularly measure glucose levels as this method provides rapid results allowing individuals to make timely decisions regarding diet, exercise, and medication.
Continuous glucose monitors are another method to measure blood glucose levels and is widely used among individuals with diabetes. A continuous glucose monitor is a device that sits on the surface of the skin and measures the amount of glucose between the cells with a probe. The device does not directly measure the blood sugar but rather tracks the interstitial glucose levels which are similar to blood glucose levels. The other part of the CGM, known as the transmitter, then sends the information to a receiver, an insulin pump, or a compatible smart device. Unlike the traditional glucose meter, CGMs will report the glucose level continuously and has an alarm that will alert the person if the glucose level is too high or low, helping to prevent emergencies. The device is able to graph the glucose readings over the time the sensor was in use and track trends. This allows for timely adjustment of diet, activity levels, medications, and/or illness In addition, the information from the CGM can be downloaded and sent to a second person or physician for their review. CGMs have also been shown to improve glycemic control, reduce Hb A1c levels, and/or reduce the risk of hypoglycemic events. They also can reduce the need for multiple fingersticks throughout the day, which may be preferred by some individuals. Popular CGM devices include Dexcom, Freestyle Libre, and Medtronic.
In addition to the above tests, glucose can be measured on routine labs. One common test ordered by healthcare providers is a Basic Metabolic Panel which is a blood test that looks at several different substances in the body, including blood glucose. Usually, individuals are told to fast for 8 hours before drawing the labs so that the provider can see the fasting glucose level. The normal range for fasting blood sugar in people without diabetes is 70 to 99 mg/dL. The range for individuals considered to have prediabetes is 100 to 125 mg/dL. If the fasting blood sugar is greater than 126 mg/dL on blood tests taken on separate occasions, individuals are considered to have diabetes.
Another useful test that is usually done via a blood test is the measurement of blood HbA1c levels. In the blood, there is a molecule called hemoglobin which carries oxygen to the cells. Glucose can attach itself to this molecule and if the blood glucose is consistently high, the value of the A1c will increase. This test, unlike the other tests, is measured as a percentage because the test measures the proportion of all the hemoglobin that has glucose attached. This test measures the average amount of blood sugar control over a period of about 3 months. In people without diabetes, the HbA1c level ranges from 4.0 to 5.7%. The range for people with prediabetes is 5.7 to 6.4%, and anything above 6.4% is considered diabetic range. Due to the HbA1c serving as a accurate indicator of overall glycemic control, regular 6 month laboratory testing of HbA1c is recommended to gauge long-term control and allows for more information to then adjust a person's lifestyle as well as routine medication dosages in such cases.
Optimal management of diabetes involves individuals measuring and recording their own blood glucose levels. By keeping a diary of blood glucose measurements and noting the effect of food and activity levels, individuals can modify their lifestyle to better control their diabetes. Studies suggest that the self-monitoring of blood glucose can improve HbA1c levels both in the short and long-term in patients with type 2 diabetes that are not on insulin. For individuals on insulin, glucose monitoring is also crucial in achieving effective dosing and timing.

Glycemic Control

Glycemic control is a medical term referring to the typical levels of blood glucose in a person with diabetes mellitus. Much evidence suggests that many of the long-term complications of diabetes, result from many years of hyperglycemia.
"Perfect glycemic control" would mean that glucose levels were always normal and indistinguishable from a person without diabetes. Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care. Poor glycemic control refers to persistent elevated blood glucose in the 200 to 500 mg/dL range. This is also measured by Hb A1c levels, which may range 6.5% or higher.

Goals

They are suggested in clinical practice guidelines released by various national and international diabetes organizations.
The glycemic targets are:
  • HbA1c of less than 7.0% if they are achievable without significant hypoglycemia
  • Preprandial blood glucose: 70 to 130 mg/dL
  • 2-hour postprandial blood glucose: Less than 180 mg/dL
Goals should be individualized based on:
In older people, clinical practice guidelines by the American Geriatrics Society recommend, in frail people who have a life expectancy of less than 5 years, a target a Hb A1c of 8% is appropriate as the risk of very low blood sugar outweighs the long term benefits of a lower A1c.
When comparing the effects of tight versus conventional glycemic control in type 2 diabetics, studies failed to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal myocardial infarction by 15%. Additionally, tight glucose control decreased the risk of progression of kidney, nerve, and eye complications, but increased the risk of severe hypoglycemia.

Lifestyle Modification

Diet

Dietary changes have been shown to significantly help patients manage diabetes. There are many diets that are effective at managing diabetes however, it is important that patients understand that there is no one diet that all patients should use. Some diets that have strong evidence and have commonly been used successfully in diabetes management and assist with weight loss include Mediterranean diet, Dietary Approaches to Stop Hypertension, Alternative Healthy Eating Index, vegetarian, low carb, or carb-controlled. In addition, it is recommended that individuals choose a diet that can be adhered to long-term. Even in the most ideal diet becomes impractical if the patient has difficulty following it.
A regular diet that has reduced variability in carbohydrates is an important factor in producing normal blood sugars. Patients with diabetes should eat preferably a balanced and healthy diet. Meals should consist of half a plate of non-starchy vegetables, 1/4 plate of lean protein, and 1/4 plate of starch/grain. Patients should avoid excess simple carbs or added fat and instead eat complex carbohydrates such as whole grains. In addition, patients should also avoid consumption of processed meat and foods and sugar-sweetened beverages. In the long term, it is helpful to eat a consistent diet and amount of carbohydrate to make blood sugar management easier. It is important for patients to eat 3 meals a day in order to reduce the chances of hypoglycemia, especially with patients that take insulin.
There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes. Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed insulin dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet. In general people with T1D are advised to follow an individualized eating plan rather than a pre-decided one.