A landmark study, the 10-year, multi-center Diabetes Control
and Complications Trial (DCCT), has now shown that intensifying
diabetes management with stricter control of blood sugar levels can
reduce long-term complications.
The
results of DCCT are extraordinary in that they prove that tight control
of glucose levels can in fact dramatically slow the onset and
progression of diabetic complications in both Type I and Type II
diabetes. Additionally, researchers have found strict attention to diet
and exercise also helps in the management of diabetes.
- Management of Type I Diabetes
Virtually
everyone with Type I diabetes (and more than one in three people with
Type II) must inject insulin to make up for their deficiency. Until
recently, insulin came only from the pancreases of cows and pigs (with
pork insulin more closely duplicating human insulin). While beef, pork
and beef/pork combinations are still widely used, there are now two
types of "human" insulin available: semisynthetic (made by converting
pork insulin to a form identical to human) and recombinant (made by
using genetic engineering). All insulin helps glucose levels remain near
normal (about 70 to 120 mg/dl).
Different
types of insulin work for different periods of time. The numbers shown
below are only averages. The onset (how long it takes to reach the
bloodstream to begin lowering the blood sugar), peaking (how long it
takes to reach maximum strength) and duration (how long it continues to
lower the blood sugar) of insulin activity can vary from person to
person and even from day to day in the same person.
Rapid or Regular Activity:
Onset is within half an hour and activity peaks during a 2 to 5 hour
period. It remains in the bloodstream for about 8 to 16 hours. These
fast-acting, short-lasting insulins are useful in special cases:
accidents, minor surgery or illnesses, which cause the diabetes to go
out of control or whenever insulin requirements change rapidly for any
reason. These are also being used more and more in combination with a
long-acting insulin or alone (prior to meals and at bedtime).
Semilente:
A special type of short-acting insulin that takes 1 to 2 hours for
onset, peaks 3 to 8 hours after injection and lasts 10 to 16 hours.
Intermediate-Acting:
Reaching the bloodstream 90 minutes after injection,
intermediate-acting insulin peaks 4 to 12 hours later and lasts in the
blood for about 24 hours. There are two varieties of this type of
insulin: Lente (called L) and NPH (called N).
Long-Acting:
These insulins, which take 4 to 6 hours for onset, are at maximum
strength 14 to 24 hours after injection, lasting 36 hours in the
bloodstream. Long-acting insulin is referred to as U (for Ultralente).
Please be aware of the following problems that exist with insulin intake:
- Hypoglycemia (low
blood sugar) is sometimes called an insulin reaction or insulin
shock. It can occur suddenly in people using insulin if too little
food is eaten, if a meal is delayed or in the case of extreme
exercise. Symptoms include feeling cold, clammy, nervous, shaky, weak or
hungry, and some people become pale, have headaches or act
strangely.
- Hyperglycemia (high
blood sugar) occurs when too much food is eaten or not enough
insulin is taken. The warning signs are large amounts of sugar in
the urine and blood, frequent urination, great thirst and nausea.
- Ketoacidosis (in
its most severe form - diabetic coma) develops when insulin and
blood sugar are so out of balance that ketones accumulate in the
blood. Symptoms include high blood sugar or ketones in the urine, dry
mouth, great thirst, loss of appetite, excessive urination, dry
and flushed skin, labored breathing, fruity-smelling breath and
possible vomiting, abdominal pain and unconsciousness.
In
addition to daily injections of insulin, regular physical activity and a
controlled diet are essential. The American Diabetes Association (ADA)
recommends the following daily dietary guidelines:
- Up
to 70 percent of all calories should be obtained from
carbohydrates and unsaturated fats. These carbohydrates should be
mainly complex carbohydrates and naturally occurring sugars
(simular to those in milk and fruits). Examples of unsaturated
fats are vegetable oils and margarine.
- Between 10 and 20 percent of calories should be obtained from protein.
- Less
than 10 percent of all calories should be obtained from fat.
Saturated fats are found in animal products and in some vegetable
oils (such as coconut, palm, and palm-kernel oils).
- Eat 30 to 35 grams of fiber.
- Eat no more than 300 mg of cholesterol.
For
Type I diabetes, the meal plan should be tailored to the person's
individual needs and is likely to include three meals and two or three
snacks a day. A person with diabetes must eat these meals and snacks at
set times each day to properly balance insulin.
- Management of Type II Diabetes
The ADA recommends diet (see ADA
guidelines stated above) and regular physical activity as the first
line of treatment for Type II diabetes. If normal glycemic levels are
not achieved within three (3) months, drug treatment is recommended.
Currently there are four (4) classes of prescription drugs available for the treatment of Type II diabetes:
- Sulfonylureas
(Diabinese, Dymelor, PresTab, Orinase, Tolinase, Micronase,
DiaBeta, Glynase, Glucotrol, Glucotrol XL and Amaryl), which
stimulate the pancreas to release more insulin.
- Biguanides (Glucophage and Metformin), which keep the liver from releasing too much glucose.
- Alpha-glucoside inhibitors (Precose), which slow the digestion of some carbohydrates.
- Thiazolidinediones,
which control glucose levels by making muscles more sensitive to
insulin and reduce the amount of glucose that the liver produces.
Clinical trials suggest that oral antidiabetic
agents - particularly the new noninsulin secretagogues (including
Troglitazone and Metformin, which act on the liver and skeletal muscle) -
may be useful in delaying or preventing development of Type II
diabetes. Both agents, acting primarily by different mechanisms of
action, also have demonstrated potential beneficial effects on serum
lipid profiles.
Although
these oral medications work in different ways, they can be combined to
work more effectively to manage Type II diabetes. When these
combinations of oral treatments are no longer effective (for about 60
percent of people with Type II diabetes), the doctor will start a
regimen of insulin alone or in combination with an oral medication.
