Diabetes Mellitus (high blood sugar) is a very common problem that can cause a plethora of serious medical problems including heart disease, stroke, blindness, leg amputation and kidney failure. The risk of these complications can be markedly reduced if diabetic patients adhere to treatment guidelines recommended by various diabetic specialists.

Blood sugar control
It has been conclusively demonstrated that good blood sugar control will reduce many complications from diabetes. Every diabetic patient should know their own "hemoglobin A1c" number. The hemoglobin A1c is a measure of the average blood sugar control during the previous two months. The hemoglobin A1c should be less than 8.0 in almost all diabetic patients and preferably less than 7 in most diabetic patients. Although no specific recommendations can be made for the individual patient, the goal is a hemoglobin A1c as low as possible without causing the individual to have problems with low blood sugars. Good blood sugar control can only be achieved when the patient stays on an appropriate diet and exercises regularly. There are many free sources of information about diabetic dies including your library and the American Diabetes Associations web site www.diabetes.org. At times, referral to a certified dietitian can be helpful.
Even with an appropriate diet, most diabetic patients will require the use of medications. Insulin is the safest, least expensive and most effective therapy to control blood sugars. There are also several different kinds of pills available to help bring the blood sugars under control. Some patients will also find it necessary to monitor their blood sugars one or more times a day if they wish to achieve good blood sugar control.

Diabetic eye care
Diabetes is the most common cause of blindness in the US. Unfortunately, early diabetic eye disease (diabetic retinopathy) has no "warning signs." Good "vision" does not imply that there is no "diabetic retinopathy." The first manifestation of a diabetic eye problem may be the loss of sight. For this reason, it is essential that diabetic patients visit an ophthalmologist for an annual retina examination.

Heart disease and stroke
Patients who have diabetes have an increased for having a heart attack or stroke. Should the diabetic have such an event, their complication rate is higher than the complication rate for a non-diabetic patient. For this reason, diabetics need to do everything they can to reduce their risk of heart disease and stroke, including stop smoking and keep your cholesterol and blood pressure within treatment guidelines.
Patients who have diabetes and smoke are almost guaranteed that they will eventually have a heart attack or stroke. If a diabetic patient is only willing to do one thing, then they should stop smoking.
All diabetics should have a fasting cholesterol test done at least once the year. It is recommended that diabetics keep their LDL cholesterol (bad cholesterol) level below 100. To achieve this goal, all diabetics need an appropriate diet and the vast majority will also need to take a cholesterol pill.
All diabetics should have their blood pressure monitored at least twice a year. The goal is a blood pressure less than 130-135/80-85. Some improvement in the blood pressure can be achieved with weight loss, exercise and a low salt diet. However, good blood pressure control frequently requires the use of medications and it is not uncommon for diabetics to need to concurrently take 3 or 4 blood pressure medicines to meet the treatment guidelines.

Kidney problems
Diabetes is a major cause for kidney failure. Most diabetics should have a urine test done once a year to assess if they have "early" diabetic kidney disease. Diabetics can reduce their risk of developing kidney failure by keeping their blood sugars and blood pressure under excellent control. Patient with "early" diabetic kidney disease should take a medicine in the class of drugs known as the "ACE inhibitors." This will help slow the rate of deterioration in kidney function.

Diabetic foot care
Diabetes is the major cause of leg and feet amputations. In order to reduce the risk of an amputation, it is essential that every diabetic patient visually inspect the bottom of their feet every day. Minor cuts and abrasions on the feet need to be treated aggressively. Should you notice a sore, redness or skin breakdown on the foot, you should immediately get off her feet and contact your physician.
In order to reduce the risk of a foot amputation, diabetics should always wear something on the feet, even when in their own home. In addition, diabetics should never wear open toed shoes or sandals, as small abrasions can quickly result in a significant problem.

What can I do
Every diabetic patient needs to take responsibility for their own medical care and ensure that they are treated according to current treatment guidelines. In order to accomplish this, the diabetic patient should keep meticulous medical records. They should maintain a chart of the testing which needs to be done, the frequency with which the testing should be done, the date the testing was done and the results of the test. You should ask your physician for a copy of all lab results. You should make sure that you understand what those results mean. If you find that you are not within current treatment guidelines, you should ask your physician whether it would be appropriate for you to begin a more aggressive treatment protocol.

Patients should also remember that there is no single treatment goal or treatment schedule that is appropriate for every patient. All treatment decisions have to be individualized by your physician for your situation. And most importantly, stop smoking.

RECOMMENDED DIABETIC TESTING


ASSESSMENT FREQUENCY DONE BY GOAL TREATMENT OPTIONS
Foot exam daily patient normal medicines or surgery
Eye exam annually ophthalmologist normal laser eye surgery
Cholesterol 1-2 times a year blood test LDL<100 or 70 medicines
Blood pressure annually physician <130/80 medicines
Urine test annually urine test normal medicines
Hemoglobin A1c 2-6 months blood test <7 exercise, diet, pills, insulin
Blood sugar

before breakfast

0-7 times

per week

home blood

sugar test

<126 mg/dL exercise, diet, pills, insulin
Blood sugar 2 hours

after meals

0-7 times

per week

home blood

sugar test

<180 mg/dL exercise, diet, pills, insulin
Note: "<" means less than

 

The above guidelines do not apply to pregnant women or to women considering becoming pregnant. In that group of patients, the goal is a fasting sugar < 90, a two hour after meal blood sugar < 120 and a hemoglobin A1c < 6.

Diabetic women who are considering becoming pregnant, should see a physician before they attempt to concieve and immediately on becoming pregnant.

Hayward Zwerling, M.D. is a Fellow of the American College of Physicians and of the American Association of Clinical Endocrinologists. He is board certified by the American Board of Internal Medicine in Internal Medicine and Endocrinology.