GETTYSBURG MEDICAL CENTER
THE CLINICAL VIEW
By: Philip E. Hoffsten, M.D.
10 May 2001

A Summary of Care for Diabetes Mellitus

In February, I wrote a column on medications and steps that can be used to help individuals with diabetes mellitus. In the past several weeks, diabetic screening clinics have been held all around the state in response to Governor Janklow’s campaign to increase diabetic awareness and help individuals with this condition avoid the devastating complications that it causes.

To reiterate briefly, in that column in February, it was noted that there are 30 million people in the United States that have what is called glucose intolerance meaning they are either diabetic or prediabetic. About one-half of these individuals are already diabetic but only one-third of them even know it. Thus diabetes mellitus provides a medical iceberg in which many and severe complications develop before the person even knows that they have the disease. The following is a summary of the important steps in finding and caring for individuals who have diabetes mellitus.

#1. For individuals 40 years of age and older and especially anyone who is also overweight, an annual check on their blood sugar taken about two hours after a meal is a critical part of detecting the condition. Simply checking a fasting blood sugar in the morning gives too rosy of a picture and individuals who are truly diabetic may not be detected for an extended period of time. Check a blood sugar two hours after a meal to know that you are not diabetic.

 #2. Once high blood sugars are documented and it is apparent that the person is diabetic or prediabetic, do not deny it. All too commonly, patients tell me that they know their blood sugars are slightly high but they are going to lose weight and exercise more and everything will be fine. Invariably, patients come back one year later, 3 pounds heavier, one year older and less inclined to do anything than they were the year before and with blood sugars higher yet. Unfortunately, it often takes a catastrophe such as a loss of vision or a diabetic foot ulcer before the person finally acknowledges that they have a problem. DIABETES IS A VERY UNFORGIVING DISEASE. Once complications occur, they are extremely difficult to reverse and regain the lost capability.

 #3. Once diabetes is diagnosed, it is critical to spare what insulin capability the person has and give the overworked pancreas relief from the exhaustion that it is experiencing. Weight control and avoidance of continued overnutrition is a single most critical part of diabetic care.

 #4. Almost all diabetics will require some type of medical intervention. At this time, the most promising medication to avoid diabetic complications of blindness, nerve damage and kidney damage are two drugs available over the past three years. One of these drugs is called Avandia and the other is called Actos. They make the person’s body more sensitive to the insulin that they already have and thereby decrease the amount of insulin the person has to secrete to control their blood sugar. While these drugs have only been available for three years, it appears that their effectiveness does not wear out as was true of the older oral diabetic medications.

 #5. In the past decade a drug called metformin (Glucophage) came on the market and now has a demonstrated effectiveness in preventing diabetic complications. Unfortunately, this medication has a number of symptomatic side effects such as abdominal discomfort and diarrhea that makes its use unacceptable to some diabetics. If a person tolerates the drug without side effects, it is a very useful medication to prevent diabetic complications and keep blood sugars in better control. 

 #6.  The last family of medication used to treat diabetes are medications that make the diabetic’s pancreas work harder and secrete more insulin.  This strategy has an intrinsic flaw.  The diabetic’s pancreas is already being asked to overwork and make more insulin than it normally would because of the diabetic’s resistance to their own native insulin.  Asking the pancreas to work harder yet seems an ill-fated strategy.  Indeed, it has been shown that the longer these medications have been used, the less effective they become and eventually the diabetic is required to use insulin itself rater than an oral pill medication. 

 #7.  If and when the day comes that the diabetic is required to use insulin in order to control their blood sugar, understand that it is probably going to take two or maybe three injections per day in order to get enough control of the blood sugar to prevent the nerve, eye and kidney complications that come with this disease.

 #8.  The best measure of control of diabetes is called a glycosylated hemoglobin or A1C test.  This test measures what the average blood sugar has been for the last two months.  Medicare will pay for this test every three months in a person with known diabetes.  If medications are being adjusted, it will cover the cost of this test more frequently.  The goal of treatment is to get this test into the normal range indicating that the blood sugar is controlled all of the time.  If this test comes into the normal range, diabetic complications are very, very unusual.

 #9.  Check your eyes with the optometrist or ophthalmologist at least once a year.  One of the most disappointing side effects of diabetes is blindness.  Diabetes is the leading cause of the blindness in the United States today.  It is a preventable condition if the diabetic will simply get their eyes checked and then treated as problems develop.

 #10.  Visit your healthcare professional a minimum of every three months and more frequently if diabetic problems are developing.  At the time that you visit with your healthcare professional, be sure to have your feet checked, your weight checked, your blood pressure checked and your diabetic control and medications reviewed. If there is any suggestion of development of heart problems, referral to a cardiologist for further evaluation is critical. It should be recognized that very frequently diabetics do not develop chest pain in response to their heart problems. Instead, their heart problems may present simply as an unusual fatigue or decreased exercise capacity. Getting an exercise stress test done on a regular basis is important for diabetics of 10 or more years’ duration.

 #11. Diabetes is now the leading cause of kidney failure in the United States. There are medications that decrease the rate of kidney failure dramatically. The most important and critical aspect of kidney protection in a diabetic is control of blood pressure. The blood pressure should be controlled at 130/80 or less. There is no such thing as a normal “high blood pressure”. If a diabetic’s blood pressure is more than 130/80, they are burning up their kidneys and future grief can be expected.

 #12. The incidence of heart attacks and stroke in diabetics is more than twice that of the general public and the complications and mortality in a diabetic with heart problems are much worse than for the general public. Control of cholesterol and blood lipids is a critical part of care. Cholesterols in a diabetic should be checked at least on an annual basis and treated vigorously to get a cholesterol under 200 mg/% and an LDL cholesterol under 100 mgl%.

 #13. Exercise is touted as an important part of diabetic care but there are many diabetics who are massively overweight and encounter difficulty exercising. The tendency for this group is to give up all effort because they “can’t exercise”. While exercise is a very beneficial part of diabetic care, nutrition control is far, far, far more important. It is unusual for one to initiate an exercise program that they will maintain for weight control but it takes nothing more than willpower and determination to stop eating much more than is needed.

 The healthcare providers at your local clinic have been trained and retrained on diabetic care because it is such an important disease at this time. Emphasis on diabetic care is pushed at both our national governmental levels, state governmental levels and certainly by the medical professional over an extended period of time. The cost of diabetic care to our insurance and Medicare providers is staggering. They are now beginning to recognize the importance of diabetic education and teaching the diabetic how to care for themselves. Pam Peterson, RN, diabetic educator, is available at St. Mary’s Hospital in Pierre and periodically at the Gettysburg Medical Center to help diabetics better learn how to care for themselves. On Saturday morning, May 19, I will be available at the Medicine Rock Café in Gettysburg for questions and discussion regarding diabetic care and how to prevent the complications from this devastating disease.