Management of Type 1 Diabetes

Goals of Management of Type-1 Diabetes

decrease plasma glucose and urine glucose excretion (eliminate caloric drain and adverse effects) and abolish ketosis

induce positive nitrogen balance (i.e. muscle building) Þ restore lean body mass and growth

prevent or minimize late complications (retinopathy, neuropathy, nephropathy, hypertension, atherosclerosis)

educate patient and family to cope with disease

Tools used to monitor glycemic control

Glycosylated Hb (HbA1c) – provides measure of time-averaged blood glucose concentration over prior 3-4 months

due to non-enzymatic attachment of glucose to hemoglobin b chain – life span of hemoglobin (RBC) is 120 days

Fructosamine – glycosylated albumin, life span is 15 days

Strategies for Management of Type-1 Diabetes

(1) Insulin

goals:

replace basal insulin thus preventing nocturnal hyperglycemia and ketosis

replace meal-stimulated insulin thus preventing post-prandial hyperglycemia

Insulin Preparations: Short acting (Regular; Lispro); Intermediate acting (NPH/Lente); Long acting (Ultralente)

Conventional Insulin Therapy:

Provide minimal insulin requirement via slow- and long-acting insulins taken together twice a day

Prevents ketoacidosis, decreases or eliminates symptoms of glycosuria, permits usual life functions

However, does not sufficiently prevent long-term complications

Fixed daily doses prescribed and altered by physician during office visits, so no patient adjustment

Intensive Insulin Therapy:

Self-blood glucose monitoring 3-4 times a day, with 3-4 self injections per day (or pump)

Insulin dosage adjustment by patient according to pre-meal blood glucose, anticipated carbohydrate intake

Consistent meals, especially in terms of carbohydrate content

Risk of hypoglycemia 3x as great as conventional therapy, so must use caution

Benefits: ß retinopathy, nephropathy, neuropathy, and cardiovascular disease. Elimination of day-to-day symptoms of hyperglycemia, Ý comfort

Adverse effects: Hypoglycemic episodes, weight gain, more effort, higher cost

Factors Affecting Insulin Requirements:

insulin requirements:	increased	decreased
caloric intake	Ý	ß
weight	gain	loss
time of life	puberty
pathological state	infection	renal failure
drugs	glucocorticoids	anti-hyperglycemic agents
pregnancy	prepartum	postpartum
menstrual period (some women)	just before	just after it begins

(2) Diet

No foods totally prohibited; once weight loss is regained, an isocaloric diet is maintained

Prevent carbohydrate loading (i.e., not too much at any one meal) – allow better control of blood glucose

Restrict fat – ß risk of atherosclerosis; Restrict alcohol – EtOH increases risk of hypoglycemia

Encourage palatable amounts of fiber – may help to decrease postprandial increase in glucose

Limit protein if kidney is affected

mid-morning, mid-afternoon, and bedtime snacks to reduce swings in blood glucose Þ hypoglycemia

Enable patients to quantitate their foods (especially carbohydrate), by using the "Food Exchange System"

example: slice of bread = potato = one "point"

Add calories and protein for growth, pregnancy, etc.

Recommended caloric intake: 50-55% CHO (complex), 30% fat (10% saturated) 15-20% protein (at least 0.8 g/kg)

Most Important: maintain regular eating schedule (to avoid periods of over/under insulinization)

(3) Exercise

Exercise decreases blood glucose in a well-controlled type 1 diabetic patient. How?

(1) Ý glucose utilization by exercising muscle

(2) no increase in hepatic glucose production due to exogenous insulin

(3) better absorption of insulin from injection sites within exercising muscle

Risk: exercise induced hypoglycemia – to prevent this, dose of insulin should be decreased before exercise

Note: exercise should not be used until diabetes has been controlled – poorly controlled patients have:

(1) deficient stores of glycogen Þ poor muscle performance, early fatigue

(2) dependence on fatty acids for fuel Þ accelerates ketosis

(4) Education

Pathophysiology, Insulin administration, home monitoring, hypoglycemia, sick days (extra testing for glucose + ketone acids), foot care and hygiene, family support