Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, April 9, 1990 TAG: 9004080022
SECTION: EXTRA PAGE: E1 EDITION: METRO
SOURCE: Jane E. Brody
DATELINE: LENGTH: Long
Betty does all this despite having insulin-dependent diabetes, a potentially life-threatening disorder of sugar metabolism that struck her suddenly more than 15 years ago.
She is among 1 million Americans whose lives and health depend on a precarious balancing act between self-injected doses of insulin, careful eating and regular physical exercise.
The goal of diabetes therapy is to keep blood sugar levels from rising too high or falling too low, either of which can have fatal consequences.
Betty is among a growing number of insulin-dependent diabetics who are striving to ward off the serious complications of diabetes by monitoring the amount of sugar in their blood throughout the day and adjusting the doses of insulin, food intake and amount of exercise accordingly to try to keep blood sugar levels as close to normal as possible.
Betty usually checks her blood sugar a dozen times a day, though others need only do the test three to five times - before meals, after exercise and before bedtime are typical.
If her sugar is too high before a meal, she may delay eating or take a brisk walk or administer a larger dose of insulin. If her sugar is low before bedtime or after exercise, she eats an extra snack.
Before the development of simple, portable blood tests done on a single drop of blood, diabetics relied on a far less precise measure of sugar in the urine, and insulin was typically taken according to a predetermined schedule one or more times a day with few, if any, impromptu adjustments. The result was often wide swings in blood sugar levels throughout the day.
Not only can maintaining near-normal blood sugars help to keep people with diabetes on a more even emotional and physical keel, it may also help to prevent the more devastating longterm consequences of the disease: damage to nerves and blood vessels that can result in kidney failure, blindness and severe circulatory problems.
Until the development in the 1970s and early 1980s of simpledevices that enabled people to monitor their own blood sugar many times a day, it was not possible to find out whether the complications of diabetes were an inherent part of the disease or the consequences of wide swings in blood glucose (the form of sugar found in the blood).
Encouraged by evidence from numerous small studies suggesting that "tight control" of blood glucose can prevent serious diabetic complications, physicians who treat diabetes are urging all who can to check their blood glucose levels frequently, especially before and after meals and physical exercise.
The advent of self-monitoring of blood glucose has also made it possible to study the benefits of tight control. Under the auspices of the National Institutes of Health, 1,400 people with insulin-dependent diabetes are participating in a 10-year trial to see if intensive insulin therapy - involving injections of insulin several times a day based on measured need - can prevent, slow or even reverse the debilitating complications of diabetes.
Not everyone with insulin-dependent diabetes develops the same complications or develops complications at the same rate, although 20 years after the onset of the disease, more than half of patients have a serious complication involving the eyes, nerves or kidneys.
Thus far there are only hints of the effectiveness of intensive therapy. For example, the incidence of diabetic retinopathy, a vision-threatening disease of the blood vessels in the retina, is 10 times more common among those with very high levels of blood glucose.
There is also evidence that kidney destruction is less likely to occur among those with well-controlled diabetes. And in some small studies, already existing damage seemed to be halted or even reversed when tight control of blood glucose was maintained.
Tight control is almost certainly beneficial to pregnant women who have diabetes. Careful regulation of blood glucose can virtually eliminate the increased risk of complications that could result in fetal loss or stillbirth, problems that had long plagued the pregnancies of women with diabetes.
One study found tight blood glucose control so reduced pregnancy complications that a net savings of $5,000 per pregnancy resulted.
The Juvenile Diabetes Foundation, a voluntary organization that sponsors research in insulin-dependent diabetes, says the national trial must assess more than just the medical benefits of tight blood glucose control.
Also at issue are possible health risks of tight control, the cost to the patient and to the health care system, the degree of commitment needed and possible deleterious effects on patients' lives.
The main hazard of tight control is the risk of an insulin reaction when blood glucose drops too low after attempts to reduce the highs.
Also at issue is how many people with diabetes are able to achieve tight control and avert wide swings in blood sugar levels.
Betty, for example, experiences unpredictable and sometimes dangerous highs and lows despite careful attention to diet and exercise and insulin needs.
"Improved metabolic control is desirable, although not always achievable in each patient," said Dr. Mark A. Sperling of Children's Hospital Medical Center in Cincinnati.
Physicians must not only consider the physical effects but also the psychological consequences of being unable to achieve tight control despite conscientious self-care.\
by CNB