and autonomic failure such as erectile dysfunction. Concomitant diseases such as the metabolic syndrome also constitute a burden.
The best way to avoid complications of diabetes and early death seems to be near-normal metabolic control, with effective treatment of hypertension, dyslipoproteinemia, and adverse life style (Table 1.16). Both fasting and postprandial hyperglycemia are predictors of chronic complications [3,7,341,342]. For prevention of chronic complications, the Kumamoto study elaborated the following glycemic thresholds: HbA1c <6.5%, fasting blood glucose <110mg/dl (<11.1 mmol/l), 2-hour postprandial glucose >180mg/dl(<10mmol/l).
Basically, the goals shown in Table 1.16 are valid for ail types of diabetes mellitus except for gestational diabetes. They may be modified under certain conditions, for example, if strict metabolic control would mean an increased risk of hypoglycemia, if life expectancy is short for other reasons than diabetes, or in geriatric patients with multiple morbidity in whom diabetes is a second-order problem. Sometimes these goals may also be incompatible with well-being, because changing a comfortable life style will often be necessary to achieve the goals. In these cases a compromise should be agreed upon between the diabetic patient and his/her care team.
Near-normal metabolic control plays a pivotal role not only in chronic, but also in acute hyperglycemia of people who have not had diabetes mellitus. Such conditions occur frequently after major surgery or other major somatic stress such as multiple trauma or severe burns. In the past, these critically ill people were usually treated only in the presence of hyperglycemia exceeding 200mg/dl(11 mmol/l) with the aim of keeping blood glucose below this level. This standard of treatment is insufficient, since a recent study has shown that lowering morning blood glucose from an average of 153 mg/dl (8.5 mmol/l) to 103 mg/dl (5.7 mmol/l) reduces mortality by almost 50% [343]
Table 1.16 Medical goals of diabetes management according to Deutsche Diabetes Gesellschaft [344]
| Capillary blood glucose | ||
| Postprandial | 130–160 mg/dl | 7.2–8.9 mmol/l |
| Fasting | 90–120 mg/dl | 5.0–6.7 mmol/l |
| Bedtime | 110–140mg/dl | 6.1–7.8mmol/l |
| HbA,1c (%) | 6.5 | |
| Triglycerides(mg/dl) | ≤150mg/dl | ≤1.71 mmol/l |
| LDL cholesterol (mg/dl) | ≤130 mg/dl | ≤3.45 mmol/l |
| HDL cholesterol (mg/dl) | ≥40 mg/dl | ≥1.04 mmol/l |
| BMI (female/male) | 25/26 | |
| Blood pressure (mmHg) | ≤140/85120/80a | |
| Healthy life style | ||
| Well-being |
a In subjects with microangiopathy
Nonpharmacological Treatment
The goals of treatment can seldom be attained by conventional methods of patient care, where the doctor makes out a prescription and the patient has to follow it. In order to keep metabolism in a near-normal range, it is necessary to check actual glycemic control frequently, often several times a day. Values that are too high or too low must be corrected, and to plan treatment according to the events of the day. These daily therapeutic measures are unpredictable and cannot be carried out by doctors and their team, only by the diabetic subjects (or those around them) themselves. Consequently, people with diabetes should no longer be seen as “patients” “suffering from” their disease, but must become active partners of their doctors (Table 1.17). To be qualified for this role, they must be knowledgeable and motivated to take on the responsibility for managing their own diabetes. Teaching, training, and empowerment of people with diabetes mellitus is thus believed to be essential, even though this has not always been proven [345–348].
The role of the doctors and their team will be to teach people with diabetes, design therapeutic options for the individual diabetic person, and arrange regular checkups (Table 1.17). Their role is also to encourage and support the patients, give ongoing advice, and help in acute and chronic problems. However, the doctors cannot take responsibility for the correctness of daily management and for therapeutic failures due to noncompliance on the part of the patients.
Teaching should enable the diabetic subjects (and if possible people in their social environment) to understand the disease and its treatment and to detect and manage complications early on (Table 1.18). Transferring knowledge and abilities is important. More important, however, is empowerment. The diabetic persons should not simply take on the doctors recommendations, but should develop their own health beliefs. Instead of obeying prescriptions, they should want to attain good control and wish to practice self-monitoring, treatment adaptation, and a healthy life style. In other words, they should be able to develop appropriate self-care behavior.
Table 1.17 Nonpharmacological management of diabetes mellitus
| A. The role of the patients: Learn about diabetes Develop health consciousness and self-management behavior Set goals for your therapy Express and discuss your wishes and expectations with your health care team Control and correct yourself regularly Adopt a healthy life style Profit from the expertise of your health care team Don't “suffer” from your diabetes Decide to want what you have realized as being good for you |
| B. The role of the doctor and the diabetes team: Teaching and training, ongoing advice, back-up. empowerment, and motivation of the persons with diabetes Discussion and consensus on goals of individual therapy Design of individual therapy Nutrition counseling and self-management plan |
Table 1.18 Topics for teaching and training of people with diabetes
| What does diabetes mellitus mean? (causes, symptoms, natural course, prevention, rights and roles) |
| Sensible eating (what to eat, nutrients and energy content, metabolic effect, shopping, cooking) |
| Physical activity (pros and cons of different activities, metabolic and cardiovascular effects, joint loading, monitoring) |
| Self-monitoring (blood glucose, body weight, skin, blood pressure, how and when to do, how to document) |
| Hypoglycemia (causes, symptoms, prevention, treatment) |
| a Oral antidiabetic drugs (action, when to take, side effects) |
| a Isulin (action, how to inject, pens and other devices, schedule, dosage) |
| Care of skin and feet (how to examine, instruments for care) |
| a Not smoking (importance, how to give up smoking) |
| Blood pressure (importance, measurement, how, when, actions at high blood pressure) |
| Chronic complications (symptoms, regular check-ups, risk, prevention, treatment) |
| When to contact the doctor or diabetes care team |
| Special situations (traveling, being ill) |
| Social problems (driver's license, insurance, diabetes risk of descendants) |
