style="font-size:15px;"> a If reasonable
An important aim of patient teaching and training is regular self-monitoring of blood glucose, body weight, skin, particularly of the feet, and blood pressure (Table 1.19). Urinary glucose determination is inadequate as the only method. Aglucosuria does not constitute proof of good metabolic control, because the renal threshold for glucose may be far above the treatment goal. Furthermore, only blood glucose self-monitoring can show the risk of hypoglycemia, which is the greatest obstacle to strict metabolic control.
Nutrition of diabetic people should contain no more than 30% of energy as fat and only 10% as saturated fatty acids. This is much less than is usually consumed in Western diets. Protein intake should not exceed 20% of energy. The majority of energy intake should be in the form of carbohydrates, preferentially complex carbohydrates. However, trained people with good metabolic control may also take some sugar (about 50 g per day) in several portions combined with food rich in fibers. Alcohol should be limited to 15 g per day for women and 30 g per day for men. Salt should be used in moderation [203,349]. About 80% of diabetic people are obese. For these people, restriction of energy intake combined with physical activity is essential in order to achieve slow but continuous weight loss. Nutritional advice must aim to keep eating enjoyable and to help diabetic subjects to satisfy their nutritional preferences within the limits of sensible eating.
Nonpharmacological treatment is the basis for management of all types of diabetes mellitus. Whether it will be successful depends not only on the commitment of the doctor and his team, but also on the cultural background and the all-round educational level of the diabetic person. Only educated, well-trained, independent-minded patients will claim their right to choose among different therapeutic options, will know what kind of service they are entitled to demand from the health care system, and will realize what they themselves have to contribute to the management of their diabetes. Only these patients will have a realistic chance of effective diabetes management and a good long-term prognosis.
Table 1.19 Rules for self-monitoring of metabolic parameters
| • Blood glucose testing is preferable for metabolic control. It is mandatory for patients on insulin or oral antidiabetic drugs that stimulate insulin secretion. It is a vital safeguard against hypoglycemia. Perform urine ketone tests during illness or when blood glucose increases above 20 mmol/l. Document all results. |
| • In well-controlled, stable patients: Fasting, before main meals, at bedtime. 1-2 times per week. |
| • In poorly controlled, unstable patients or during illness: Fasting, postprandially. before meals, at bedtime, daily until stabilized. |
| • During intensified insulin treatment: Before each insulin dose, if necessary postprandially. |
| • If hypoglycemia is suspected. |
| Other self-monitoring: |
| • Check body weight, inspect feet at least weekly. |
| • Check blood pressure, if normal monthly, if elevated more often, possibly several times per day until targets of control are achieved. |
| • Record special events. |
The benefit of nonpharmacological treatment has been shown. Weight reduction reduces mortality considerably [63]. Teaching improves metabolic control and may reduce the need for pharmacotherapy [347,350]. Well-established tools of pharmacological treatment of diabetes cannot be used without teaching, training, and empowerment of the patient.
Pharmacological Treatment of Type 1 Diabetes
General Aspects
The person with type 1 diabetes mellitus needs insulin from the very start of the disease. It is useless and may be dangerous to try a treatment without insulin. Different types of insulin treatment are presently practiced, which may be described as: (1) conventional insulin therapy, (2) intensified or functional insulin therapy, either by means of multiple subcutaneous injections, or by continuous subcutaneous insulin infusion. Other therapies, such as intraperitoneal or intraportal insulin infusion, are still experimental.
Conventional insulin therapy is characterized by a prescribed insulin formulation, dosage, and time of application. The quality of metabolic control is monitored by the diabetes care team. The patient performs blood glucose self-monitoring to prevent hypoglycemia but not as a basis for adapting treatment. Nutrition is inflexible, as the amount of carbohydrates and the time of eating are fixed in order to compensate for the blood glucose-lowering effect of insulin and physical work, and are mainly dictated by the pharmacokinetics of the injected insulin. Metabolic control in type 1 diabetes is poorer with conventional therapy than it is with intensified therapy [127]. For this reason, conventional therapy should be avoided in type 1 diabetes. For type 2 diabetes, it may be satisfactory.
By contrast, intensified (functional) insulin therapy is flexible. This aims to imitate physiological insulin secretion (but without combining insulin with C-peptide and amylin and without releasing insulin into the portal vein). The nutrition-independent (basal) insulin requirement is covered by an injection of long-acting insulin or several injections of intermediate-acting insulin or by continuous subcutaneous infusion at a basal insulin rate. In addition, bolus insulin is given to correct hyperglycemia or to cover nutrition-dependent insulin requirements. This method allows nutrition and physical activity to remain variable and also allows immediately correction of blood glucose deviations. However, it requires frequent self-monitoring of blood glucose and the diabetic subject must be able to adjust the insulin properly. The risk of weight gain is increased.
Practical Aspects
When type 1 diabetes mellitus is diagnosed, the patients need much attention, because they need to realize that they have acquired a life-long disease that will change their life. Usually the diagnosis is made because of deranged metabolism. These patients should initially be treated as inpatients. The ketoacidotic patient must be treated as an emergency case. The initial inpatient period should be used for intensive teaching and training which will be continued on an outpatient basis. To make insulin therapy easier, the use of insulin pens should be favored.
If insulin therapy is not initiated on a ward, it may for the purpose of training be started as conventional insulin therapy.
Conventional insulin therapy (CT) is usually performed with intermediate-acting human NPH insulin (NPH = neutral protamine Hagedorn) or mixtures of human NPH insulin and short-acting regular insulin (Table 1.20). Since the duration of action of NPH insulin is less than 24 hours it must be given twice a day or more often. Because there is a delay before NPH insulin begins to act, it is usually given 30-45 minutes before breakfast and dinner. In view of the nutrition-dependent insulin need over the course of the day, about two-thirds of the daily dose is given in the morning and one-third in the evening. If the postprandial blood glucose increment is unacceptably high, mixed insulins are given in the morning or also in the evening. The proportion of regular insulin in mixtures may be chosen anywhere in the range between 10% and 50%.
To compensate for the action of insulin, carbohydrate intake must be properly distributed over the day. The dietary regimen also depends on physical activity and must be developed by trial and error. As a proposal to start with, total daily carbohydrate intake may be divided in eight parts with two-eighths given
