Diabetes management-overview

The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentrations of glucose in the blood. 

Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin.

Diabetes mellitus type 1 is usually due to the autoimmune destruction of the insulin-producing beta cells of the pancreas. 

Diabetes mellitus type 2, is thought to result from autoimmune attacks on the pancreas and/or insulin resistance. 

The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. 

Other forms of diabetes mellitus, may represent some combination of insufficient insulin production and insulin resistance. 

Some degree of insulin resistance may also be present in a person with type 1 diabetes.

The main goal of diabetes management and control is, to restore carbohydrate metabolism to a normal state. 

To achieve this goal, individuals with an absolute deficiency of insulin require insulin replacement therapy, which is given through injections or an insulin pump. 

Insulin resistance, in contrast, can be corrected by dietary modifications and exercise. 

Diabetes management includes prevention or treatment of the many complications that can result from the disease itself and from its treatment.

Treatment goals are related to effective control of blood glucose, blood pressure and lipids, to minimize the risk of long-term consequences associated with diabetes. 

HbA1c of less than 6% or 7.0% if they are achievable without significant hypoglycemia.

Preprandial blood glucose: 3.9 to 7.2 mmol/L (70 to 130 mg/dL).

2-hour postprandial blood glucose: <10 mmol/L (<180 mg/dL)

Diabetes management goal goals individualized based on:

Duration of diabetes

Age/life expectancy


Known cardiovascular disease or advanced microvascular disease

Hypoglycemia awareness

For frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as HbA1c of 8% is appropriate.

The glucose cycle is affected by two factors: entry of glucose into the bloodstream and also blood levels of insulin to control its transport out of the bloodstream

The glucose cycle system is sensitive to diet and exercise.

Diabetes management is affected by the need for patient anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose system.

Diabetic management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of blood glucose levels, multiple times a day in many cases.

Controlling other cardiovascular risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the major aspects  of diabetes management; Checking cholesterol, LDL, HDL and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. 

Controlling blood pressure  with diet and antihypertensive treatment protects against the retinal, renal and cardiovascular complications of diabetes. 

Care to prevent the development of diabetic foot ulcers is required diabetic care.

The normal person has an average fasting glucose level of 4.5 mmol/L (81 mg/dL), with a lows of down to 2.5 and up to 5.4 mmol/L (65 to 98 mg/dL).

Optimal management of diabetes involves patients measuring and recording their own blood glucose levels. 

By keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control diabetes. 

A level of <3.8 mmol/L (<70 mg/dL) is usually described as a hypoglycemic attack.

Most diabetics know when they are going into a hypoglycemic attack and usually are able to eat food or drink something sweet to raise their levels. 

Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia.

Among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from nocturnal hypoglycemia.

National Institute of Health statistics show that 2% to 4% of all deaths in diabetics are from hypoglycemia.

In children and adolescents following intensive blood sugar control, 21% of hypoglycemic episodes occurred without explanation.

In addition to the deaths, diabetic hypoglycemic periods of severe low blood sugar can also cause permanent brain damage.

Levels of glucose greater than 13–15 mmol/L (230–270 mg/dL) are considered high, and should be monitored closely to ensure that they reduce rather than continue to remain high. 

High blood sugar levels, hyperglycemia, usually happens over a period of days rather than hours or minutes, and if untreated, this can result in diabetic coma and death.

Prolonged elevated levels of glucose in the blood over time, results in serious diabetic complications in those susceptible and sometimes even death. 

Many of the long-term complications of diabetes, especially the microvascular complications, result from many years of hyperglycemia.

The percentage of hemoglobin which is glycated is used as a proxy measure of long-term glycemic control.

The hemoglobin A1c or glycated hemoglobin reflects average glucose levels over the preceding 2–3 months. 

In nondiabetic persons with normal glucose metabolism the glycated hemoglobin is usually 4–6%.

As of  2020 guidelines called for an HbA1c of around 7% or a fasting glucose of less than 7.2 mmol/L (130 mg/dL).

People with a life expectancy of less than nine years, do not benefit are over-treatment  and do not experience clinically meaningful benefits.

Poor glycemic control refers to persistently elevated blood glucose and glycated hemoglobin levels, which may range from 200 to 500 mg/dL (11–28 mmol/L) and 9–15% or higher over months and years before severe complications occur. 

Meta-analyses on the effects of tight vs. conventional, or more relaxed, glycemic control in type 2 diabetics have failed to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal heart attack by 15%. 

Tight glucose control decreased the risk of progression of retinopathy and nephropathy, and decreased the incidence peripheral neuropathy, but increased the risk of hypoglycemia 2.4 times.

Food  takes several hours to be digested and absorbed.

Insulin administration can have glucose lowering effects for as little as 2 hours or 24 hours or more, depending on the nature of the insulin preparation used and individual patient reaction.

The onset and duration of the effects of oral hypoglycemic agents vary from type to type and from patient to patient.

Control and outcomes of both types 1 and 2 diabetes may be improved by patients using home glucose meters to regularly measure their glucose levels.

Regular blood testing, especially in type 1 diabetics, is helpful to keep adequate control of glucose levels and to reduce the chance of long term side effects of the disease. 

There are many different types of blood monitoring devices available.

The principle of these devices:  a small blood sample is collected and measured. 

The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter. 

This test strip contains various chemicals so that when the blood is applied, a small electrical charge is created between two contacts, and a chemical reaction occurs and the strip changes color. 

The meter then measures the color of the strip optically.

Self-testing is clearly important in type I diabetes where the use of insulin therapy risks episodes of hypoglycemia and home-testing allows for adjustment of dosage on each administration.

Self-testing benefit in type 2 diabetes is more controversial, but recent studies suggest that self-monitoring does not improve blood glucose or quality of life.

Regular 6 monthly laboratory testing of HbA1c provides some assurance of long-term effective control and allows the adjustment of the patient’s routine medication dosages.

Continuous Glucose Monitoring (CGM) CGM technology givespeople living with diabetes an idea about the speed and direction of their glucose changes. 

Certain foods can be identified as causing one’s blood sugar levels to rise and other foods as safe foods- that do not make a person’s blood sugar levels to rise. 

Each individual absorbs sugar differently.

HbA1c levels: the ratio of glycated hemoglobin in relation to the total hemoglobin. 

A persistently raised plasma glucose levels cause the proportion of these molecules to go up. 

HbA1c levels measure the average amount of diabetic control over a period originally thought to be about 3 months, which is the  average red blood cell lifetime: thought to be more strongly weighted to the most recent 2 to 4 weeks. 

In the non-diabetic, the HbA1c level ranges from 4.0 to 6.0%; patients with diabetes mellitus who manage to keep their HbA1c level below 6.5% are considered to have good glycemic control. 

The HbA1c test is not appropriate if there has been changes to diet or treatment within shorter time periods than 6 weeks or there is disturbance of red cell aging: recent bleeding or hemolytic anemia, or a hemoglobinopathy.

In such cases, the alternative Fructosamine test is used to indicate average control in the preceding 2 to 3 weeks.

Continuous glucose monitoring devices have been manufactured which provide ongoing monitoring of glucose levels on an automated basis during the day.

The number of health-related apps accessible is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. 

Monitoring the feet can help in predicting the likelihood of developing diabetic foot ulcers. 

Using a special thermometer to look for spots on the foot that have higher temperature indicate the possibility of an ulcer developing.

People with type 1 diabetes who use insulin can eat whatever they want, preferably a healthy diet with some carbohydrate content; in the long term it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier.

There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes.

In general people with type 1 diabetes are advised to follow an individualized eating plan rather than a pre-decided one.

People diagnosed with type two diabetes can use exercise as a way to maintain their blood sugar and it has been shown to work just as well as medications. 

Exercise improves blood sugar levels, allow sthe body to be more sensitive to insulin, reduce the risk of heart disease and stroke which are common illnesses associated with diabetes.

By exercising, the body is more sensitive to insulin allowing for better absorption of glucose by the muscle cells, not only during but up to 24 hours later as well.

Exercise helps with glycemic control and lowers HbA1c levels by approximately 4.2 mmol/mol (0.6%).

It is recommended people with type two diabetes take part in 150 minutes on average of exercise a week.

Studies on youth and young adults with type one diabetes where the HBA1c was monitored in both a controlled group and intervention group showed no consistent effect on glycemic control. 

Generally, exercise in type 1 diabetes does not affect blood sugar management.

Type one diabetics are prone to nocturnal hypoglycemic episodes due to exercise as the translocation and expression of GLUT4, which is an insulin-regulated glucose transporter that is used to give glucose to muscle and fat cells, are increased by exercise.

Although exercise may not offer any direct benefit to lower blood glucose levels in those with type one diabetes, many other benefits such as a decreased risk of cardiovascular diseases, including blood pressure, lipid profiles, endothelial function, body composition and insulin sensitivity occur.

The two most effective forms of exercise for people with type two diabetes are aerobic and resistance training.

Aerobic exercise has been shown to largely improve HbA1c, and contributes to weight loss and the enhanced metabolic regulation of lipids and lipoproteins.

Aerobic exercise may be any form of continuous exercise that elevates breathing and heart rate.

Resistance training is an optimal form of exercise for patients with type two diabetes, building muscle strength by lifting weights, training in calisthenics, yoga, or using weight machines. 

This form of exercise was linked to a 10% to 15% increase in strength, blood pressure, BMD health, insulin sensitivity, and muscle mass.

Current diabetes guidelines recommend strength training two to three times per week in addition to aerobic activities.

The combination training is the most effective in reducing HbA1c instead of a singular form of exercise on its own.

The American Diabetes Association recommends 150 minutes of moderate to vigorous aerobic exercise a week spread over three to seven days with no more than 2 days between each session paired with 2 to 3 nonconsecutive sessions of strength training.

Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, improves cholesterol, reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress and contributes to positive self-esteem.

The beneficial results from exercise begin to fade within 48 to 96 hours, requiring ongoing exercise program to maintain the health benefits associated with these forms of training.

A goal for diabetics is to avoid or minimize chronic diabetic complications, as well as to avoid acute problems of hyperglycemia or hypoglycemia. 

Adequate control of diabetes leads to lower risk of complications associated with unmonitored diabetes including kidney failure, blindness, heart disease and limb amputation. 

The most prevalent form of medication is hypoglycemic treatment through either oral hypoglycemics and/or insulin therapy. 

There is emerging evidence that full-blown diabetes mellitus type 2 can be evaded in those with only mildly impaired glucose tolerance.

Patients with type 1 diabetes mellitus require direct injection of insulin as their bodies cannot produce enough, or any, insulin. 

For type 2 diabetics, diabetic management consists of a combination of diet, exercise, and weight loss, in any achievable combination.

Obesity is very common in type 2 diabetes and contributes greatly to insulin resistance. 

Weight reduction and exercise improve tissue sensitivity to insulin and allow its proper use by target tissues.

Patients who have poor diabetic control after lifestyle modifications are placed on oral hypoglycemics. 

Some Type 2 diabetics eventually fail to respond to these and must proceed to insulin therapy. 

For type 1 diabetics, there will always be a need for insulin injections throughout their life.

Both type 1 and type 2 diabetics can see dramatic improvements in blood sugars through modifying their diet, and some type 2 diabetics can fully control the disease by dietary modification.

Insulin therapy requires close monitoring and a great deal of patient education.

Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose uptake is controlled by insulin, and vice versa. 

In addition, there are several types of insulin with varying times of onset and duration of action.

Small, portable insulin infusion pumps are available that allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated blood glucose levels. 

There is no clear evidence that controlling hyperglycemia reduces diabetic macrovascular and cardiovascular disease, there are indications that intensive efforts to normalize blood glucose levels may worsen cardiovascular and cause diabetic mortality.

Drivers with type 1 diabetes have twice as many collisions as their non-diabetic spouses, demonstrating the increased risk of driving collisions in the type 1 diabetes population. 

Diabetes can compromise driving safety in several ways: diabetic retinopathy or peripheral neuropathy, hypoglycemia.

 Hypoglycemia can affect the thinking process, coordination, and state of consciousness.

Such a disruption in brain functioning is called neuroglycopenia. 

Neuroglycopenia can impair driving ability.

Hyperglycemia is a risk factor for developing gum and tooth problems, especially in post-puberty and aging individuals. 

Diabetic patients have greater chances of developing oral health problems such as tooth decay, salivary gland dysfunction, fungal infections, cavities, inflammatory skin disease, periodontal disease or taste impairment and thrush of the mouth.

Increased blood sugar levels translate into greater sugars and acids that attack the teeth and lead to gum diseases. 

Gingivitis can be as a result of increased blood sugar levels along with an inappropriate oral hygiene. 

Periodontitis is an oral disease caused by untreated gingivitis and which destroys the soft tissue and bone that support the teeth. 

Diabetics experience more severe periodontitis because diabetes lowers the ability to resist infection and also slows healing.

Dental care is more important for diabetic patients than for healthy individuals. 

Maintaining better control of blood sugar levels with diabetes results in less likely to develop oral health problems when compared to diabetic patients who control their disease moderately or poorly.

The prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes.

Self-management of diabetes is negatively affected by diabetes-related distress and depression.

There is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population.

Depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms.

In type  2 diabetic patients with a body mass index of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure.

Diabetes type 1 is caused by the destruction of enough beta cells to produce symptoms; these cells, which are found in the Islets of Langerhans in the pancreas, produce and secrete insulin, the single hormone responsible for allowing glucose to enter from the blood into cells.

The hormone amylin, is another hormone required for glucose homeostasis.

The Bio-artificial pancreas: is a cross section of bio-engineered tissue with encapsulated islet cells delivering endocrine hormones in response to glucose: artificial pancreas is to implant bioengineered tissue containing islet cells, which would secrete the amounts of insulin, amylin and glucagon needed in response to sensed glucose.

When islet cells have been transplanted insulin production, and glycemic control is restored, but at the expense of continued immunosuppression drugs. 

Stem cell research has also been suggested as a potential avenue for a cure since it may permit regrowth of Islet cells which are genetically part of the treated individual, thus perhaps eliminating the need for immuno-suppressants.

Stem cell transplantation is an experimental treatment for type 1 diabetes, but it is not yet an approved or widely available therapy.

Gene therapy can be used to manufacture insulin directly.

Gene therapy might eventually be used to cure the cause of beta cell destruction, thereby curing the new diabetes patient before the beta cell destruction is complete and irreversible.

Gene therapy can be used to turn duodenum cells and duodenum adult stem cells into beta cells which produce insulin and amylin naturally. 

Teplizumab a monoclonal antibody drug which aims to delay type 1 diabetes by reprogramming the immune system to stop mistakenly attacking pancreatic cells.[10

Type 2 diabetes is usually first treated by increasing physical activity, and eliminating saturated fat and reducing sugar and carbohydrate intake with a goal of losing weight. 

One can restore insulin sensitivity when weight loss is modest, for examost especially when it is in abdominal fat deposits. Diets that are very low in saturated fats have been claimed to reverse insulin resistance.[109][110]

Cognitive Behavioural Therapy is an effective intervention for improving adherence to medication, depression and glycaemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and comorbid depression.

Testosterone replacement therapy may improve glucose tolerance and insulin sensitivity in diabetic hypogonadal men. 

Testosterone may have a protective effect on pancreatic beta cells, which is possibly exerted by androgen-receptor-mediated mechanisms and influence of inflammatory cytokines.

Gastric bypass surgery may normalize blood glucose levels in 80–100% of severely obese patients with diabetes. 

Gastric bypass surgery may have the additional benefit of reducing the death rate from all causes by up to 40% in severely obese people.

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