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Saturday, December 7, 2013
Diabetes Complications in spite of Good Blood Sugar Control
I am 25 and have had Type I Diabetes for 23 years. I started the insulin pump 3 years ago. Since then, I have had a major uprising in my complications. I have suffered 2 vitreous hemorhages in my eye and have had acute renal failure. What`s odd is that my blood glucose levels NEVER break 150, and i am in reasonably good shape. My Diabetes Doctors, Nephrologists, and GPs are unable to tell me why this is occurring. Can complications worsen with tighter diabetes control? Can some people get complications regardless of good blood sugar control?
I empathize with your situation - it is very important for you to get clear and understandable answers to make good judgements in this situation. I am going to give you a bottom line answer first and then explain: The bottom line is that you should continue to strive for the best blood sugar and blood pressure and probably lipid (blood fats) control that you can and try to eliminate any other modifiable risk factors that you have (like stopping smoking if you smoke tobacco and assuring that you are taking a small dose of aspirin every day if you and your health care providers have considered the risks associated with that and determined that the risks outweigh the benefits), even though it is very frustrating to have complications proceed when you are doing your best. Whether your blood sugars are higher than 150 depends very heavily on the timing of when you do your blood tests. It is valuable to test results both prior to meals and at the peaks after meals which are generally thought to be 2-3 hours after meals. However, it is impossible to get a complete picture with finger prick testing alone. A diabetes specialist center may be able to assist you in conducting a continuous glucose monitoring study which measures blood sugar every few minutes for a 72 hour period - you will be amazed to see how high and how low your sugars sometimes go that you were never aware of before!
The longer part of the answer is that there are a number of factors which determine complications of diabetes and blood sugar control is only one of them although it is one of the most important that you can do something about. In most people, the level of blood sugar control seems to be the single most important determinant. In contrast, there are some groups in whom no matter how bad their blood sugar control is, they seem to get less complications than you would predict from blood sugars and others in whom no matter how good their blood blood sugars are, they seem to get more than the blood sugars would predict. Their are several research groups focussed on trying to understand why this is; in part it may reflect the effects of inherited genes and in part possibly some environmental influence. That is why I included blood pressure control and lipid control as well: there is good evidence that blood pressure makes a difference in kidney, heart and probably eye complications and that blood fats are important in limiting heart complications. However, it may also be that in the next few years, we will see more evidence for lipid control being important for both eye and kidney complications - these questions are being tested in important international clinical trials supported by the US National Institutes of Health. It is therefore important that you express to your Congressional representatives and the President how you feel about the support for diabetes research.
So, as you well know, one of the difficult things is that you never really get a vacation from diabetes. And it is human to be able to try harder for a while, and then have to back off for a while. But it remains the best policy to do the best you can with your diabetes control as much of the time as possible - in the long-range, it will pay off.
Please feel free to write back again.
Robert M Cohen, MD
Professor of Clinical Medicine
College of Medicine
University of Cincinnati