I often tell my patients that diabetes is a numbers game.
We know from medical research that keeping your blood sugar, blood pressure, and cholesterol levels within a desired range can dramatically reduce the risk of developing complications from diabetes.
Every year, the American Diabetes Association (ADA) publishes guidelines for the medical care of patients with diabetes. While it is essential that health care providers are aware of these guidelines, I think it is equally important that patients understand the goals of treatment.
Understanding the goals of treatment can help patients better communicate with their health care providers (primary care provider, eye specialist, podiatrist, etc.) and help set targets for improving their health. It is important to understand that not all patients will have the same treatment goals. For example, the presence of other health problems, such as heart disease or kidney problems, could change an individual’s blood glucose targets. Therefore, it is important to discuss one’s individualized targets with your health care provider. Individuals with diabetes most also assume an active role in their care.
Blood Sugar Control
The ADA recommends a fasting glucose level of 80-130 mg/dl. Non-fasting blood sugars should be less than 180 mg/dL. Individuals who are meeting treatment goals should have and hemoglobin A1c at least two times per year.
Individuals who have had a change in medication, or who are not meeting blood glucose goals, should have their hemoglobin A1c checked every three months. Keeping one’s hemoglobin A1c less than 7 percent has been shown to reduce the risk of developing complications from diabetes. A reasonable hemoglobin A1c goal for many adult patients with diabetes is less than 7 percent. Different A1c goals may be appropriate for elderly individuals or those with a history of severe low blood sugars. Patients who are on multiple insulin injections or an insulin pump should check blood sugar multiple times per day including before meals/snacks and at bedtime. It is unclear from the medical literature how often individuals who are treated with oral medications should check their blood sugars. In order to be useful, blood glucose testing in these individuals, must be used to make changes in diabetes management or treatment.
Blood pressure should be measured at every routine visit. Individuals with diabetes and high blood pressure should have a blood pressure level of less than 140/90mmHG. Patients found to have blood pressure values higher than 140/90 should be started on medication to help lower their blood pressure.
The most common medications used to treat blood pressure in patients with diabetes are the ACE inhibitors. This class of blood pressure medication has been shown to reduce blood pressure and help protect the kidneys from damage related to diabetes. Most patients with diabetes will require several medications to control their blood pressure. Individuals with diabetes should have a yearly urine test called a microalbumin ratio to check for small amounts of protein in the urine. Protein in the urine is often the first sign of damage to the kidneys from diabetes.
Recent recommendations from the American Heart Association and the American Diabetes Association stress the need for use of cholesterol-lowering medications called statins in almost all patients with diabetes. Depending on one’s age and risk factors for heart disease, your doctor may recommend either moderate or high intensity statin treatment.
Individuals with diabetes should have their cholesterol levels checked on a regular basis. In addition, most, but not all, individuals with diabetes may benefit from treatment with a daily aspirin. Aspirin has been shown to reduce the risk of heart disease in many individuals with diabetes. Patients should discuss with their primary care provider whether or not an aspirin would be beneficial.
Adults with diabetes should perform at least 150 minutes per week of moderate intensity physical activity. Moderate intensity activities are typically activities that will cause your heart rate to increase and break a sweat, but you should be able to carry on a conversation with someone who is exercising with you. Examples of moderate intensity exercise include walking, raking leaves or a bike ride. Resistance training should also be part of your regular exercise routine.
All patients with diabetes should stop smoking and should receive counseling from their health care providers regarding the various options to help him quit smoking.
Emotional wellbeing is an important part of diabetes care and depression is common in patients with diabetes. Psychological and social problems can get in the way of an individual’s ability to take good care of their diabetes. All patients with diabetes should be screened for depression by their primary care provider.
Immunizations & Vaccines
It is recommended that all patients with diabetes obtain the flu shot every year. In addition, individuals should make sure they up-to-date with their pneumonia vaccine. It is also recommended that patients with diabetes be vaccinated against hepatitis B.
It is important that each patient work with her primary care provider to develop an individualized diabetes treatment plan.
Matthew Gilbert, DO, is an endocrinologist at the University of Vermont Medical Center and associate professor at the Larner College of Medicine at UVM.