There are few bigger challenges for medical practitioners than taking care of patients with type 1 diabetes mellitus. The difficulties are numerous. Glucose homeostasis is normally controlled by a complex physiology of precise variations in insulin secretion that exactly counter the wide swings in nutrient intake, physical activity, and stress of modern society. Attempts over the years to approximate this system using subcutaneous insulin have suffered from insulin preparations that lack the pharmacokinetics of the normal system. In addition, the average physician received little training in insulin usage during his or her internship and residency, and there have been few CME programs in this area. Also, there is a clear understanding by most physicians that if they aggressively push insulin doses to tolerance, the result too often is hypoglycemia that can vary anywhere from annoying to life-threatening. Finally, patients are not always advocates for their care; sometimes the attitude is "The fewer shots, the better" or "I feel great, so why must I do so many finger sticks?" The net consequence is that premixed insulins are the most prescribed insulin preparations in the United States, and national surveys continue to show distressingly high HbA]c values.
To paraphrase Bob Dylan, "The times, they are changing." A number of events occurred in the 1990s that provided us the tools, know-how, and incentive to do better. Best known is the demonstration in both type 1 and type 2 diabetes of the benefits of intensive glycemic control for the prevention of microvascular complications (1-3), a fact that is understood and expected by many patients. Parenthetically, the long-term risk of suboptimal glycemic control, which was also made obvious by these studies, underlies the diabetes treatment guidelines and performance measures that have become widespread. New insulin preparations are now available that better approximate normal insulin secretion (4-7; reviewed in Chapter 6)—intensive treatment programs (often termed "basal-bolus") that combine these insulins into physiologically correct 24-hour insulin exposure are increasingly being used. Also, insulin-delivery systems (pens, syringes with "skinny" and short needles, pumps) and blood glucose monitoring equipment have become easier to use, more reliable, and less painful.
This chapter is intended to demystify insulin therapy in type 1 diabetes (and diabetes in general) by providing a conceptual framework for what to do and how to do it. This is not to say it is easy. Obtaining the target HbA ]c (generally less than 7%) without significant hypoglycemia in a patient with type 1 diabetes often requires a team of experts—physician, registered dietician (RD), and certified diabetes educator (CDE)—to analyze diet and lifestyle practices and look for clues to day-to-day variations in glycemia. Whether the primary physicianl or a diabetes specialist is the main caregiver will depend on many factors. This chapter does not dictate who it should be. What it does espouse is that insulin programs be used that are based on the unique diet, exercise, and work habits of each patient, i.e., that we get away from the one-size-fits-all approach to insulin treatment. Patients may go through a difficult time for a while trying to cope with all the things asked of them with an intensive treatment program. However, over the long term, they will have a better understanding of their diabetes and how to manage it, and a greater chance for a life unencumbered by hypoglycemia and end-organ complications.
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All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.