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Prevention of Complications of Diabetes: an emphasis on hypoglycaemia

“The patient with diabetes who knows more lives longer” Elliott P. Joslin

Diabetes refers to a group of metabolic disorders characterised by hyperglycaemia. One (1) in every four (4) adults in CARICOM countries has diabetes; type 2 diabetes is more prevalent than type 1 diabetes in St Lucia. Diabetes (type 2) can be considered a lifestyle and inherited disease, complications of which can affect every major organ system of the body. The disease increases mortality at least two fold.

In general, we all should eat healthy meals, and remain physically active. We aim for good health, rather than a particular body mass index, but weight loss is key to reducing insulin resistance. Here are a few things you may not know about insulin and hypoglycaemia as you aim for increased self-education and empowerment in the management of diabetes.

Insulin, introduced in 1922, saved the life of fourteen year old Leonard Thompson in Toronto, eleven year old Elisabeth Hughes Gossett in Washington and then men and women throughout the world with type 1 diabetes. The transformative change in life expectancy and quality of life among this population, which was at the time admittedly smaller, resulted in all four scientists involved eventually sharing credit in the historically renowned Nobel Prize in Physiology or Medicine in 1923. These scientists: Banting, Best, Macleod and Collip, sold their patents to the University of Toronto for $1, allowing lifesaving insulin to be available worldwide.

Insulin should be administered carefully because an excessive dose can result in hypoglycaemia. Precipitous adjustments in insulin doses should be avoided. In most cases, basal and rapid-acting insulin can be increased by two to four units at a time. Physicians who follow this protocol rely on clients to admit to any non-adherence or poor health literacy or numeracy. Hypoglycaemia may cause:
Changes in cognition
Ischaemic cerebral damage
Increased cardiovascular risk
Oxidative stress (linked to cancer, atherosclerosis, myocardial infarction)
Cardiac arrhythmia
A decrease in confidence in and adherence to, insulin.

In addition, mixing of hypoglycaemics is not recommended, such as a combination of insulin and a sulphonylurea such as Daonil or Diamicron. Studies indicate an increase in mortality with this combination.

The benefits of intensive blood glucose control early after diagnosis are greater than intensive control after years of elevated blood glucose. This is not counter-intuitive; still here are some reasons why:
Early control of blood glucose allows for better control in the years that follow, as well as fewer complications referred to as “metabolic memory”.
Hyperglycaemia may be fatal for persons who have mostly Type 1 diabetes due to ketoacidosis.
Chronic hyperglycaemia may be fatal to persons with Type 2 diabetes if a hyperosmolar state develops.
Weight loss, extreme fatigue, blurred vision, (skin) infections and other symptoms such as polyuria reduce quality of life.
Complications are more likely to occur: peripheral neuropathy, autonomic neuropathy including gastroparesis, peripheral arterial disease and amputations, kidney disease, retinopathy and blindness, erectile dysfunction, depression, dementia and stroke. This list is not exhaustive.
Acute neuropathy and other adverse outcomes as mentioned below

Blood glucose levels should be lowered gradually to avoid hypoglycaemia but also iatrogenic conditions. In rare cases, rapid correction of blood glucose can result in treatment-induced neuropathy “insulin neuritis”. This is an acute neuropathy associated with severe neuropathic pain and or symptoms of autonomic neuropathy. The condition is treated symptomatically and usually alleviates with time. The same cannot be said of cardiovascular events, diabetes-related retinopathy and mortality rates which are higher after intensive correction of long-standing untreated diabetes. Thus, rapid reductions in glycaemia after long-standing hyperglycaemia may be associated with poor outcomes; early diagnosis and management is preferable.

Variability in blood glucose levels throughout the day (glycaemic variability) may also be associated with poor outcomes. A certain amount of variability is expected but this is increased in persons with diabetes and becomes defined as pathological when cardiovascular risk increases. Cellular oxidative stress promotes numerous medical conditions; hypoglycaemia may occur at an increased frequency with glycaemic variability.

Blood glucose fluctuations can be detected by blood glucose testing at seven useful points in the day – paired readings with meals and at night (or using a continuous glucose monitor). Average blood glucose targets are individualised but the A1C is less helpful when blood glucose fluctuates too widely and may even appear normal. If you take medications for diabetes, please take your medications as prescribed and communicate your concerns with your diabetes physician.

Later control of blood glucose is not as beneficial as early control, but the second best time to make healthful changes is now.