Intensified Diabetes Management

Intensified diabetes management is a proactive approach. Most people with type 1 diabetes should use this approach. It requires careful attention to meals and exercise planning, but allows a more flexible schedule. It’s like flying a jumbo jet compared to a one-engine plane. It may be more complex but there is also more potential. The benefits are that people can change their activities more, and don’t have to eat meals at the same time every day because they are taking insulin before every meal. Intensified therapy aims to provide a steady stream of insulin throughout the day, similar to the way the pancreas does. This is done with 4 or 5 daily injections, or an insulin infusion pump and extra insulin at mealtime.

How does intensified diabetes management work?

Fast-acting or short-acting insulin is usually taken with all meals (breakfast, lunch, and dinner) and sometimes with an afternoon or evening snack. Intermediate-acting insulin is taken at bedtime. The dose of the fast-acting insulin is based on 3 things:

• the current blood sugar level
• the amount of carbohydrate about to be eaten
• the activity planned over the next 2 to 3 hours

When the blood sugar goes higher than 7 mmol/L (125 mg/dL) before a given meal, there is a chance to give some extra short-acting or fast-acting insulin right then, to bring the blood sugar back into the target range. Likewise, if the blood sugar level is under 4 mmol/L (70 mg/dL) just before a meal, or if a lot of exercise is planned in the next few hours, the insulin dose can be reduced immediately.

What are the health benefits of intensified diabetes management?

Intensified diabetes management was central to the ground-breaking Diabetes Control and Complications Trial (DCCT). This was a U.S. government-funded study that looked at the effects of tight blood sugar control on the risk of diabetes complications. In this study, more than 1,400 volunteers from many sites across the U.S. and Canada were divided into 2 groups. One group managed their diabetes with intensified therapy. The other group continued with traditional therapy. At the end of the 9-year period, the 2 groups were compared. The intensified therapy group showed an average HbA_1c reading of 7.2%. This was significantly lower than the traditional treatment group’s average of 8.9%. The intensified therapy group also had fewer signs of complications from diabetes:

• diabetic eye disease (retinopathy) had started in only one-quarter as many people as in the traditional treatment group
• kidney disease (nephropathy) occurred in only half as many
• nerve disease (neuropathy) in only one-third as many

Some people under intensified management showed early signs of these 3 complications before the study began. Among this group, far fewer had their complications develop further.

Are there any risks with intensified diabetes management?

When a person tries to keep blood sugar levels closer to normal, this may increase the risk of low blood sugar or insulin reactions (hypoglycemia). The volunteers in the DCCT who used intensified management reported hypoglycemic reactions 3 times as often as those using traditional therapy. For those who are not able to recognize and treat their own hypoglycemia, such as very young children, intensified treatment could be dangerous.

What factors should be considered when deciding to use intensified diabetes management?

Families who choose this approach must prepare for the extra work and make sure they have the support of their diabetes team. Young people who are already achieving fairly tight control with standard therapy may find little benefit in switching. This would include people with A_1c of less than about 7.5%. The main benefit would be to have more flexibility in their lifestyle. Those with high hemoglobin A_1c results of 10% or more may want to bone up on standard therapy before making the leap to intensified therapy. All the same, there is no doubt that intensified therapy is the standard of care for teens and adults with Type 1 diabetes.