The main goal of diabetes treatment is to normalize insulin activ-ity and blood glucose levels to reduce the development of vascular and neuropathic complications. The importance of tight blood glucose control was demonstrated by the Diabetes Control and Complications Trial (DCCT), a 10-year prospective clinical trial conducted from 1983 to 1993. The trial investigated the impact of intensive glucose control on the development and progression of complications such as retinopathy, nephropathy, and neurop-athy. A cohort of 1,441 people with type 1 diabetes were ran-domly assigned to conventional treatment (one or two insulin injections per day) or intensive treatment (three or four insulin injections per day or insulin pump therapy plus frequent blood glucose monitoring and weekly contacts with diabetes educators). Results demonstrated that the risk for developing retinopathy, neuropathy, and early signs of nephropathy (microalbuminuria and albuminuria) was dramatically reduced. The reduction was attributed to control of blood glucose levels to normal or near-normal levels. The ADA now recommends that all patients with diabetes strive for glucose control to reduce their risks for complications (ADA, Implications of the Diabetes Control and Complications Trial, 2003).
The major adverse effect of intensive therapy was a threefold in-crease in the incidence of severe hypoglycemia (severe enough to require assistance from another person), coma, or seizure. Because of these adverse effects, intensive therapy must be initiated with caution and must be accompanied by thorough education of the patient and family and by responsible behavior of the patient. Care-ful screening of patients is a key step in initiating intensive therapy.
A study conducted in the United Kingdom and reported in 1998 supported the results of the DCCT in type 2 diabetes and demonstrated a decrease in complications in patients with type 2 diabetes receiving intensive therapy compared to those receiving conventional therapy (United Kingdom Prospective Diabetes Study Group [UKPDS], 1998; ADA, Implications of the United Kingdom Prospective Diabetes Study, 2003).
Therefore, the therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypo-glycemia and without seriously disrupting the patient’s usual lifestyle and activity. There are five components of diabetes man-agement (Fig. 41-2):
• Nutritional management
• Pharmacologic therapy
Treatment varies because of changes in lifestyle and physical and emotional status as well as advances in treatment methods. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy by the patient. Although the health care team directs the treatment, it is the patient who must manage the complex therapeutic regimen. For this reason, patient and family education is an essential component of diabetes treat-ment and is as important as all other components of the regimen.
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