Managing diabetes, risk


Q: My diabetes was discovered 15 years ago, and my blood sugars have been well-controlled on two doses of insulin a day. Are there any other steps I can take to avoid the complications of diabetes?

A: Diabetes can cause excessive urination, increased thirst and weight loss as the result of high blood sugar (glucose) levels. These symptoms are usually easy to eliminate with a reduction in blood glucose with diet, pills or insulin.

The greater concern for people with diabetes are the late complications of the disorder. Some of these result from diabetes-specific damage to nerves and small blood vessels (microvascular disease) which can lead to kidney failure and vision loss. Other complications arise from narrowing of large blood vessels (microvascular disease) due to the more rapid development of the atherosclerotic changes that can occur in all of us as we grow older. As a result, individuals with diabetes have a greater risk of heart attacks, strokes and leg pain when walking.

About two years ago, a report from the Diabetes Control and Complications Trial provided strong evidence that strict control of blood glucose levels slowed the development of nerve, kidney and eye damage.

These results make it clear that efforts to maintain good blood glucose levels are well worthwhile. Other studies have shown that kidney damage can also be slowed or prevented by controlling blood pressure, administering an ACE inhibitor drug at the earliest evidence of kidney disease (usually based on the detection of small amounts of protein in a 24-hour urine collection), and possibly a low protein diet. Frequent careful eye examinations are essential because laser treatment can be "sight-saving" if started at the first signs of damage to the retina.

Excellent control of blood sugar, however, does not seem to prevent the serious problems resulting from the accelerated macrovascular disease in diabetes. Studies have shown that the danger from the major risk factors for coronary artery disease (high cholesterol, high blood pressure and cigarette smoking) is magnified in patients with diabetes. And for this reason you should devote as much attention to controlling these risk factors as you do to maintaining good blood glucose levels. Support for the benefits of aggressive reduction of cholesterol has recently come from a Scandinavian study which showed that lowering cholesterol levels in diabetic individuals, using an HMG CoA reductase inhibitor drug, resulted in a significant decrease in heart attacks, deaths from coronary artery disease and even deaths from all causes over a period of 5 1/2 years.

Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine.

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