diabetes management diabetes management the term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentration of a sugar called glucose in the blood. diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. the pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. other forms of diabetes mellitus, such as the various forms of maturity onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. some degree of insulin resistance may also be present in a person with type 1 diabetes. the main goal of diabetes management and control is, as far as possible, to restore carbohydrate metabolism to a normal state. to achieve this goal, individuals with an absolute deficiency of insulin require insulin replacement therapy, which is given through injections or an insulin pump. insulin resistance, in contrast, can be corrected by dietary modifications and exercise. other goals of diabetes management are to prevent or treat the many complications that can result from the disease itself and from its treatment. overview goals the treatment goals are related to effective control of blood glucose, blood pressure and lipids, to minimize the risk of long-term consequences associated with diabetes. they are suggested in clinical practice guidelines released by various national and international diabetes agencies. the targets are: hba1c of less than 6% or 7.0% if they are achievable without significant hypoglycemia preprandial blood glucose: 3.9 to 7.2 mmol/l (70 to 130 mg/dl) 2-hour postprandial blood glucose: <10 mmol/l (<180 mg/dl) goals should be individualized based on: duration of diabetes age/life expectancy comorbidity known cardiovascular disease or advanced microvascular disease hypoglycemia awareness in older patients, clinical practice guidelines by the american geriatrics society state "for frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as hba1c of 8% is appropriate". issues the primary issue requiring management is that of the glucose cycle. in this, glucose in the bloodstream is made available to cells in the body; a process dependent upon the twin cycles of glucose entering the bloodstream, and insulin allowing appropriate uptake into the body cells. both aspects can require management. another issue that ties along with the glucose cycle is getting a balanced amount of the glucose to the major organs so they are not affected negatively. complexities daily glucose and insulin cycle the main complexities stem from the nature of the feedback loop of the glucose cycle, which is sought to be regulated: the glucose cycle is a system which is affected by two factors: entry of glucose into the bloodstream and also blood levels of insulin to control its transport out of the bloodstream as a system, it is sensitive to diet and exercise it is affected by the need for user anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose system management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of blood glucose levels, multiple times a day in many cases it changes as people grow and develop it is highly individual as diabetes is a prime risk factor for cardiovascular disease, controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management. checking cholesterol, ldl, hdl and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. checking the blood pressure and keeping it within strict limits (using diet and antihypertensive treatment) protects against the retinal, renal and cardiovascular complications of diabetes. regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot. annual eye exams are suggested to monitor for progression of diabetic retinopathy. early advancements late in the 19th century, sugar in the urine (glycosuria) was associated with diabetes. various doctors studied the connection. frederick madison allen studied diabetes in 1909–12, then published a large volume, studies concerning glycosuria and diabetes, (boston, 1913). he invented a fasting treatment for diabetes called the allen treatment for diabetes. his diet was an early attempt at managing diabetes. blood sugar level blood sugar level is measured by means of a glucose meter, with the result either in mg/dl (milligrams per deciliter in the us) or mmol/l (millimoles per litre in canada and eastern europe) of blood. the average normal person has an average fasting glucose level of 4.5 mmol/l (81 mg/dl), with a lows of down to 2.5 and up to 5.4 mmol/l (65 to 98 mg/dl). optimal management of diabetes involves patients measuring and recording their own blood glucose levels. by keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. for patients on insulin, patient involvement is important in achieving effective dosing and timing. hypo and hyperglycemia levels which are significantly above or below this range are problematic and can in some cases be dangerous. a level of <3.8 mmol/l (<70 mg/dl) is usually described as a hypoglycemic attack (low blood sugar). most diabetics know when they are going to "go hypo" and usually are able to eat some food or drink something sweet to raise levels. a patient who is hyperglycemic (high glucose) can also become temporarily hypoglycemic, under certain conditions (e.g. not eating regularly, or after strenuous exercise, followed by fatigue). intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the patient requires assistance from by-standers in order to treat the episode. in the united states, there were annually 48,500 hospitalizations for diabetic hypoglycemia and 13,100 for diabetic hypoglycemia resulting in coma in the period 1989 to 1991, before intensive blood sugar control was as widely recommended as today. one study found that hospital admissions for diabetic hypoglycemia increased by 50% from 1990–1993 to 1997–2000, as strict blood sugar control efforts became more common. among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from nocturnal hypoglycemia in the so-called 'dead-in-bed syndrome,' while national institute of health statistics show that 2% to 4% of all deaths in diabetics are from hypoglycemia. in children and adolescents following intensive blood sugar control, 21% of hypoglycemic episodes occurred without explanation. in addition to the deaths caused by diabetic hypoglycemia, periods of severe low blood sugar can also cause permanent brain damage. although diabetic nerve disease is usually associated with hyperglycemia, hypoglycemia as well can initiate or worsen neuropathy in diabetics intensively struggling to reduce their hyperglycemia. levels greater than 13–15 mmol/l (230–270 mg/dl) are considered high, and should be monitored closely to ensure that they reduce rather than continue to remain high. the patient is advised to seek urgent medical attention as soon as possible if blood sugar levels continue to rise after 2–3 tests. high blood sugar levels are known as hyperglycemia, which is not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. if left untreated, this can result in diabetic coma and death. a blood glucose test strip for an older style (i.e., optical color sensing) monitoring system prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death. there is currently no way of testing for susceptibility to complications. diabetics are therefore recommended to check their blood sugar levels either daily or every few days. there is also diabetes management software available from blood testing manufacturers which can display results and trends over time. type 1 diabetics normally check more often, due to insulin therapy. a history of blood sugar level results is especially useful for the diabetic to present to their doctor or physician in the monitoring and control of the disease. failure to maintain a strict regimen of testing can accelerate symptoms of the condition, and it is therefore imperative that any diabetic patient strictly monitor their glucose levels regularly. glycemic control glycemic control is a medical term referring to the typical levels of blood sugar (glucose) in a person with diabetes mellitus. much evidence suggests that many of the long-term complications of diabetes, especially the microvascular complications, result from many years of hyperglycemia (elevated levels of glucose in the blood). good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care, although recent research suggests that the complications of diabetes may be caused by genetic factors or, in type 1 diabetics, by the continuing effects of the autoimmune disease which first caused the pancreas to lose its insulin-producing ability. because blood sugar levels fluctuate throughout the day and glucose records are imperfect indicators of these changes, the percentage of hemoglobin which is glycated is used as a proxy measure of long-term glycemic control in research trials and clinical care of people with diabetes. this test, the hemoglobin a1c or glycated hemoglobin reflects average glucose levels over the preceding 2–3 months. in nondiabetic persons with normal glucose metabolism the glycated hemoglobin is usually 4–6% by the most common methods (normal ranges may vary by method). "perfect glycemic control" would mean that glucose levels were always normal (70–130 mg/dl, or 3.9–7.2 mmol/l) and indistinguishable from a person without diabetes. in reality, because of the imperfections of treatment measures, even "good glycemic control" describes blood glucose levels that average somewhat higher than normal much of the time. in addition, one survey of type 2 diabetics found that they rated the harm to their quality of life from intensive interventions to control their blood sugar to be just as severe as the harm resulting from intermediate levels of diabetic complications. in the 1990s the american diabetes association conducted a publicity campaign to persuade patients and physicians to strive for average glucose and hemoglobin a1c values below 200 mg/dl (11 mmol/l) and 8%. currently, many patients and physicians attempt to do better than that. as of 2015 the guidelines called for an hba1c of around 7% or a fasting glucose of less than 7.2 mmol/l (130 mg/dl); however these goals may be changed after professional clinical consultation, taking into account particular risks of hypoglycemia and life expectancy. despite guidelines recommending that intensive blood sugar control be based on balancing immediate harms and long-term benefits, many people – for example people with a life expectancy of less than nine years – who will not benefit are over-treated and do not experience clinically meaningful benefits. poor glycemic control refers to persistently elevated blood glucose and glycated hemoglobin levels, which may range from 200 to 500 mg/dl (11–28 mmol/l) and 9–15% or higher over months and years before severe complications occur. meta-analysis of large studies done on the effects of tight vs. conventional, or more relaxed, glycemic control in type 2 diabetics have failed to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal heart attack by 15%. additionally, tight glucose control decreased the risk of progression of retinopathy and nephropathy, and decreased the incidence peripheral neuropathy, but increased the risk of hypoglycemia 2.4 times. monitoring a modern portable blood glucose meter (onetouch ultra), displaying a reading of 5.4 mmol/l (98 mg/dl). relying on their own perceptions of symptoms of hyperglycemia or hypoglycemia is usually unsatisfactory as mild to moderate hyperglycemia causes no obvious symptoms in nearly all patients. other considerations include the fact that, while food takes several hours to be digested and absorbed, insulin administration can have glucose lowering effects for as little as 2 hours or 24 hours