Physician writes 'Insider's Guide' for managing Type-I diabetes

November 14, 1999

Drawing on his professional, as well as his personal experience, a University of Maryland School of Medicine physician has written the first set of comprehensive, concise and practical guidelines for primary care doctors to help their patients with Type I diabetes to prevent complications.

The guide's author is Stephen Havas, M.D., M.P.H., professor of Preventive Medicine, Epidemiology and Medicine at the University of Maryland School of Medicine. Dr. Havas also has Type I diabetes, which is sometimes called juvenile diabetes, or insulin-dependent diabetes. Unlike most people with the condition, he has tightly controlled his diabetes and avoided complications for more than forty years.

Dr. Havas' 20 guidelines are published in the November issue of American Family Physician, a journal of the American Academy of Family Physicians. They describe how to closely control blood sugar levels and take other steps to prevent serious complications of diabetes, such as blindness, kidney failure, heart disease, stroke, nerve damage and amputations.

"About one million Americans have Type I diabetes, and the vast majority do not have it under good control. Most develop the disease as children who will live with it the rest of their lives. The problem is that unless they follow the kinds of guidelines in this article, they are likely to become disabled by serious complications and to die prematurely," says Dr. Havas.

Major clinical studies have shown that the severe complications of diabetes often can be prevented. The most important factor in preventing complications is tight control of blood sugar, which means keeping those levels in the normal range as often as possible. It is achieved by balancing caloric intake, physical activity and insulin dosage throughout each day.

According to Dr. Havas, "Most patients with Type I diabetes would benefit from tight control, but many physicians are not teaching their patients how to achieve this because they haven't been trained in how to do it."

In his article, Dr. Havas has put forth clear and simple guidelines to help family physicians work with their patients to communicate why tight blood sugar control is so important, how it can be implemented, and how it can help them take control of their long-term health. He says doctors should encourage their patients to monitor themselves by regularly testing these blood sugar levels throughout the day, and at bedtime. He recommends the use of certain kinds of insulin during the day and at night, and suggests that doctors teach their patients about the onset, peak, and duration of different kinds of insulin.

He also encourages physicians to help patients develop healthy eating and exercise habits. Regular exercise is even more important for people with diabetes than it is for those without the disease, yet only about one-third of diabetic patients exercise regularly. Exercise improves blood sugar, cholesterol, and blood pressure levels, reduces the risk of heart disease, decreases stress, and makes people feel better.

Dr. Havas also says patients must learn the signs, symptoms, and management of hypoglycemia (low blood sugar). Friends and family members also should be able to recognize the symptoms, which can include fatigue, lower speech or movement, confusion, irritability, unexplained sweating, pale skin, and even yawning. If left untreated, hypoglycemia can result in serious complications, including coma and death.

Stress is an important factor in diabetes management, adding to why the management of Type I diabetes is so complicated. Some forms of stress, such as an infection, can cause blood sugar to rise. Other forms, like emotional stress, can result in dangerously low blood sugar levels. Dr. Havas adds that when people with diabetes are under stress, they are not as alert to clues their body may be sending them about the need for food or more insulin.

There are well-respected programs around the nation, such as the Joslin Center for Diabetes at the University of Maryland Medical Center, which can help patients in a comprehensive and multi-disciplinary fashion to learn about diabetes and how to manage medication, diet, and exercise. But most diabetes patients receive their diabetes care from their primary care physicians. It is those patients whom Dr. Havas hopes to help with his guide.

Implementing tight control is not easy. It involves day-to-day regulation of food intake, exercise, insulin, and coping with occasional hypoglycemia. According to Dr. Havas, "Physician support is critical, particularly in the early stages." He hopes his guidelines will help doctors teach their patients all the steps of tight blood sugar control so they can live long and healthy lives.

University of Maryland Medical Center

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