Long-Term Maintenance for People With Diabetes

As a diabetic or prediabetic trying to get and stay healthy, you need at least two other players on your healthcare team: a physician and a registered dietitian. Additionally, diabetes nurse educators can be quite helpful in teaching you to manage your condition. Other care team members may include physician assistants, nurse practitioners, pharmacists, and nutritionists.

Dietitians are particularly helpful consultants when diabetes is first diagnosed and periodically thereafter to answer food questions, check on compliance with diet recommendations, and to review new dietary guidelines. Unfortunately, a majority of dietitians still believe the out-dated idea that high-carbohydate eating is healthy for diabetics and others who have demonstrable difficulty processing carbs. Be sure the dietitian you choose supports a carbohydrate-restricted and paleo-friendly way of eating.

Many primary care physicians such as family physicians and internists are well-trained to co-manage diabetes with you. I chose the word “co-manage” carefully. It’s not like you have appendicitis and can turn over all management to a surgeon. With diabetes, you have to do more work than your physician. Your doctor will review your home glucose records, adjust medications, periodically examine you, and check blood work. You need a doctor who will support, or at least tolerate, your low-carb paleo way of eating.

An endocrinologist can be an invaluable team member, either as your main treating physician or as a consultant to your primary care physician. You should definitely see one if you are not close to the standard treatment goals after working with your primary care physician.

PERIODIC TESTS, TREATMENTS, AND GOALS

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with type 2 diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) ADA guidelines with supporting documentation are available free on the Internet (search for “Standards of Medical Care in Diabetes—2013”):

• Lipid profile (every two years if results are fine and stable)
• Comprehensive foot exam
• Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
• Serum creatinine and estimate of glomerular filtration rate
• Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
• Comprehensive eye exam by an ophthalmologist (if exam is normal, every two or three years is acceptable)
• Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
• Flu shots

Additionally, the ADA guidelines recommend:

• Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
• Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. “The optimal macronutrient composition of weight loss diets has not been established.” (Macronutrients are carbohydrates, proteins, and fats.)
• Limit alcohol to one (women) or two (men) drinks a day.
• Limit saturated fat to less than seven percent of calories.
• During initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
• In the early stages of diabetic chronic kidney disease, reduce protein intake to 0.8-1.0 grams per kilogram of body weight. In later stages, reduce to 0.8 grams per kilogram of body weight.
• Those at risk for diabetes, including prediabetics, should aim for a) moderate weight loss (about seven percent of body weight) if overweight, through low-fat/reduced-calorie eating, b) exercise: 150 minutes per week of moderate-intensity aerobic activity.

Some of my dietary recommendations you’ve read on my blogs conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by over 350 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

GENERAL TREATMENT GOALS

The ADA suggests general therapeutic goals for adult non-pregnant type 2 diabetics:

• Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
• Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
• Hemoglobin A1C: under 7%
• Blood pressure: under 130/80 mmHg
• LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l.)
• HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
• Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2007 proposed somewhat “tighter” goals:

• Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
• Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
• Hemoglobin A1C: under 6.5%

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely. For instance, there’s not much reason to aim for blood sugars of 100 mg/dl (5.56 mmol/l) in a 79-year-old expected to die of lung cancer in four months. The goal is comfort and symptom relief, even if sugars are 220 mg/dl (12.2 mmol/l).

Admittedly, the aforementioned goals are difficult for many diabetics to achieve, but they are worth your effort in terms of avoiding long-term complications of diabetes. You will need to see your doctor every three to six months, and more often if your glucoses are not well-controlled or you have other medical issues.

Steve Parker, M.D.