BLOOD GLUCOSE CONTROL AND RISK FOR COMPLICATIONS
Can Maintaining Tight Blood Glucose Control in Diabetics Minimize the Risk for
Long Term Complications?
Lindsey Indovina
The Pennsylvania State University
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BLOOD GLUCOSE CONTROL AND RISK FOR COMPLICATIONS
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Can Maintaining Tight Blood Glucose Control in Diabetics Minimize the Risk
for Microvascular and Macrovascular Complications?
With the uprising in the implementation of self-monitoring of blood glucose
(SMBG), a correlation between blood glucose control and prevention of
microvascular and macrovascular complications has been noted. Numerous studies
have revealed that the more a person can keep their blood glucose levels near the
normal range, the less likely they are to develop secondary diseases related to
hyperglycemia or hypoglycemia. The previous standard of only measuring
glycosylated hemoglobin (HbA1c), which reveals blood glucose control over a two to
three month period, does not give an indicator of the rise and fall of glucose
throughout the day. These hourly rises and falls of blood glucose levels could be the
key to the prevention of complications. If diabetics are able to keep their blood
sugars steady and close to the normal range throughout the day, the likelihood of
future health problems and development of secondary diseases decreases
significantly.
Complications in diabetes are categorized by whether they are
macrovascular or microvascular. Microvascular are disorders of smaller vessels and
they include diabetic nephropathy, neuropathy and retinopathy. Macrovascular
complications include atherosclerosis, coronary artery disease and cerebrovascular
disease, with cardiovascular disease accounting for nearly 70% of mortality.
Cerebrovascular accidents and myocardial infarctions are very common
macrovascular complications (Mattila and de Boer, 2010, p. 2230). According to
Despande et. al (2008), “People with diabetes are 2 to 4 times more likely to develop
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stroke than people without diabetes. More than 70% of people with diabetes have
high blood pressure” (p. 1258). Polypharmacy has become a problem in diabetes
management as well since providers often prescribe numerous medications to treat
the secondary conditions in addition to the diabetes. Unfortunately, a common side
effect of some medications is an increase in blood glucose levels, which creates a
vicious cycle and wreaks havoc on the patient’s body. In addition to these issues,
research is now showing a link between type 2 diabetes and brain shrinkage. This
study found that those with fasting blood sugars above the normal range (70-100
mg/dL) are more likely to have shrinkage in the brain (“High Blood Sugar,” 2012, p.
3). This can create neurological disturbances and may be a factor inducing dementia
in the older adult with diabetes. Diabetes is one of the top causes of death in the
United States, though some believe it may be closer to the number one cause of
death than was originally thought. Deshpande et. al (2008) believes that “diabetes is
likely to be underreported as a cause of death due to the many complications
associated with diabetes that ultimately cause death” (1257). The accompanying
illnesses of diabetes are a scary reality and any research on prevention should be
analyzed and considered carefully in diabetes management.
Much of the research assessing the prevention of complications related to
blood glucose control focuses on the difference between conventional and
contemporary (intensive) diabetes therapy. In general, conventional therapy
consists of one to two insulin shots per day for type 1 diabetics and management
through diet and exercise for type 2 diabetics. Intensive therapy include insulin
pump therapy or greater than three insulin shots per day for type 1 diabetics and
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oral or insulin agent therapy for type 2 diabetics. In the article by Meetoo et al.
(2011), “Contemporary diabetes management places heavy emphasis on individual
responsibility to adequately control blood glucose to minimize the development of
microvascular complications and to control blood pressure and cholesterol levels to
reduce risks of macrovascular complications from occurring.” (p. 920). The
individual responsibility given by SMBG allows diabetic patients to control blood
glucose levels throughout the day in order to lower HbA1c levels and track their
blood sugar peaks. The HbA1c is not useful in tracking blood sugar trends
throughout the day and is better for indicating whether a change in diabetes
treatment is warranted. This article also discussed how researchers in the UK
Prospective Diabetes Study (UKPDS) (1998) found that “intensive blood glucose
control yielded a 25% reduction in the risk of microvascular complications and a
16% risk reduction for myocardial infarction (MI) compared with conventional
therapy” (p. 920). A meta-analysis conducted to determine the relationship between
HbA1c levels and cardiovascular disease found that for every 1% increase in HbA1c
concentration, the risk for cardiovascular disease increased 15% in patients with
type 1 diabetes, and by 18% in those with type 2 diabetes (Shogbob and Levy,
2010). This research supports the idea that tighter glucose control yields a clinically
significant reduction in risk for complications. The hope that these complications
may be prevented with control may inspire patients with diabetes to gain stricter
control over their diabetes. Diabetes is not an easy disease to manage, so offering
these statistics to patients may trigger more frequent blood sugar checks. A patient
who checks their blood sugar often can detect hyperglycemia trends throughout the
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day and can then administer insulin more frequently. Mattila and de Boer (2010)
note that, “due to the numerous complications, the overall risk of dying among
people with diabetes is at least double that of their peers without diabetes.” (p.
2230). Though this fact may leave some patients feeling defeated, it could help
patients to know that keeping blood glucose levels close to normal may minimize
their chance of dying prematurely. It is comforting to know that research has been
proving that stricter diabetes management has positive indicators of a patient’s
future.
Patient education is crucial in helping patients gain control of their diabetes
and their health. It is important for the patient to learn the normal blood sugar
range, the effects of not maintaining that blood sugar range on their body, and
different steps they can take to keep their diabetes in check. It is important for
nurses to stay up to date on their diabetes information so that they can most
accurately and effectively deliver the information to their patient. Meetoo et. al
(2011) argues that, “Nurses have a key role in educating people with diabetes about
the purpose of blood glucose testing and about the technique involved in the
effective use of a glucometer” (p. 924). At the time of diagnosis, many patients learn
the how to manage their diabetes in the hospital, and then go home only to realize
they never fully understood the process of blood sugar testing and medication
administration. It is important for the nurse to do follow up care and have the
patient demonstrate how to care for their diabetes so that they are confident in the
process. It is also important for the patient to understand the results of the HbA1c
test. Patients should understand that if their HbA1c levels are not within the normal
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range, their medication regimen and therapy should be re-evaluated with their
medical provider and changes should be made. Meetoo et. al (2011) suggests that,
“…people with diabetes should be empowered by learning how to interpret the
results and make appropriate changes to improve them” (924). The nurse can
facilitate this by not making the patient feel ashamed for poor test results, but
instead use it to inspire them and work with the care team to alter the care regimen
to bring the levels lower at the next drawing. Nurses should be certain that their
patient has a complete understanding of diabetes and how to manage it effectively
in order to help them feel in control of their disease and help them to prevent the
complications that may accompany uncontrolled diabetes.
While preventing complications is not a perfect science, it is important that
diabetics learn how to control their diabetes so that the risks are minimized.
Understanding the complications, keeping up to date with research, and being
educated on diabetes management can all be useful in preventing microvascular and
macrovascular complications. Maintaining intensive therapy by measuring blood
glucose several times throughout the day with SMBG and having the HbA1c test
drawn can show level of blood glucose control and can help a patient and care team
predict the likelihood of future health problems. With correct information and
thorough patient teaching, long-term complications may be delayed or prevented.
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References
Deshpande, A. D., Harris-Hayes, M., & Schootman, M. (2008, November).
Epidemiology of diabetes and diabetes-related complications. Physical Therapy,
88(11), 1254-1264. Retrieved from Nursing Reference Center.
High blood sugar linked to brain shrinkage. (2012, December). Harvard Health Letter,
38(2). Retrieved December 2, 2013, from Nursing Resource Center.
Mattila, T. K., & de Boer, A. (2010). Influence of intensive versus conventional glucose
control on microvascular and macrovascular complications in type 1 and 2
diabetes mellitus. Drugs, 70(17), 2229-2245. Retrieved from Nursing Reference
Center.
Meetoo, D. D., McAllister, G., & West, A. (2011). Assessing glycaemic control: Selfmonitoring of blood glucose. British Journal of Nursing, 20(15), 919-925.
Retrieved from Nursing Reference Center.
Shogbon, A. O., & Levy, S. B. (2010, May 15). Intensive glucose control in the
management of diabetes mellitus and inpatient hyperglycemia. American Journal
of Health-System Pharmacy, 67, 798-805. Retrieved December 2, 2013, from
Nursing Reference Center.