Establishing a Treatment Plan THE BASIC TREATMENT PLANS AND HOW WE STRUCTURE THE

Establishing a Treatment Plan
THE BASIC TREATMENT PLANS AND
HOW WE STRUCTURE THEM

Part 1 of 4
Although there are only two major types of diabetes— type 1 and type 2—there are so many variations, particularly in type 2, that a treatment plan that works for one diabetic won’t necessarily work for another. Each plan has to be tailored to the individual.

The basic treatment plans increase in complexity with the severity of the disease.

For type 2 diabetes
Level 1: Diet (and appropriate weight loss)*
Level 2: Diet (and appropriate weight loss) plus exercise
Level 3: Diet (and appropriate weight loss) plus exercise plus an oral insulin-sensitizing or insulin-mimetic agent
Level 4: Diet (and appropriate weight loss) plus exercise plus insulin injections, with or without an oral agent

For type 1 diabetes
Same as level 4 above, with the addition of multiple daily insulin injections, with questionable benefit from exercise in controlling blood sugars, and with benefit from oral insulin-sensitizing agents only when insulin requirements are excessive, as with those who are obese or who have polycystic ovarian syndrome (PCOS; see Appendix E).
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STRUCTURING A TREATMENT PLAN

What are normal blood sugar levels? What range do we find in nondiabetics? The answers depend upon whom you ask. I’ve seen figures in the scientific literature over the years ranging anywhere from 60 to 140 mg/dl. My experience checking random blood sugar readings on nonobese nondiabetics, as well as figures from large population studies,
tells me that for most nondiabetics, blood sugar levels cover a pretty narrow range of about 80–95 mg/dl (by finger stick), except after meals containing large amounts of fast-acting carbohydrates.

I usually select a target of 90 mg/dl for most of my patients who take insulin. This target is not an average, but one we try to maintain 24 hours a day. Even if you average 90 mg/dl but your blood sugars are bouncing back and forth between 60 and 140 mg/dl, you’re still on the roller coaster. Our object is to find a treatment plan that will get you off the roller coaster and keep you off.

For those who do not need insulin injections to maintain blood sugars, I set a target of 80–85 mg/dl. This assumes that you’re comfortable at such levels, that is, not experiencing symptoms of hypoglycemia (low blood sugars).

One of the most important considerations in setting up an initial target is that people who have had high blood sugar levels for many months or years usually experience unpleasant symptoms of hypoglycemia as blood sugars approach normal. Someone who has grown accustomed to blood sugars consistently over 300 mg/dl may feel “shaky” at 100 mg/dl. In such a case, we might start with 160 mg/dl as the initial target. We’d then lower the target to its ultimate value over a period of weeks or months as treatment proceeds.

It’s unusual when an initial meal plan and dosage of medication instantly results in the desired blood sugar profiles. Some people, a few days into their regimen, may find something objectionable, such as not enough to eat for a certain meal. Because of this, it’s often necessary to experiment with a plan, making small changes based upon personal preferences and blood sugar profiles.
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People tend to become discouraged if they cannot see rapid improvement, and so, where warranted, I try to make adjustments to the regimen every few days in order to demonstrate that our efforts are accomplishing positive results. To this end, I ask patients to bring or to fax to my office their blood sugar profiles about one week after their final training visit, if initial treatment is by diet alone. If I’ve prescribed insulin, I like to see profiles within a few days. I certainly try to make sure that no blood sugars are below 70 mg/dl during this trial period. I ask all new patients to phone me at any time of the day or night if they experience a blood sugar under 70 or become confused about their instructions. Additional repeat visits or phone calls may be necessary every few days or weeks, depending upon how rapidly blood sugar profiles reach our ultimate target.

Many new patients come to my office from out of town, some traveling distances of thousands of miles. Clearly, frequent office visits would be impractical in such cases. For these patients, I often schedule follow-up “telephone visits” instead of office visits. Patients will fax their blood sugars on Glucograf II data sheets to me.

These subsequent office or telephone interactions enable me to fine-tune the original plan, and also to reinforce the training program by catching any mistakes that a patient may inadvertently make. This interactive training is much more effective for patients than just reading a book or hearing a few lectures. Continued……..

Part 2 next: Beginning Treatment with your Doctor or Diabetes Educator

We would like to thank the publisher Little Brown and Company and Dr. Richard K. Bernstein, for allowing us to provide excerpts from Diabetes Solution.

Copyright © 2003 by Richard K. Bernstein, M.D.
All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

Author’s Note
This book is not intended as a substitute for professional medical care. The reader should regularly consult a physician for all health-related problems and routine care.

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