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Managing Types 1 and 2 with Tight Control

separator There’s a good chance you’ve heard about tight control, either from your doctor or other member of your diabetes care team, or from things that you’ve read. In 1993, results of the Diabetes Control and Complications Trial (DCCT) showed that when people with type 1 diabetes practiced what’s called “tight control,” aggressively keeping their blood sugars as close to normal as possible, they lowered their risk of eye, kidney and nerve diseases.

At the time, researchers believed that tight control would be beneficial for people with type 2 as well, even though the DCCT study looked only at people with type 1. Then, in 1998, researchers in the United Kingdom produced a study that showed that people with type 2 who aggressively keep their blood sugar under control reduce their risk of blindness and kidney failure by 25 percent. Additionally, those with type 2 who took aggressive steps to control high blood pressure decreased their risk of stroke and heart failure, as well as their risk of blindness and kidney disease.

And yet another study, published recently in the New England Journal of Medicine, has shown that people with type 1 who practice tight control reduce the buildup of plaque in their arteries, which lowers their risk of heart disease. See the news article in this month’s issue for more information about this.

What’s the difference between tight control and standard control?
For people with Type 1 diabetes, standard control usually involves one or two insulin shots a day (usually the same amount of insulin every day) and fewer than 2 daily tests of blood sugar levels. When you practice tight control, you test your blood sugar more frequently each day and usually inject insulin more frequently as well. The test readings help you figure out what your dose of insulin should be.
With tight control, you’re keeping a small amount of insulin in your body at all times and adding extra insulin when you eat. This type of diabetes management comes close to imitating the way your pancreas would produce insulin if it were able to.
For people with type 2 who don’t take insulin, practicing tight control is a little bit different. It could include being aggressive about managing your weight, because getting rid of extra pounds helps to keep your blood sugar levels in the normal range. To lose the weight, your best bet is to talk with a dietitian or diabetes educator to find a food plan that works for you. You’d also need to exercise, even if you don’t need to lose weight, because getting regular exercise is another way to help control your blood sugar levels.

Tight control can be challenging
“Test my blood sugar even more than I already do? No way. I spend enough time dealing with it already.” That’s what a lot of people say when they think about changing from standard control to tight control.

There’s no doubt about it, practicing tight control is challenging. It can also be easy to tell yourself that eye, kidney, heart and nerve disease won’t happen to you. Or that even if the complications do affect you, it’s a long time away from now and you’re too busy to think about it.

Thinking positively is helpful, but you have to be realistic too. And the truth is that the more successful you are at keeping your blood sugar within the normal range, the better your chances are of avoiding complications, including the loss of legs or arms.

Who should not practice tight control?
According to the DCCT study, there are some people who should not practice tight control. These include:
Children. Some researchers say children should wait until age 13 to practice tight control, others say it’s okay after age 7. Talk with your doctor if you’re interested in tight control for your child.
Most elderly people. One of the effects of tight control is that it brings a higher risk of low blood sugar. This can be dangerous for seniors, because low blood sugar can cause strokes and heart attacks.
People who don’t experience warning signs of low blood sugar. Most people do experience symptoms indicating their blood sugar is low, such as shakiness, dizziness, sweating, hunger, confusion, etc. If you don’t get these warning signs during a low blood sugar episode, tight control is probably not for you.
Your healthcare team is there to guide you

Talk with your doctor to find out whether you are a good candidate for tight control. If you are, and you decide that you would like to try tight control, you’ll have plenty of help. Your diabetes care team will help you learn exactly what you need to do. They’ll help you to figure out
  • Exactly what your blood glucose level should be before and after meals
  • How to adjust your insulin to your particular lifestyle—the type of work you do, your level of activity, the kind of food you eat and when you eat it.
  • How often you should meet with a dietitian to review what you eat
  • How you should take care of your diabetes if you become pregnant
  • What your family and friends should do if your blood sugar becomes so low that you need their help

Remember: tight doesn’t mean perfect
If you do become committed to practicing tight control, congratulations. You’ve taken a big step to avoid serious complications in the future. But don’t be too hard on yourself if you make a mistake now and then. Keep in mind that any improvement at all will lower your chances of developing complications.

American Diabetes Association; Diabetes Care, 1998, 21:2180-2184; The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine 1993 Sep 30;329(14):977-986; National Institute of Diabetes and Digestive and Kidney Disorders
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