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How Important is Glycemic Control?
How Important is Glycemic Control? -- Posted by Gumbo on 11-02-04 18:35
How Important is Glycemic Control?
Originally Published:20040801.
Mr. J is a 50-year-old type 2 diabetic suffering from depression, a diabetic
foot ulcer, and chronic urinary tract infections. he takes Humalog insulin
in the morning and Lantus in the evening, plus sliding scale coverage if his
blood glucose level rises.
Blood is drawn for glycosylated hemoglobin (hemoglobin AIC) and blood
glucose tests, and the results confirm Mr. J's dietary non adherence and the
effect on his overall health status.
A patient like Mr. J who has a poorly controlled blood glucose level and
poor eating habits is at risk for numerous physiologic problems.1 An
elevated blood glucose level creates a negative effect on the wound healing
process, causing wounds to heal slowly or not at all.2'8 This is especially
a problem for patients with diabetes. Combined with medication, dietary
intake plays a significant role in the repair of wounds because the diet
also provides protein, calories, fluids, and other nutrients.
When the blood glucose level is elevated, glucose does not diffuse easily
through the pores of the cell membrane. This creates a dehydrating effect;
the increased osmotic pressure in the extracellular fluids causes water to
transfer out of the cells. Loss of glucose in the urine causes osmotic
diuresis, increasing urinary losses of electrolytes and water. Both
extracellular and intra cellular dehydration can occur, which affects the
healing time of the skin.9
An elevated blood glucose level also damages both the blood vessels and the
nerves. In addition, it places the patient at risk for developing peripheral
vascular disease. Several studies show the importance of optimal insulin
control in diabetes to lower the incidence of neuropathy.10
Free radicals generated by the autoxidation reactions of sugar and sugar
adducts to protein are possible sources of oxidation stress and damage to
protein in patients with diabetes. Glycoxidation products accumulate in
tissue collagen at an accelerated rate in patients with diabetes.4 This
oxidative stress leads to complications in diabetes, such as tissue damage
and cell death, which are reversed by antioxidants.
Controlling the blood glucose level has also been related to the rate of
infection. Poor glycemic control-which impairs the body's ability to
eliminate bacteria-leads to an increase in infections.5,11"14 Urinary
tract,15 respiratory,16 and soft tissue infections are particularly common
in people with diabetes.17'18 Soft tissue infections of the lower
extremities and gangrene are serious complications.19
In addition, hyperglycemia decreases oxygen to the tissues. Delivery of
leukocytes and antibiotic agents to the wound is impaired due to lack of
blood flow. Oxygen is necessary for macrophage mobility and growth of
granulation tissue during wound healing.
Hyperglycemia can cause neuropathy or damage to the intestinal nerves,
causing diarrhea, vomiting, or bloating, which affect the nutritional status
of the diabetic.20
* Management Strategies
Based on the latest guidelines from the American Diabetes Association, goals
of medical nutritional therapy for all diabetics are below.21
Attain and maintain optimal metabolic outcomes including: blood glucose
levels in the normal range or as close to normal as possible to prevent or
reduce the risk for complications of diabetes; a lipid and lipoprotein
profile that reduces the risk for macrovascular disease; blood pressure
levels that reduce the risk for vascular disease. Prevent and treat the
chronic complications of diabetes. Modify nutrient intake and lifestyle as
appropriate for the prevention and treatment of obesity, dyslipidemia,
cardiovascular disease, hypertension, and nephropathy. Improve health
through healthy food choices and physical activity. Address individual
nutritional needs taking into consideration personal and cultural
preferences and lifestyle while respecting the individual's wishes and
willingness to change.
Mr. J consults a dietitian and a certified diabetes educator (CDE). Mr. J
admits that he often skips meals and does not monitor his blood glucose
level on a daily basis. He usually consumes sodas, milkshakes, cookies, and
chips, along with fast food items.
The dietitian completes a nutritional assessment, including a history of the
patient's food preferences and meal times (see Table: "Mr. J's Nutritional
Assessment"). The dietitian and the CDE establish treatment goals that
include diet, medication management, blood glucose monitoring, and
appropriate skin care.
Mr. J's new diet plan encourages a selection of: vegetables, starches and
legumes high in fiber, which are beneficial for glucose control. They also
help to maintain normal bowel function;22 whole fruits instead of juice for
fiber and their positive effect on blood glucose levels; an oral supplement
to be taken during the day, formulated for diabetics containing fructose,
which promotes glucose removal from the blood.23,24 Supplements with a high
rate of monosaturated fatty acids are also beneficial for blood glucose and
serum lipid control; energy bars designed for diabetics, alternated with
liquid products for variety; MUFAs, including olive, canola, or peanut oil,
peanut butter, and nuts.26
Protein comprises 20% of Mr. J's daily caloric intake, with an emphasis on
lean meats, poultry, and fish. Additionally, he and his family are taught to
read food labels so they select products with the appropriate
carbohydrate/protein balance. Portion control is emphasized, as well as
spacing meals evenly throughout the day. Over the next 3 months, Mr. J
consistent amounts of carbohydrates and keeps detailed records of his
glucose level and insulin coverage required. At the end of 3 months, his
glycosylated hemoglobin and blood glucose levels improved and his wound is
showed positive signs of healing after off-loading treatment.
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