February 9, 2003
Complications
Question from Houston, Texas, USA:
For background, I have had type 1 diabetes for over 16 years now and have been on the insulin pump for more than four years. I have been working very hard at trying to keep myself in good control and trying not to give in to burnout. In doing so, I test my blood sugars routinely 7 to 10 times a day (several times, just for the peace of mind to know where I stood at the time), and I feel results have been pretty positive since my A1c for the past several years has been within 5.4-6%, and the doctors have not found any prominent evidence of complications, except for a pinpoint size spot in my eye. My eye specialist did not seem concerned with it and said it would not need surgery, but this finding still concerns me very much because I worry if it is a sign of things to come.
Even though I have not in the past had evidence of complications, I am becoming very concerned about developing them, especially because I started a new, and increasingly stressful, job which causes me to be sitting and working for very long hours out of fear of losing my job (not good with today’s economy). So, my routine daily walking and exercising I did the years before in college has dropped almost to null for this year. I am beginning to get back to exercising in the gym, but I am very concerned if I have put myself at much greater risk for complications due to this long period of inactivity, particularly with the spot in my eye. To add to my concerns, my blood sugars have not, in my view, seemed as stable as before. My A1c is still below 6%, and my average sugars are within the 120s mg/dl [6.7 mmol/L], but almost daily I will swing from high sugars being in the low-to-mid 200s mg/dl [11.1 mmol/L] to low in the 40s mg/dl [2.2 mmol/L] (mainly caused by my anxiety to the highs so that I over-compensate with insulin).
How much have I increased my risk for complications this year? Can I still recover from it, even if I have to work harder at it? If so, what must I do differently? I’m pretty scared of the future at this point particularly since I am just getting married, and I am concerned about the burden I may be in the future to my wife (although, she is an occupational therapist, and has been so supportive of me thus far).
Answer:
Have you increased your risk for complications? It is not hard to extrapolate that the increased stress of your job may make your sugars harder to control. On the other hand, hemoglobin A1c is still the best predictor of microvascular complications. Remember that the DCCT demonstrated significant benefit when the hemoglobin A1c was kept at an average of 7.2%, and it sounds like you are doing better than this. I would say you might be a beneficiary of that protection with your good control.
There is some concern that frequent and large swings in sugars are not good. This puts a premium on smoothing out the blood sugar curve during the day. You would be better off if you could prevent the rapid swings. This can be done by using restraint when administering insulin for high blood sugars. If the swings are predictable, you may be able to change the pump’s basal rate to help prevent this. You might consider some stress management counseling and factor in your blood sugar management.
JTL
