The Good News About Preventing Diabetes Complications

By Faramarz Ismail-Beigi, MD, PhD

Every now and then, patients with diabetes ask me: “Doctor, even though most of my blood sugar numbers are high, I feel good. I don’t understand why I should take all these pills and insulin injections.” This is a great question. The main reason to have control of your blood sugar (glucose) is to prevent complications of diabetes. Diabetes, during its early years, produces no major symptoms unless the blood sugar gets very high. Then, the person will make a lot of urine, become thirsty, and not feel well. This is true in all types of diabetes.

So, you may ask,

“What are the complications we should prevent?”

We classify diabetes complications into two categories:

1) Complications that damage small blood vessels in your body

Diabetes can damage small vessels in the eyes, nerves, and kidneys. These can lead to blindness, loss of sensation in hands and feet, and kidney failure. These complications are serious, and can have a very negative effect on a person’s well-being.

2) Complications that damage the large blood vessels

Complications that damage large blood vessels cause “hardening of the arteries” that feed your heart, brain, and body. These complications are also very serious and can lead to heart attack, stroke, loss of arms or legs, and even early death. It is important to know that all these complications can happen, even if you feel healthy.

“How can I prevent these complications?”

The answer to this question can vary depending on whether you have type 1 or type 2 diabetes. However, no matter which type of diabetes you have, good blood sugar control is the most important way to prevent damage to small blood vessels. Also, as described further below, you can do many things to prevent the complications related to the large blood vessels.

“What is type 1 diabetes and who gets it?”

This type of diabetes (previously called juvenile diabetes) often starts in children and young adults, but it can start at any age. It begins after damage and loss of cells that produce insulin. For this reason, people with this form of diabetes do not produce insulin, and their health and wellness depends on taking insulin on a regular basis.

Two important studies (called DCCT and EDIC), which involved more than 1,400 volunteers with type 1 diabetes, have shown that good blood sugar control plays a very important role in preventing small vessel complications in the eyes, nerves and the kidneys. The results were so dramatic that doctors and patients all over the world started to aim for better blood sugar control. The studies have also shown that good blood sugar control can help prevent large vessel disease that can lead to heart attacks and strokes in people with type 1 diabetes.

“What is the best way to get good blood sugar control? Which insulin regimen is best?”

These are questions that each person should discuss with their health-care team. Today we have better insulins and better tools and technologies to help people get their blood sugars under control.

Like everyone else, people with type 1 diabetes can develop a rise in blood cholesterol and fats (lipids), high blood pressure, and “hardening of the arteries” with increasing age. Attention should be given to controlling the harmful effects of these changes, as well as stopping smoking.

“What is type 2 diabetes and who gets it?”

This form of diabetes (previously called “adult-onset diabetes”) is the most common form of the disease. Currently, more than 20 million people in the United States have it. Type 2 diabetes is on the rise, and it is estimated that millions more people in the USA and across the world will be affected in the next 20 to 30 years. Type 2 diabetes can run in families and is increasing in children and young adults. We often see this disease in people who are overweight. Type 2 diabetes is not just a problem of blood sugars. It also affects blood pressure, cholesterol, and fats, inflammation in the body, and blood clotting.

Normally, cells in the pancreas release proper amounts of insulin. This helps sugar enter into cells throughout the body for energy. One main problem of type 2 diabetes is the “resistance” of cells to insulin. This means that it takes more insulin to produce the same effect. On top of that, people with type 2 diabetes do not make enough insulin for what their body needs. In other words, there is also a problem with the cells that produce insulin. The tie-in with obesity comes from the fact that there is higher “resistance” to insulin with higher body weight.

This brings us to the important role of nutrition and physical activity, and their critical effect on the prevention of type 2 diabetes. We all agree that the best way to prevent complications of diabetes is to prevent the disease in the first place. The Diabetes Prevention Program (DPP) and other studies done in Europe and China have shown that type 2 diabetes can be prevented in about 50% of people that are highly likely to get type 2 diabetes. These people prevented type 2 diabetes through a healthy meal plan and moderate physical activity that resulted in moderate weight loss. I suggest to my patients that they should include physical activity as a part of their daily life, and not just as an add-on. There should be a time of the day that is devoted solely to your personal health and well-being. The positive effects of a healthy diet, weight loss, and exercise can add to each other.

You can lose weight by working with your health-care team and having a meal plan that contains adequate amounts of fiber, fruits, and vegetables, and has the appropriate amount of calories. Losing weight and keeping it off it is not easy and requires a lifestyle change in both attitude and behavior. As the author Thomas Paine once said, “The harder the conflict, the more glorious the triumph.”

“What about medications, and how can I prevent the complications of type 2 diabetes?”

Again, you need to talk to your health-care provider about this. Here our goals and targets for sugar control are more complex, because type 2 diabetes is different in different people. Your goals may depend on many factors, such as your age, how long you have had diabetes, and your overall health. It is important to know that managing diabetes is more than just controlling blood sugar. Controlling blood pressure and cholesterol levels are also very important. You may have to take a daily aspirin, and stopping smoking is a must. An important study named Steno-2 showed that doing all of the above at the same time can reduce heart attacks and death by close to 50%. So, each one of these factors plays an important role in the development of large vessel disease.

Aim to get your blood sugar values close to normal especially if you are young or middle-aged and your diabetes is new. This recommendation is based on results of a large study conducted in England (the UKPDS trial) in patients who were recently discovered to have type 2 diabetes. The study showed that good control of blood sugar and blood pressure reduces the risk of damage to both small and large blood vessels and their complications. We try to reach this goal while avoiding frequent episodes of low blood sugar.

Three very large studies related to this topic have been carried out with the help of more than 22,500 participants with type 2 diabetes (the ACCORD, ADVANCE, and the VA Diabetes Trial). The results suggest that in people who have had type 2 diabetes for many years, trying to get their sugar levels very close to normal (or normal) does not always reduce the risk of complications associated with large vessel disease. However, they did show benefits in preventing small blood vessel complications. This is why the goal for blood sugar control is not the same for every person and must be tailored to each patient.

To reduce the risk of large vessel disease in type 2 diabetes, we should always pay attention to blood pressure, blood cholesterol, and fat control. I have listed the targets recommended for most patients with type 2 diabetes in the box. Remember that getting to these goals at the same time makes a very large difference in preventing complications.

The great news is that diabetes complications can be prevented. Today we have many new therapies, tools, and technologies to treat diabetes to prevent complications. The first step is to know your goals. Staying informed and engaged in your own care, and working closely with your health-care team will ensure that you will remain healthy!

Dr. Faramarz Ismail-Beigi is a professor of Medicine, Endocrinology, and Physiology and Biophysics at Case Western Reserve University, University Hospitals of Cleveland, and the Cleveland VA hospital. He received his doctoral degree and post-graduate training at Johns Hopkins School of Medicine in Baltimore. He also serves as the Medical Director of Joslin Diabetes Clinic at St. Vincent Charity Hospital in Cleveland. He conducts basic and clinical research in diabetes.