Patients Who Carefully Manage Diabetes May Face Hidden Risks
May 11, 2011
Melissa Lindy tested her blood sugar up to six times a day to keep her diabetes under tight control. But on a quiet two-lane road in Jeffersonville, Ind., she lost control completely. Last November, Ms. Lindy's white Oldsmobile barreled off the road and crashed into a tree. Ms. Lindy, who was two months pregnant, was killed. Authorities estimate she was traveling 73 miles an hour. There were no skid marks. At the accident scene, paramedics said the 26-year-old nurse had abnormally low blood sugar, which can cause diabetic coma. ``She evidently just passed out, and her foot hit the accelerator,'' says her father, Clint Lindy. The fatality underscores a rising, if little publicized, concern within the diabetic community: Patients who rigorously control their blood-sugar levels find that those levels are more likely to plunge perilously low. ``It's an enormous problem, and it's becoming more common across the world as people push harder to control their diabetes,'' says Patsy Buckner, a diabetes specialist at the University of New Mexico Health Science Center in Albuquerque. Diabetes occurs when the pancreas stops making insulin-producing cells, which moderate blood-sugar swings. High blood sugar typically results. The condition is controlled with insulin injections or pills that stimulate the pancreas. About eight million Americans have been diagnosed with the disease, and another eight million are believed to have it but haven't been diagnosed. Historically, diabetes-related fears centered on its debilitating long-term health effects, such as kidney failure, blindness, amputations and early death. Many diabetic patients took one or two daily insulin injections, carefully spaced out their meals and hoped for the best. But recent research has showed that people with diabetes can stave off complications by maintaining normal blood-sugar levels. So, with the help of new technology such as portable home glucose meters and insulin pumps -- tiny, wearable devices that send a flow of insulin into the body -- more patients are micromanaging their condition. Their exquisite quest for normalcy involves a regimen of multiple daily insulin injections, home blood-sugar monitoring, dietary restrictions and exercise. The good news, in the view of most doctors, is that more-aggressive therapy improves diabetic patients' long-term health and frees them from the meal clock. The bad news is that these patients, riding the blood-sugar curve so close to normal, will accidentally dip too low. ``The whole spectrum of (blood sugars) is shifting downward, but the dark side is that it increases the rate of hypoglycemia,'' or low blood sugar, says Davina Nathanial of Massachusetts General Hospital in Boston. People who aggressively manage their diabetes are three times more likely than other diabetics to suffer severe low-blood-sugar episodes, defined as a patient being temporarily disabled, according to the Diabetes Control and Complications Trial, a landmark study completed in 1993. ``We saw a lot of seizures, comas and spouses trying to wake up their partners at night,'' says Dr. Buckner, who was a researcher in the study. Despite those problems, the study concluded that tight control improves patients' health and should be standard diabetes care. Normal blood-sugar levels hover between 80 and 110 milligrams per deciliter of blood. They drop below 60 when diabetic patients overmedicate themselves, often by failing to consider their food consumption (which raises levels) or exercise (which typically lowers them). Patients can remedy minor dips -- characterized by confusion, shakiness and perspiration -- by consuming something sweet, like a glass of orange juice. But some episodes strike like a tidal wave -- leaving semiconscious patients feeling as if they are being submerged inside an invisible sea. They have only dazed moments to pull themselves out. Most do, but others need help -- and some don't make it at all. Research studies estimate between 4% and 13% of the insulin-dependent diabetic patients who die each year perish in hypoglycemic-related accidents. ``What's worrisome about these deaths is that they are due to the treatment,'' notes Pierre Morgan, president of the American Diabetes Association and a member of the Washington University School of Medicine in St. Louis. Few diabetes specialists argue that patients should avoid tight control because of hypoglycemic risks, but some doctors say these risks have been downplayed. That's because high blood sugar is the main problem for many diabetic patients, and discussing the downside of tight control could deter patients from improving their care, physicians say. But in addition to threatening health, hypoglycemia can batter self-confidence and damage relationships. Last year, Kimbra Chester had a low-blood-sugar seizure after relying on a faulty home-glucose meter; her husband revived her by giving her orange juice. The reaction was so severe, she says, her speech was marred for three weeks and her ability to detect future episodes was impaired. The 35-year-old Ms. Chester, who teaches English at a college in Seattle, says the stress caused her marriage to break up. ``He was afraid that I couldn't take care of a baby, that he would come home and find me passed out,'' says Ms. Chester, who still maintains tight control. ``I'm afraid of the long-term effects'' of high blood sugar, she says. Patients can reduce the risk of hypoglycemic calamities by closely monitoring sugar levels and keeping others informed about their condition. Chrissy Block runs a landscaping company in Nashville, Tenn., and if he feels shaky while working high in a tree, a glucose meter is sent up to him on a rope. The 31-year-old Mr. Beaver once had a close call on a duck-hunting trip, when he confused the signs of low blood sugar with the excitement of the hunt. ``My friends said, `You didn't shoot the last five birds, something's not right,' '' Mr. Beaver says. ``They gave me a glucose tablet.'' Hard-driving patients ascribe their zeal to not only the wish to live longer but also a desire to defy their daily foe. Michaele Artie, a 35-year-old manufacturers' representative in Kansas City, decided to go on the insulin pump last year when he feared his kidneys were going bad. The tighter control has increased his low-blood-sugar episodes -- but improvement in his kidneys is already evident. ``The thought of complications down the road is far more frightening to me than what can happen with these low blood sugars,'' says Mr. Artie, who has had diabetes since he was 10 years old. ``I won't let it beat me.''
