Simple but very encouraging words and all the best in your endeavour. But please, do it fast, and safe!

The standard rule presented to patients used to be, ‘Achieve excellent blood sugar control while avoiding hypoglycemic episodes,’ but recently it has been demonstrated that occurrences of the most severe form of hypoglycemia, requiring the intervention of others to bring the patient out of it, are tripled by strict control, so there is in principle no way to approach normalization of blood sugar while avoiding hypoglycemia. (L. Perlmutter, et al, “Glycemic Control and Hypoglycemia,” Diabetes Care, vol. 31, p. 2072 (2008)) What makes matters worse is that the majority of diabetics cannot accurately estimate their blood glucose levels, and the better the blood sugar control, the greater the risk of hypoglycemia unawareness. (S. Frankum and J. Ogden, “Estimation of Blood Glucose Levels by People with Diabetes,” British Medical Journal of General Practice, vol. 55, no. 521, p. 944 (2005))

With respect to hypoglycemia, diabetics suffer from two diseases: not just a metabolic abnormality requiring a highly approximate control of blood sugar by insulin injections, but also a delayed mobilization of glycogen to release hepatic stores of glucose in response to hypoglycemic crises. Instead of the body providing glucose as quickly as it is required by hypoglycemia, the diabetic body is maddenly slow in responding, and typically releases massive amounts to correct hypoglycemia six or seven hours late. This creates an interesting paradox that the effort to achieve improved glucose control increases the number and severity of hypoglycemic episodes, which then in turn elevate blood sugar later at an unpredictable time and in an unpredictable amount, thus worsening blood sugar control.

Clinicians who are not themselves diabetics often blame their patients for overtreating hypoglycemic episodes, but since I have never found myself facing a team of worried paramedics at home or waking up in the hospital emergency ward without grasping some half-eaten candy in my hand, my motivation to restrict my treatment of hypoglycemia is limited. Since the patient cannot know exactly how low the blood sugar level is trending during a hypoglycemic attack, it is impossible in such an emergency to judge what constitutes overtreating the problem. Ironically, anyone who has ever suffered severe hypoglycemia in a hospital setting will know that the response of hospital staff to such an emergency is a massive overtreatment of the problem with enough glucose to raise the blood sugar above 400 for the rest of the day.

Although patients are taught the comforting oversimplification that their blood sugar levels are a function of external, easily measured and controlled factors, such as the food consumed, its glycemic index, the insulin injected, and the exercise performed, in fact there are numerous internal processes within the body which the patient can neither know nor measure which exert a profound influence on blood sugar variation. High activity of the renin-angiotensin system has been linked to severe hypoglycemia in type 1 diabetics. (P. Kristensen, et al, “Vascular Endothilial Growth Factor During Hypoglycemia,” Metabolism, vol. 58, no. 10, p. 1430 (2009)) The metabolism of subcutaneously injected insulin is so slow and unpredictable that there can be a daily variation in the quantity absorbed and processed amounting to 50%. (D. Warrell, et al, ‘Oxford Textbook of Medicine’ (Oxford: Oxford University Press, 2005), vol. 2, p. 332) Changing levels of thyroid hormone, adrenal output, growth hormone, and pituitary function all have a profound action on blood sugar levels and insulin requirements. (A. Dutour, et al, “Hormonal Response to Stress in Brittle Diabetes,” Psychoneurology, vol. 21, no. 6, p. 525 (1996); J. Unger, “A 62 Year Old Man with Brittle Type 1 Diabetes,” Clinical Diabetes, vol. 20, no. 1, p. 37 (2002); K. Naing, et al, “Recurrent Hypoglycemia in a Patient with Brittle Diabetes,” Practical Diabetes International, vol. 18, no. 1, p. 13 (2001)) I find in my own case that lecturing can increase my blood sugar by an amount varying from 10 to 180 points, depending on how stressful it turns out to be, but there can be nothing like ‘carb counting’ in anticipation of the highly variable effect of stressful situations. Taking insulin after the fact is useless for controlling the hyperglycemic effect of stress, given the extremely slow response of injected insulin to blood sugar.

In all of this, it is important not to lose sight of the ultimate goal of all medical treatment, which is to provide patients with a better net quality of life by any interventions undertaken. While many clinicians today focus exclusively on strict blood sugar control as identical to improved quality of life for the patient, in fact the very high cost of this regimen in relation to patient lifestyle has to be taken into account. If perfect glucose normalization is in principle impossible with presently available treatments, then the effort to achieve normalization can consume the patient’s entire life, thus utterly negating the quality of life which is what medicine exists to improve. Significantly, one study has determined that diabetics rate their loss of quality of life from intensive glucose management to be equivalent to their loss of quality of life from an intermediate level of diabetic complications. (E. Huang, et al, “Patient Perception of Quality of Life with Diabetes Related Complications and Treatments,” Diabetes Care, vol. 30, no. 10, p. 2478 (2007))