As physicians, what we see and learn in practice helps to inform the recommendations and advice that we share with our patients. Our observations require us to be agile; we must change our perceptions not only based on clinical guidelines and evidence, but also on what we see on a day-to-day basis. As an endocrinologist, I must be mindful of the fact that every case of diabetes has its unique characteristics of what works and what does not work for each individual patient.
Much has changed about diabetes in the 35 years that I have been a practicing endocrinologist. Major advances have been made in the way that we approach blood glucose management. Where blood glucose testing was previously restricted to hospital environments and labs, today we see much more affordable home testing options and even continuous glucose monitoring technology that can calculate and deliver blood glucose levels around the clock in near real-time. New research, technologies, and medications in prevention of heart attack and stroke have improved both longevity and quality of life for people with diabetes.
All of these advancements in diabetes care have allowed me the privilege to witness the well-being and success of many of my patients and their loved ones over multiple generations. It warms my heart to see patients in our clinic who are now in their 90’s after living successfully for many decades with diabetes. Some have been patients with me since the beginning of my practice, and continue to lead healthy, productive lives after more than 50 years with type 1 diabetes. To put that into perspective, at diagnosis, a lot of these patients were told not to expect to live beyond their teen years.
A few weeks ago, I stood at the bedside of a longtime patient as she cuddled her healthy newborn. At age 11, when she was first diagnosed with type 1 diabetes, her parents had taken much of the responsibility for diabetes care. Her metabolic control during those early teenage years was quite good, with her HbA1C values hovering near 7%, and no evidence of diabetes complications. Although I was not her physician at the time, this type of tight control is precisely what we like to see in our diabetes patients during adolescence. By the time I met her during her freshman year of college, however, her control of her diabetes had deteriorated precipitously. As is common among young adults with diabetes, she had trouble integrating diabetes self-care into the demands of a rigorous academic schedule and her many extracurricular activities.
The transition from living at home to living independently is often a complicated one for young people with diabetes. As they leave home to further their education or begin work, the responsibility for caring for their diabetes falls more heavily on them with little to no guidance or supervision. Work or class schedules may vary day to day, along with meal times and composition that can be unpredictable from one meal to the next. Instead of meals prepared at home with consideration given to quantity and quality as related to unique dietary needs, institutionally prepared meals are the rule, resulting in choices limited to items of high caloric density, saturated fat, and salt. Carbohydrate content is misleading and extremely challenging to estimate, even after years of experience, making it hard to guess meal time rapid acting insulin doses.
There are challenges to try new things with this newfound freedom as well. New activities, such as sports and other campus events, present challenges and opportunities that may not have been a factor in diabetes management before. There may also be pressure to try alcohol or other mood-altering or judgement-impairing substances in social settings, which can have a profound and unexpected impact on blood glucose control.
These are the challenges I see often, and this young woman found it difficult to integrate diabetes management into the varying class schedules, erratic meal times, and late night study routines of college life. In addition, initiation of oral contraceptive therapy at about that time further impacted her blood glucose control. Her A1C rose to 10% briefly, but by the end of her sophomore year she had worked hard to coordinate the requirements needed to control diabetes with her other activities and responsibilities.
Achieving successful longevity while living with diabetes requires a plan and dedication, especially when success is defined by significant life events such as starting a family. As part of our plan for her diabetes care, this young woman and I talked about her plans for the future, and if a family was something she was intending to pursue at any point. We both knew that any plans for having a baby were well in the future, but I’ve always felt that it is important for patients to realize that while diabetes does not pose insurmountable odds to having a healthy baby, it is important to plan carefully and early to achieve the best results possible.
Good diabetes control in young adulthood may have a carry over effect on future risk of complications. Moreover, patients who are poorly controlled as young adults appear to be at risk for continued poor glycemic control, and hence are at higher risk of complications. Thus, good control during the period of emerging adulthood has important implications for the health of future children. As patients begin to consider starting a family, there are certain aspects of diabetes management that will take on a new significance.
The evidence base for managing diabetes in pregnancy shows that inadequately controlled hyperglycemia (high blood sugars) appears to be the predominant cause of increased risk of fetal malformations and perinatal complications in infants of mothers with diabetes. Normal blood sugar control is crucial to the development of the growing fetus. Pregnancy may not be confirmed until about six weeks gestation, and by this time organ development is well underway. Achieving control after conception is confirmed can possibly be too late to prevent fetal malformations, such as abnormalities in the development of the heart and vascular system, the nervous system, and even skeletal structure.
Better control makes a mother-to-be a better hostess for her growing baby in the womb. If she has advanced nerve damage, she may suffer slowed stomach emptying. This can not only aggravate pregnancy-related morning sickness and result in protracted nausea, vomiting, and dehydration, but it can frustrate attaining glycemic goals due to deranged nutrient absorption and may retard fetal growth.
Pre-emptive eye care is imperative with pregnancy and diabetes as well. A pre-conception eye examination may serve as re-assurance of the absence of any damage, or direct intervention with laser surgery if needed. An ophthalmologist is a specialist in this area, and can provide anyone with diabetes, pregnant or otherwise, with guidance for how to maintain eye health and limit ocular complications over a lifetime with diabetes.
Type 1 diabetes is an autoimmune disease where the body attacks insulin producing cells in the pancreas as if they were foreign, rendering these islet cells insufficient for producing insulin. Patients with diabetes are at increased risk of other autoimmune disorders as well. Autoimmune thyroid disease is the most common of these. Tests of thyroid function are important before conception. For patients taking thyroid replacement, it is important to recognize that the dose requirement for thyroid hormone is increased during pregnancy. This augmented dose requirement begins early after conception, and continues throughout the pregnancy. Many authorities recommend an empiric increase in thyroxine dose once pregnancy is confirmed with further adjustments guided by blood tests of thyroid function.
It is standard practice to recommend lower blood sugar targets for pregnant women with diabetes, and even tighter acceptable ranges of control, as maintaining blood glucose targets lowers the risk of adverse outcomes for both mother and baby. Every person with diabetes is different, so targets must be individualized, and each patient should work closely with her diabetes caregiver to establish blood glucose targets that are appropriate. Patients planning to transition to pump therapy from subcutaneous injections should do so well in advance of the planned time of conception, giving ample time to adjust to the changed diabetes management style. It is suggested that somewhere between 3-6 months of stable good control on a new regimen is prudent before attempting to conceive. My practice is to achieve an HbA1C below 7%, aiming for blood sugar values as near normal as possible without undue hypoglycemia (low blood sugars).
Some medicines that are are commonly prescribed to women with diabetes should absolutely be avoided during pregnancy. In particular, statin drugs used to lower cholesterol and certain blood pressure lowering medicines (angiotensin converting enzyme inhibitors or angiotensin receptor blockers) used to control hypertension and protect against diabetes-related kidney disease can have devastating effects on a developing fetus and should be stopped in advance of conception.
Another important consideration for patients with type 1 diabetes who are planning for a family is the financial impact of the addition. New babies are expensive, with increases in costs in almost every financial impact area, including food, shelter, clothing, healthcare, and time, among others. For the mother with diabetes, there is also an increased cost of diabetes care that will need to be included in family budgeting. Patients should anticipate that the costs of their diabetes care will increase during pregnancy, including co-payments for visits to specialty physicians, frequent obstetrical visits that may also include a perinatologist (a physician who specializes in high risk pregnancies), eye care professionals, dieticians, and a certified diabetes educator (CDE). The costs of co-payments for these visits and the lost time from work will take a toll. Insulin requirements will increase as the pregnancy progresses, and more frequent glucose testing will be necessary before, during, and after the pregnancy.
The working prospective mom with diabetes will need to assure that there is flexibility to allow for meals and snacks on as predictable of a schedule as possible, including time and accommodations for the more frequent glucose monitoring. If engaged in shift work, it can be beneficial to request a temporary fixed daily work schedule to limit the unpredictability of shifting schedules that can break routine diabetes management strategies during the pregnancy.
After delivery, in addition to the needs of her newborn, the mom with type 1 diabetes will need to continue her regimen of glucose monitoring and insulin administration. Insulin requirements plummet immediately after delivery and may remain lower than usual for some time. The decision to nurse or not has an impact on glucose control as well. If she is on thyroid hormone, she may require a dose adjustment in the first 6-8 weeks post partum.
All of these insights into the lives of mothers-to-be with diabetes are things that I have learned over many years of trials and successes with my patients with diabetes. It is incredibly rewarding when a patient, like the young woman mentioned earlier, are able to draw on the management skills requisite for maintaining good diabetes control and apply these to other areas of her life. Having the privilege of being a part of her life as she graduated from college (the first in her family), earned a master’s degree in public health, and now cradling her newborn daughter, further reminds me how much personal and professional investment is required in life with diabetes, for everyone involved, and how rewarding the payoffs can be for all of the hard work.
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