Intensive Insulin Therapy and Risk of Foot Ulcers.

What Is Type I Diabetes?

It is a chronic condition in which the pancreas in the body produces insufficient or no insulin to maintain blood glucose levels. Insulin is a hormone with two primary functions-

1. Regulate Blood Sugar Levels-

• The carbohydrates consumed are converted to simple sugars in the digestive system, which enter the bloodstream.

• The pancreas responds to this increased blood glucose level by secreting insulin.

• Insulin triggers and promotes glucose absorption by the skeletal system and the fat tissue from the bloodstream.

• The absorbed glucose is used for energy, protein, and fat synthesis.

2. Store Excess Glucose For Energy-

• Insulin also plays an important role in lowering the excess glucose in the blood.

• It stimulates the liver to convert and store the excess glucose into glycogen.

• In between meals, when the blood sugar levels are low, the liver will convert the stored glycogen into glucose and release it into the blood with the help of another hormone called glucagon.

This process of converting glucose to glycogen by insulin and then the glycogen to glucose by glucagon keeps the blood sugar levels within the normal range, which is necessary for healthy physiological functions.

Type 1 diabetes is an autoimmune condition in which the patient's immune system attacks the cells in the pancreas that produce insulin. As a result, the pancreas produces little to no insulin, which can be dangerous because it throws off the blood sugar balance in the body. Although type 1 diabetes often has an early onset, it can affect people at any age.

A few symptoms of type 1 diabetes are-

• Increased thirst.

• Frequent urination.

• Extreme hunger and anger (hangry).

• In children, it can cause unusual bed-wetting.

• Unintended weight loss.

• Fatigue and weakness.

• Blurred vision.

• Fruity breath.

If left untreated, type 1 diabetes will cause serious damage to different organs, including the heart, liver, eyes, kidneys, etc. Eventually, these complications turn into life-threatening conditions, including diabetic coma, brain damage, and death. Type 1 diabetes cannot be cured, but it can be treated. Treatment focuses on managing blood sugar levels with insulin therapy, diet, and lifestyle to prevent complications.

What Is Insulin Therapy?

In patients suffering from type 1 diabetes, insulin therapy compensates for the low or lack of insulin in the body. There are various types of insulin therapies, so it is important for the clinician and the patient to communicate before deciding on the one that suits the patient’s needs.

A few key points to remember before choosing the therapy are-

• The blood sugar level is not entirely dependent on the food-to-insulin ratio.

• It also changes based on the patient's drinks and energy during physical activities.

• The blood sugar level is different at different times of the day.

• It also gets influenced if the patient has other unrelated medical conditions, hormonal changes, is on medication, etc.

So, it is important to know the patient's body and habits before finalizing the type of therapy.

The different types of insulin therapy are-

Conventional Insulin Therapy-

• It involves injecting insulin twice a day, and it is often preferred by patients with a regular daily routine, as it is easy for them to inject insulin at the same time every day.

• For patients on conventional insulin therapy, a mixture of pre-made short-acting and long-acting insulin is prescribed. They must inject this mixture before breakfast and before their evening meal.

• The amount of insulin is fixed and based on the planned amount of food consumed over the course of the day. This leads to a regimented lifestyle; if the patient chooses to do any unplanned physical activity, they will have to balance the blood sugar with extra snacks between meals.

• The downfall of conventional insulin therapy is that it does not effectively prevent the long-term complications of type 1 diabetes.

Intensive Insulin Therapy-

This type of insulin therapy is comparatively more effective at preventing type 1 diabetic complications than conventional insulin therapy. The principles behind intensive insulin therapy are constant monitoring and flexibility.

Two types of insulin are needed to complete the therapy. They are-

• Basal Dose: This long-acting insulin is given once or twice daily; it covers the body’s basic insulin needs.

• Bolus Dose: This is the short-acting insulin that the patient injects before every meal to process carbohydrates. The patient will be given the insulin to carbohydrate (I: CHO) ratio and the correction factor.

• The I: CHO will tell the patient about the amount of carbohydrates that can be covered with one unit of short-acting insulin. The correction factor will inform the patient about the amount of blood sugar that will drop with one unit of short-acting insulin.

• The I: CHO will help the patient determine the bolus dose they will have to administer before the meal, and the correction factor will help them reduce their blood sugar level if it accidentally increases during one of their random monitoring sessions.

• The goal of intensive insulin therapy is to maintain the blood sugar level at all times of the day so that the patient has greater flexibility in their daily life.

Why Do Diabetic Patients Suffer From Foot Ulcers?

Prolonged high blood sugar causes damage to the nerves, especially the peripheral nerves in the arm and the leg; this condition is known as diabetic neuropathy. This condition is common to both type 1 and type 2 diabetic patients.

Blood sugar levels in most diabetic patients are not constantly monitored; it is due to a lack of awareness of the condition. This results in prolonged excess glucose levels in the body, known as hyperglycemia. Hyperglycemia induces cellular hypoxia (state of oxygen deprivation) in different organs in the body; the blood vessels and the peripheral nerves are the first tissues to be affected by this phenomenon. If left untreated, hypoxia will cause the death of these tissues, leading to diabetic neuropathy. The nerves in the legs and the arms get affected early on due to their peripheral nature. Patients with diabetic nephropathy will develop the following symptoms-

• Numbness.

• Tingling.

• Sharp pain or cramps.

• Muscle weakness.

• Extreme sensitivity to touch.

If the symptoms are left untreated, the patient will develop sores and breaks in the skin that will lead to ulcers in the affected limb. Ulcers formed due to diabetic neuropathy are difficult to heal and often become infected, leading to amputation of the limb. This can be prevented by

• Maintaining blood sugar levels close to normal and constantly monitoring them.

• Cessation of smoking.

• Regular check-ups with the podiatrist.

• Good nail care.

• Using moisturizing lotion.

• Protecting the feet by wearing the right kind of shoes.

Conclusion:

Modern diabetes management with intensive insulin therapy is all about self-management of blood sugar as effectively as possible. Living with diabetes, either type 1 or type 2, is stressful and overwhelming, but it is possible to manage it with patient education. People on intensive insulin therapy should learn a few skills, like adjusting their diet, physical activities, and stress-management techniques. Well-informed patients will follow the treatment plan and avoid complications, giving themselves a flexible life similar to that of a non-diabetic person.