A

Program for Normal Glycemic Control

of Insuliri'dependent Diabetes
JOHN R. WILLIAMS, JR., AND KATHARINE ALLING

A method of instruction enabling patients to control their diabetes is described. The patients learn
through home glucose monitoring how their blood sugar levels vary with changes in diet, exercise, and
insulin. They learn to chart accurately all the factors influencing their control in a manner that enables
them, as well as the physician, to analyze them quickly. From this information they learn to anticipate
the results of various changes in life-style and, thus, to live beyond the customary constraints of the
disease without loss of glycemic control. Significant improvements in neuritis, impotence, and creatinine clearance rates are reported, DIABETES CARE 3.- 160-162, JANUARY-FEBRUARY 1980.

uring the past 14 mo we have taught 64 insulindependent diabetic patients to maintain blood
sugar levels within the range of 50-150 mg/dl.
We have done so with the initial goal of preventing, arresting, or reversing the complications of diabetes, as evidence in the literature demonstrates can be done in
laboratory animals.1*2
Our patients are drawn from our practice of internal medicine which has for many years specialized in juvenile-onset
diabetes. They range in age from 7 to 65 yr, with a mean age
of 35; 34 of the 64 patients are male, and they represent a
broad range of economic and educational backgrounds.
We have adopted the instruction of patients as our
method and have used home glucose monitoring to confirm
for the patients the effect upon their blood sugar levels of
various factors influencing their diabetes. We begin by
establishing, with the patient, the amount of carbohydrate he or she may eat at each meal. This quota is based
largely upon the patient's customary eating habits, and it is
the dietary program to which the patient is most apt to adhere. It is explained that consistency at the outset is crucial
to the success of our joint efforts. We adjust this quota only
slightly to insure that the carbohydrate distribution
throughout the day conforms to a pattern of approximately
28, 36, and 36% for the three meals eaten, with the carbohydrate content of any snacks deducted from the quota of an
adjacent meal. Variations of as little as a slice of bread (12 g

160

or so of carbohydrate) can markedly influence postprandial

blood sugar levels. Unless a patient is obese, we allow the
consumption of fat and protein ad libitum, only urging the
patient not to gorge himself. Once the carbohydrate quota is
established, the patient agrees to conform to it closely during
the early weeks on the diabetic control program.
Patients are instructed in the accurate use and maintenance of a home glucose analyzer, and agree to test their
blood sugar levels seven times a day: before and an hour after
each meal, and before bed. We have found that adherance to
this schedule during the first weeks on the program is pivotal
to the program's success. As control develops, patients can
be assured increasing freedom from monitoring procedures,
though, in our experience, none have been willing to test
less often than once each day, at varying times. Most, once
control is secure, prefer to test at least twice each day.
We have found that two-thirds of our program patients,
once diabetic control is established, are able to maintain that
control within the range described with morning administration of insulin alone. However, it is clear that the method of
administration is of the utmost importance. Key factors include the time interval between the morning injection and
breakfast, the avoidance of scar tissue at the site of injection,
and the amount of activity to be engaged in. It has been our
experience that small doses (2 or 3 U) of regular insulin injected intramuscularly at the same time that intermediateacting insulin is injected subcutaneously will prevent the hy-

DIABETES CARE, VOL. 3 NO. 1, JANUARY-FEBRUARY 1980

PROGRAM FOR NORMAL GLYCEMIC CONTROL/JOHN R. WILLIAMS, JR., AND KATHARINE ALLING

perglycemia that commonly occurs after breakfast. This can

also be accomplished by increased activity immediately after
eating.
Patients learn to grade their activity level during the three
usual activity periods of the day on a scale of 1 to 5, where 3
represents their normal activity level for the period. A grade
of 1 would be minimal; 2, less than usual; 4, more than usual;
and 5, maximal.
Our patients learn to record the above-mentioned data on
a chart which we have designed for ease of analysis (Figure
1). They learn to graph carbohydrate intake to the nearest
5 g, indicating with an arrow the quota for each meal. They
record the type and time of insulin administered, as well as
the dose. They graph exertion in the manner described, as
well as any insulin reactions they may experience, and they
record blood sugar readings seven times each day, always following the biologic clock at the bottom of the graph. This
chart allows an experienced patient to isolate and identify
any features of the day that have caused glycemic excursions,

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to analyze them, and (as in the case of the patient whose

chart is shown) to anticipate their recurrence with appropriate countermeasures.
We find that an average of 8 wk of intensive training in
the office is required to teach a patient mastery of his diabetes. Thefirst2 - 4 wk are given to the establishment of basic
control: the maintenance of blood sugar levels within the 50
- 150-mg/dl range 90% of the time. This is accomplished by
the judicious variation of insulin dose, diet, and activity in
relation to the patient's recorded blood sugars. During the
second 4 wk, the patient learns to vary one component of
the regime by altering another, thus balancing the factors
upon which control depends. This is the simpler of the two
parts of the program and yet it is of vital importance to the
patient's continuing compliance.
At the end of this period, the patient is able to eat essentially anything he wants, including occasional sweets, and to
vary his activity as his life dictates, while still maintaining
blood sugar levels between 50 and 150 mg/dl.
The results we offer here reflect the first 10 mo of the program and its initial studies.3 We have demonstrated that patients can and will comply with all the demands of our program, and that they can learn to operate and to maintain the
machines accurately. We have further demonstrated that patients can be taught within 8 wk to maintain blood sugar
levels within a range of 50-150 mg/dl while living and eating as they desire.
Relative to complications, we have found that the numbness, tingling, and pain associated with diabetic neuritis
begin to clear within a week or two of the onset of good control, and that they are almost completely gone after 2 mo.
This has proved true for all of the 18 patients with this complication at the time of our neuropathy study.
Of four adult males who had been under good control for 3
mo and who had had potency problems in the past, three
have had very significant improvements in potency. Two of
these had not had erections in over 2 yr.
The results of repeated creatinine clearance tests in the 11
cases of patients with initial clearance rates below 75 cc/min
are shown in Table 1. These results, taken from our preliminary nephrology study, indicate that control increases creatinine clearance significantly.
We now believe that the treatment of choice for almost all
patients with juvenile-onset diabetes, as well as for many patients with maturity-onset diabetes, is the use of a program
such as we have described. It has become clear, however,
that patients who understand no more than how to test their
own blood sugars may be done more harm than good. Intelligent analysis of the factors governing their diabetic control
forms the basis of freedom for patients from the customary
constraints of the disease.
This work was supported by a grant from the Ames Company.

DIABETES CARE, VOL. 3 NO. 1, JANUARY-FEBRUARY 1980

161

PROGRAM FOR NORMAL GLYCEMIC CONTROL/JOHN R. WILLIAMS, JR., AND KATHARINE ALLING

TABLE 1
Creatinine clearance
Patient

Start

Date

CCR

Date

CCR

1
2
3
4
5
6
7
8
9
10
11

9/8/78
11/15/78
11/28/78
12/12/78
1/9/79
1/23/79
3/13/79
3/20/79
3/20/79
4/3/79
4/17/79

9/13/78
11/14/78
12/4/78
12/12/78
12/29/78
2/16/79
3/8/79
3/19/79
3/20/79
4/3/79
4/11/79

58.0
38.3
33.9
48.5
58.0
23.6
41.0
34.0
52.0
67.0
55.0

3/9/79
2/16/79
2/22/79
2/6/79
2/16/79
3/5/79
4/25/79
5/3/79
4/26/79
4/17/79
4/17/79

66.0
44-4
50.0
62.0
30.6
48.0
135.0
41.0
51.0
42.0
76.0

Date

CCR

Date

CCR

3/9/79
3/29/79
4/18/79
4/23/79
3/26/79

47.0
42.0
65.0
90.0
43.0

4/27/79
4/17/79

82.0
43.0

4/9/79

66.0

Persistent UTI; Prostatectomy 5/18

5/16/79
5/14/79

52.0
92.0

CCR, creatinine clearance rate (cubic centimeters per minute); UTI, urinary tract infection.

Address reprint requests to John R. Williams, 380 Monroe Avenue, Rochester, New York 14607.
REFERENCES
1

Matas, A. J., Sutherland, D. E. R., andNajarian, J. S.: Current

status of islet and pancreas transplantation in diabetes. Diabetes 25:
791, 1976.

162

Mauer, S. M., Sutherland, D. E. R., Steffes, M. W., Leonard,

R. J., Najarian, J. S., Michael, A. F., and Brown, D. M.: Studies
on the rate of regression of the glomular lesions in diabetic rats
treated with pancreatic islet transplantation. Diabetes 24: 280-85,
1975.
3
Presented at the 39th Annual Meeting of the American Diabetes Association in Los Angeles in June, 1979, by J. R. Williams
and K. Ailing.

DIABETES CARE, VOL. 3 NO. 1, JANUARY-FEBRUARY 1980