Relation of metabolic control to complications in diabetes mellitus

Abstract

Insulin-dependent diabetes mellitus is the most common endocrine-metabolic disease of childhood, with a prevalence of one in 500 children younger than 18 years and an annual incidence of approximately 16 in 100,000 population? The metabolic derangements require daily treatment with insulin, attention to nutrition, and self-monitoring of blood or urine glucose. In addition, patients face the possibility of long-term complications involving the microvasculature and macrovasculature, risk they share with the larger group of patients with non-insulin-dependent diabetes mellitus. The complications are responsible for about 5000 annual cases of blindnes~ z and an increasing number of patients requiring dialysis and renal transplantation. 3 Diabetes mellitus is the leading cause of both new cases of blindness and end-stage renal disease in adults. Although these complications appear after puberty and usually after 10 to 15 years of established diabetes, by which time most patients are no longer under the care of their pediatrician, the genesis of the complications may occur during the early years of diabetes. It has long been debated, often with more heat than light, whether the complications result from the metabolic derangements of diabetes and whether they can be related to the degree of long-term metabolic control. The issue is more than just philosophic; if complications are related to the degree of metabolic control, then pediatricians caring for children with diabetes must recommend that patients Reprint requests: Mark A. Sperling, M.D., Division of Endocrinology, Children's Hospital Research Foundation, Cincinnati, OH 45229. maintain as near normal metabolism as is feasible and provide the level of care that allows patients to reach this goal. Physicians Cannot be expected to transmit such recommendations if they are not convinced of the possible relation between metabolic control and complications, and the potential benefits of good metabolic control. In 1976 an editorial in the Journal posed two questions regarding control of diabetes mellitus: Is it achievable? Is it desirable? 4 Evidence accumulated in the ensuing interval has decidedly swung the balance in favor of an affirmative response to the second question, at least. We review the clinical evidence linking long-term microvascular compli