Type 1 diabetes

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What is type 1 diabetes?

Type 1 diabetes is a condition that results in high levels of blood sugar because the pancreas is either producing too little or no insulin. It is a long-standing condition and is usually seen in the younger age group.

Alternate names

  • Juvenile diabetes / Insulin-dependent diabetes / T1DM / Autoimmune diabetes

Is type 1 diabetes a medical emergency?

Type 1 diabetes is not a medical emergency, but some of the complications that can arise from it may require immediate medical attention.

Causes of type 1 diabetes

The exact cause of juvenile diabetes is not known. It is thought to be immune-mediated, wherein the immune system attacks and destroys the Beta cells of the Islets of Langerhans in the pancreas. The Beta cells produce insulin which regulates carbohydrate and fat breakdown, and insulin is required by the cells of the body to utilize the glucose from the bloodstream. The low levels or absence of insulin, therefore, results in high levels of blood sugar.

The following may have a role to play in the development of type 1 diabetes:

  • Genetics
  • Environmental factors
  • Pancreatic disease, tumors or trauma may also lead to reduced insulin production

Risk factors for type 1 diabetes

The following are the risk factors for developing juvenile diabetes:

  • Family History: Individual with a family history of diabetes are at a greater risk of developing juvenile diabetes
  • Age: It is commonly seen in the younger age group, with two peaks in the age group of 4-7 years, and 10-14 years
  • Genetic: There are about 50 genes that are identified with the development of Type 1 Diabetes, and the presence of these genes poses a greater risk for developing Type 1 Diabetes

Signs & symptoms of type 1 diabetes

The symptoms and signs of juvenile diabetes include:

  • Polydipsia: Increased thirst
  • Polyuria: increased urination (and bedwetting in young children who previously didn’t have the problem)
  • Polyphagia: Increased hunger
  • Weight loss
  • Blurred vision
  • Weakness and lethargy
  • Sleepiness and irritability
  • Deep and labored breathing

Investigations

The investigations that are done to establish a diagnosis of juvenile diabetes include:

  • Blood tests:
    • Random blood sugar test
    • Fasting blood sugar test: By taking a blood sample 8 - 10 hours after a previous meal and testing for blood sugar levels
    • Post-prandial blood sugar test: By taking a blood sample exactly 2 hours after the first morsel of a meal is taken
    • Glycated hemoglobin (HbA1c): It is a measure of the percentage of glucose that is carried by hemoglobin and is an indication of the blood sugar levels over a period of 2 - 3 months
    • Autoantibodies - The measurement of antibodies such as IAA, GAD, and IA2 helps to differentiate type 1 from type 2 diabetes
  • Urine tests: A complete urine examination is done to check for the presence of sugars as well as ketone bodies

Diagnosis of type 1 diabetes

The diagnosis of type 1 diabetes is based on medical history, clinical evaluation, and the results of the investigations. A diagnosis of diabetes is established if:

  • Fasting blood sugar is more than 125 mg/dl on two separate occasions
  • Postprandial blood sugar is more than 200 mg/dl on two separate occasions
  • Random blood sugar is more than 200 mg/dl on two separate occasions
  • HbA1c is more than 6.5% on two separate occasions

Type 1 diabetes is confirmed if there is also the presence of:

  • Ketone bodies in the urine
  • There is a presence of autoantibodies such as IAA, GAA/GAD, IA2

Treatment options for type 1 diabetes

Type 1 diabetes cannot be cured and the aim of treatment is to maintain blood proper glucose levels and prevent complications

A. Medical management

Medical management of juvenile diabetes includes the following:

  • Insulin replacement: Is done by administering insulin either through an insulin syringe or an insulin pump. The different types of insulin that can be administered include:
    • Fast-acting insulin or insulin analogs: They start working within 5 - 10 minutes and their action lasts for about 3 - 4 hours
    • Short-acting insulin: They start working within 30 minutes and their action lasts for 5 - 8 hours
    • Intermediate-acting insulin: They start working within 1 - 3 hours and their action lasts for 16 - 24 hours
    • Long-acting insulin: They start acting within 1 - 2 hours and their action lasts for about 24 hours
  • Anti-hypertensive medication: Such as angiotensin-converting enzyme (ACE) inhibitors may be required if there is coexisting high blood pressure
  • Cholesterol-lowering medications: Such as statins may be required to prevent the formation of atherosclerotic plaques and protect the heart
  • Artificial pancreas: An advanced system that automatically and continuously monitors blood glucose and delivers the appropriate doses of insulin as and when required

B. Role of diet/exercise/lifestyle changes/preventive measures

Juvenile diabetes cannot be prevented. Once it is diagnosed it is important to maintain a healthy lifestyle and take a few precautions to keep the condition under control and to prevent Type 1 diabetes-related complications. They include:

  • Monitoring blood glucose levels at regular intervals
  • Consulting with a nutrition counselor to prepare a meal plan that includes a healthy diet of fruits, vegetables, and whole grams, and ensuring that the food consumed is nutritious, low in fat, and high in fiber. It is also necessary to monitor the intake of carbohydrates so as to adjust the dose of insulin accordingly.
  • Getting regular exercise without overtly exerting in a single session, and carefully monitoring blood sugar levels when engaging in physical activity
  • Monitoring blood sugar levels before driving vehicles
  • Monitoring blood sugar levels before engaging in heavy work at the workplace
  • Monitoring for signs of hypoglycemia in elderly individuals
  • Prenatal counseling for women with juvenile diabetes who wish to get pregnant is essential, as the risk of complications for both the mother and the fetus is greatly increased with this condition

Complications

The complications of type 1 diabetes include:

  • Severe hypoglycemia: Drop in blood sugar levels
  • Diabetic ketoacidosis: Resulting from the breakdown of fats, in the absence of glucose, leading to the production of ketone bodies
  • Hypoglycemia unawareness: Which is the loss of the ability to recognize the presence of low sugar levels
  • Cardiovascular: Juvenile diabetes greatly increases the risk of heart and blood vessel disease and can cause coronary artery disease, high blood pressure, heart attack
  • Neurological: Can cause damage to the nerves, leading to diabetic neuropathy and may affect the peripheral nerves in the limbs, the nerves supplying the gastrointestinal tract,
  • Renal: Can cause damage to the filtering mechanism of the kidneys leading to diabetic nephropathy, and eventually kidney failure or end-stage kidney disease
  • Erectile dysfunction in men
  • Pregnancy complications: Type 1 diabetes greatly increases the risk of complications in pregnant women, especially in the first trimester
  • Eyes: Can cause damage to the blood vessels supplying the retina leading to diabetic retinopathy and eventually loss of vision
  • Infections: Individuals with Type 1 diabetes are at a greater risk of infections of the feet leading to blisters, and ulcers that are slow to heal. Infections of the skin can also occur
  • Urinary tract infections: There is a greater risk of developing urinary tract infections
  • Depression
  • Hair loss
  • Risk of developing other autoimmune diseases such as lupus, rheumatoid arthritis, autoimmune thyroiditis, celiac disease, etc.

Prognosis

The prognosis of type 1 diabetes when improperly managed is poor primarily owing to the systemic complications that can develop. The prognosis for women is worse than in men, and the overall life expectancy for people with juvenile diabetes is reduced by about 10 -12 years.

When to contact the doctor or hospital/how to identify the emergency or complications?

Type 1 diabetes may lead to certain complications that are medical emergencies and it is important to get immediate medical attention. They include:

  • Severe hypoglycemia: Can present with
  • Sweating and shaking of the body
  • Hunger
  • Dizziness or lightheadedness
  • Rapid or irregular heart rate
  • Fatigue & sleepiness
  • Headaches & Blurred vision
  • Irritability & confusion
  • Seizures
  • Diabetic ketoacidosis: Can present with
    • Nausea and/ or vomiting
    • Abdominal pain
    • Fruity breath smell

If any of these symptoms are seen it is advisable to visit the emergency department.

Indications for hospitalization if required

Hospitalization is not required for juvenile diabetes that is managed well. However, some complications may warrant a visit to the emergency department and a hospitalization till stabilized.

Suggested clinical specialist/departments to consult for this condition

Type 1 diabetes will be attended to by endocrinologists.

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