Front-Shop Magazine

Type 1 Diabetes Mellitus

Dr Michelle Blou Mb Bch (Wits)

Type 1 Diabetes Mellitus (DM) is also known as Insulin Dependent Diabetes Mellitus (IDDM). As the name suggests patients that are diagnosed with this condition require treatment with insulin (only available in injectable form) for the rest of their lives. Type 1 diabetics depend on insulin for survival. Patients with Type 1 DM do not produce any insulin of their own unlike those with Type 2 DM who usually are managed with oral agents and do have some  insulin production which is inadequate. Patients with Type 2 DM can progress to become insulin dependent.

Diabetes is a life-long disease for which there is not yet a cure. In summary:

• Type 1 diabetes, often called juvenile or insulin-dependent diabetes
• Type 2 diabetes, often called adult or non-insulin-dependent diabetes
• Gestational diabetes, which occurs during pregnancy.

For all types of diabetes, the metabolism of carbohydrates (including sugars such as glucose), proteins, and fats is altered.

PREVALENCE
It is estimated that about 5%–10% of North American diabetes patients have type 1 DM. The prevalence of type 1 in other parts of the world differs. Type 1 diabetes can occur at any age, but it usually starts in people younger than 30.

CAUSES
The cause of Type 1 DM remains largely unknown and is the subject of extensive research. It may affect patients of any age including children and young healthy adults. The thinking is that a trigger factor initiates an autoimmune process in genetically susceptible people. It is thought that the body’s response to a viral infection triggers the autoimmune process. An autoimmune process is a derangement of the immune system whereby the body attacks its own tissue with resultant disease.

In the case of Type 1 DM the target of this process are the Beta (β)-cells in the Islets of Langerhans of the pancreas which are responsible for the production and secretion of insulin. The β-cells are destroyed in the process rendering the individual dependent on exogenous insulin for the rest of their lives.

SYMPTOMS
The role of insulin in the body is to finely regulate glucose metabolism. Insulin is a hormone that is needed to convert sugar (glucose), starches and other food into energy needed for daily life.The lack of insulin results in significantly raised glucose levels in the blood known as hyperglycaemia. This hyperglycaemia spills over into the urine which is usually devoid of glucose in a healthy person-the presence of glucose in urine is known as glycosuria. Hyperglycaemia and glycosuria assist in making the diagnosis of diabetes.

The patient with Type 1 DM typically complains of excessive thirst (polydypsia) and increased frequency of urination (polyuria) which results from the increased blood and urine levels of glucose. Another typical symptom of Type 1 DM is dramatic weight loss as a result of the body’s inability to metabolise ingested glucose.

In summary the presenting symptoms are:

• increased thirst
• increased urination
• weight loss despite increased appetite
• nausea
• vomiting
• abdominal pain
• fatigue
• absence of menstruation

LABORATORY TESTS
The evidence for the diagnosis for Type 1 DM is usually abundant from the history and the symptoms described.

Certain blood tests confirm the diagnosis:

• urinalysis shows glucose and ketone bodies (evidence of the metabolic acidosis known as ketoacidosis  associated with Type 1 DM) in the urine
• fasting blood glucose is elevated
• random (non-fasting) blood glucose exceeds is elevated (this must be confirmed with a fasting test)
• insulin test (low or undetectable level of insulin)
• C-peptide test (low or undetectable level of the protein C-peptide, a by-product of insulin production).This is the most definite laboratory test to distinguish type 1 from type 2 diabetes  as  the C-peptide assay is a measure of endogenous insulin production as external insulin does not have C-peptide in its structure
• Anti-islet antibodies, or lack of insulin resistance, determined by a glucose tolerance test, would also be suggestive of type 1.

TREATMENT   
At diagnosis, the immediate goals of treatment are to treat diabetic ketoacidosis (also called DKA) and high blood glucose levels. Because of the sudden onset and severity of symptoms in type 1 diabetes, treatment for newly diagnosed people may involve hospitalisation and patients may even present in a hyperglycaemic coma.

The long-term goals of treatment are to prolong life, reduce symptoms, and prevent diabetes-related complications such as blindness, kidney failure, and amputation of limbs, all of these conditions are a results of the long term effects of uncontrolled blood glucose on the vascular and nervous  systems.

These goals are accomplished through education, insulin use, meal planning, weight control, exercise, foot care, and careful self-testing of blood glucose levels.

Insulin
Insulin lowers blood sugar by allowing it to leave the blood stream and enter cells. Everyone needs insulin. People with Type I diabetes can’t make their own insulin, and they must take insulin every day.

Insulin is injected under the skin using a syringe, or in some cases, an infusion pump delivers the insulin continuously. It is not available in an oral form because it is a protein which would be degraded by gastric acid before it could be absorbed.

Insulin preparations differ in how fast they start to work and how long they last therefore long acting and short acting insulins are commercially available. The health care professional reviews blood glucose levels to determine the appropriate type of insulin the person should use. More than one type of insulin may be mixed together in an injection to achieve the best control of blood glucose.

Doses are individualised and the injections are needed, in general, from 1 to 4 times a day. People are taught how to give insulin injections by their health care provider or a diabetes nurse educator. Initially, a child’s injections may be given by a parent or other adult. By age 14, most children can be expected to give their own injections.

Diet
Meal planning and the role of the dietician is an essential part of the treatment of diabetes, since food intake and the administration of insulin must be synchronised so as to optimally regulate blood glucose.

Exercise
Regular exercise is especially important for the person with diabetes. Before people with diabetes begin any exercise program, they should obtain medical approval. Type 1 diabetics must take special precautions before, during and after participation in intense physical activity or exercise.

Self-Testing
Blood glucose monitoring is done by checking the glucose content of a small drop of blood. The testing is done on a regular basis and will inform the person with diabetes how well diet, medication, and exercise are working together to control diabetes. Testing will identify high and low blood-sugar levels before serious problems develop.

Foot Care
People with diabetes are prone to foot problems as a complication of the illness. Diabetes causes damage to the blood vessels and nerves, which can result in a decreased ability to sense trauma or pressure on the foot. A foot injury could go unnoticed until severe infection develops.

Small infections can rapidly progress to gangrene, necessitating amputation of the affected limb.

To prevent injury to the feet, diabetics should adopt a daily foot care routine.

Treating low blood sugar
Low blood sugar, known as hypoglycaemia, can occur in diabetics when they use too much insulin, exercise too much, or have not eaten enough food. Hypoglycaemia can develop quickly. Symptoms include weakness, shaking, sweating, headache, nervousness, and hunger and if left untreated coma. This is a potentially dangerous situation. If these symptoms occur and a blood sugar test kit is available a test should be done.

If the level is low, the person with diabetes should ingest something with sugar such as Coke. If a test kit is not available, sugar should be eaten anyway as there is far more risk associated with hypoglycaemia than hyperglycaemia.

Treating high Ketones
When there is not enough insulin to move glucose into cells, glucose can build up in the blood. The body then looks for other forms of energy and uses fat as a fuel source. As fats are broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous to body tissue. This condition is known as ketoacidosis.

You can check for ketones using a simple urine test available at pharmacies. This test should be performed every 4-6 hours anytime a person with diabetes is registering an abnormally high blood sugar; sick; unusually thirsty or has a dry mouth; urinating frequently; or vomited.

he warning signs that ketoacidosis is getting serious might include flushed face, dry skin and mouth, nausea or vomiting, stomach pain, deep, rapid breathing, or fruity breath odour.

If these symptoms occur, it is an emergency that can lead to coma and even death.

Follow-Up of the diabetic patient

• Physician/Educator visits at least 4 times a year
• Measurement of  glycosylated haemoglobin (HbA1c) measured 2-4 times a year to evaluate r overall glucose control
• Cholesterol and triglyceride levels and kidney function evaluated yearly
• Yearly consultation with an  ophthalmologist
• Bi-annual dentistry check-ups
• Daily monitoring of feet
• Yearly flu injection unless contra-indicated.

Patient Education
The patient is the most important person in managing their diabetes. Diabetes education is a crucial part of the treatment plan. Diabetes education basically involves learning how to live with diabetes.

The patient should be knowledgeable about the basic principles of diabetes management which include:

• how to recognize and treat low blood sugar (hypoglycaemia)
• how to recognize and treat high blood sugar (hyperglycemias)
• diabetes meal planning
• how to administer insulin
• how to monitor blood glucose and urine ketones
• how to adjust insulin and/or food intake during exercise
• how to handle sick days
• Where to buy diabetic supplies and how to store them.

Prognosis   
The outcome for people with diabetes varies.  To some extent it depends on the attitude of the patient. Recent studies show that tight control of blood glucose can prevent or delay the progression of eye disease, kidney disease and nervous system disease that is caused by diabetes. However, complications may occur even when good diabetes control is achieved with insulin and diet.

Type 1 DM is currently not curable but patients can live a normal and full life provided they abide by the requirements of this condition which need to be integrated into their lifestyles.