Diabetes - type 1

Definition

Type 1 diabetes is a chronic (lifelong) disease that occurs when the pancreas does not produce enough insulin to properly control blood sugar levels.

See also:

• Diabetes
• Gestational diabetes
• Type 2 diabetes

Alternative Names

Causes

Diabetes is a lifelong disease for which there is not yet a cure. There are several forms of diabetes. Type 1 diabetes is often called juvenile or insulin-dependent diabetes. In this type of diabetes, cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells.

Without enough insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy despite high levels in the bloodstream. This leads to increased hunger.

In addition, the high levels of glucose in the blood cause the patient to urinate more, which in turn causes excessive thirst. Within 5 to 10 years, the insulin-producing beta cells of the pancreas are completely destroyed and the body can not longer produce insulin.

Type 1 diabetes can occur at any age, but it usually starts in people younger than 30. Symptoms are usually severe and occur rapidly.

The exact cause is unknown.

Symptoms

• Increased thirst
• Increased urination
• Weight loss despite increased appetite
• Nausea
• Vomiting
• Abdominal pain
• Fatigue
• Absence of menstruation

Exams and Tests

The following tests can be used to diagnose diabetes:

• Urinalysis shows glucose and ketone bodies in the urine, but a blood test is required for diagnosis
• Fasting blood glucose is 126 mg/dL or higher
• Random (nonfasting) blood glucose exceeds 200 mg/dL (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)

Treatment

The immediate goals of treatment are to treat diabetic ketoacidosis 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 hospitalization.

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.

These goals are accomplished through education, insulin use, meal planning and 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 1 diabetes can't make their own insulin, and they must take insulin every day.

Insulin is injected under the skin or inhaled. In some cases, a pump delivers the insulin continuously. Insulin does not come in pill form.

Insulin preparations differ in how fast they start to work and how long they last. 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.

The injections are needed, in general, from one to four 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 (but should not be required) to give their own injections.

DIET

Meal planning for type 1 diabetes requires consistency to allow food and insulin to work together to regulate blood glucose levels. If meals and insulin are out of balance, extreme variations in blood glucose can occur.

The American Diabetes Association and the American Dietetic Association has information for planning healthy, balanced meals. A consultation with a registered dietitian or nutrition counselor can be helpful.

PHYSICAL ACTIVITY

Regular exercise helps control the amount of sugar in the blood and helps burn excess calories and fat to achieve optimal weight.

Ask your health care provider before starting any exercise program. Those with Type 1 diabetes must take special precautions before, during, and after 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.

The results can be used to adjust meals, activity, or medications to keep blood sugar levels within an appropriate range. It will provide valuable information for the health care provider to suggest changes to improve care and treatment. Testing will identify high and low blood sugar

FOOT CARE

Diabetes causes damage to the blood vessels and nerves, which can result in a decreased ability to feel injury to or pressure on the foot. A foot injury could go unnoticed until severe infection develops.

Additionally, diabetes affects the body's immune system, decreasing the body's ability to fight infection. Small infections can rapidly progress to death of the skin and other tissues. Amputation may be needed.

See: Daily foot care routine

TREATING LOW BLOOD SUGAR

Low blood sugar, known as hypoglycemia, can occur from too much insulin, too much exercise, or too little food. Hypoglycemia can develop quickly in people with diabetes. Symptoms typically appear when the blood sugar level falls below 70. Watch for weakness, shaking, sweating, headache, nervousness, and hunger.

If these symptoms occur and you have a blood sugar test kit available, do a blood sugar check. If the level is low, the person with diabetes should eat something with sugar: fruit juice, several teaspoons of sugar, a cup of skim milk, or regular soda. If you don't have a test kit handy, sugar should be eaten anyway - it can't hurt. Symptoms should go away within 15 minutes. If the symptoms don't go away, more sugar should be eaten and the sugar level tested again.

AFTER the symptoms go away, more substantial food can be eaten. Eat simple sugar first to get the situation under control. Even if you or your child is hungry, "real" food should not be eaten until the sugar level comes up - real food won't produce enough sugar and takes too long to digest.

If you are a parent, relative, or friend of someone experiencing these symptoms, monitor the person closely. If symptoms become worse -- confusion, seizures, or unconsciousness -- give the person a shot of glucagon. If you don't have glucagon, call 911 immediately.

You should have some glucagon stored for emergencies. Make sure everyone in your home, as well as babysitters and caregivers, knows how to use it. Periodically remind everyone how to use it, and check the expiration date.

Don't panic. Glucagon works very fast -- usually within 15 minutes. Lay the person on the side to prevent choking. If the person is not better in 15 minutes, call 911.

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. This condition is known as ketoacidosis.

You can check for ketones using a simple urine test available at pharmacies. This test should be done every 4-6 hours anytime a person with diabetes has a blood sugar above 240 or if they are sick, unusually thirsty, has a dry mouth, frequent urination, or vomiting.

The 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 odor.

If these symptoms occur, call the doctor or go to the emergency room right away. If left untreated, this condition will lead to coma and even death.

MONITORING

Visit your health care provider or diabetes educator at least four times a year. Have your glycosylated hemoglobin (HbA1c) regularly checked. Cholesterol and triglyceride levels should be checked yearly, along with kidney function.

Visit your ophthalmologist (preferably one that specializes in diabetic retinopathy) at least once a year, or more frequently if signs of diabetic retinopathy develop.

See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.

Check your feet every day for early signs of injury or infection. Make sure your health care provider inspects your feet at each visit.

Stay up-to-date with all of your vaccinations and get a flu shot every year in the fall.

EDUCATION

You are the most important person in managing your diabetes. Diabetes education involves learning how to live with your diabetes and helps prevent complications. You should know the basic steps to diabetes management:

• How to recognize and treat low blood sugar (hypoglycemia)
• How to recognize and treat high blood sugar (hyperglycemia)
• Diabetes meal planning
• How to give insulin
• How to monitor blood glucose and urine ketones
• How to adjust insulin and food intake during exercise
• How to handle sick days
• Where to buy diabetes supplies and how to store them

Support Groups

For additional information and resources, see diabetes support group.

Outlook (Prognosis)

The outcome for people with diabetes varies. Studies show that tight control of blood glucose can prevent or delay complications to the eyes, kidneys, and nervous system. However, complications may occur even in those with good diabetes control.

Possible Complications

Emergency complications include:

• Ketoacidosis
• Hypoglycemia

Long-term complications include:

• Vascular disease, including blocked arteries and heart attacks -- risk can be reduced by treating high cholesterol and blood pressure, exercising regularly, and avoiding or quitting tobacco products
• Eye problems, including diabetic retinopathy , retinal detachment, glaucoma, and cataracts
• Kidney disease (diabetic nephropathy)
• Nerve damage (diabetic neuropathy)
• Foot problems, including skin changes, arterial insufficiency, neuropathy, and specific foot deformities (hallux valgus, bunion, hammertoe, and calluses)
• Infections of the skin, female genital tract, and urinary tract

When to Contact a Medical Professional

If you are newly diagnosed with type 1 diabetes, you should probably have medical follow-up weekly until you have good control of blood glucose. Your health care provider will review results of home glucose monitoring and urine testing, and a diary of meals, snacks, and insulin injections.

As the disease becomes more stable, follow-up visits will be less frequent. Periodic visits to your health care provider is very important for monitoring potential long-term complications associated with diabetes.

Call your health care provider or go to the emergency room if you have symptoms ketoacidosis:

• Increased thirst and urination
• Nausea
• Deep and rapid breathing
• Abdominal pain
• Sweet-smelling breath
• Loss of consciousness (This may occur in insulin dependent diabetics who miss a dose of insulin, or if they are sick or have an infection.)

Go to the emergency room or call 911 if you have symptoms of severe hypoglycemia or insulin reaction:

• Trembling
• Weakness
• Drowsiness
• Headache
• Confusion
• Dizziness
• Double vision
• Lack of coordination
• Convulsions or unconsciousness

You can treat early signs of hypoglycemia at home by eating sugar or candy or taking glucose tablets. If your signs of hypoglycemia are still not relieved or if your blood glucose levels remain below 60 mg/dL, go to the emergency room.

Standards of medical care in diabetes--2007. Diabetes Care. Jan 2007;30 Suppl 1:S4-S41.

Larsen PR, Kronberg HM, Schlomo M, et al. Williams Textbook of Endocrinology. 10th ed. St. Louis, Mo: WB Saunders; 2003:1427-1468, 1485-1504.

Armstrong C. ADA Releases Standards of Medical Care for Patients with Diabetes. Am Fam Physician. Sept 2006; 74(5); 871-874.