TYPE 1 DIABETES MILLITUS (T1DM)

BACKGROUND

Type 1 diabetes happens when your pancreas stops making insulin.

Insulin is a hormone that helps the body's cells use sugar (glucose) for energy. It also helps the body store extra energy in muscle, fat, and liver cells. Without insulin, this sugar can't get into your cells to do its work. It stays in your blood instead. And then your blood sugar level gets too high.

Type 1 diabetes is different from type 2 diabetes. In type 1 diabetes, the body stops making insulin. In type 2, the body doesn't make enough insulin, or the body can't use insulin the right way. Type 1 diabetes can occur at any age, but it usually starts in children or young adults. That's why it used to be called juvenile diabetes.

DISEASE OCCURRENCE IN POPULATION:

According to WHO, the number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014. In 2012, an estimated 1.5 million deaths were directly caused by diabetes and another 2.2 million deaths were attributable to high blood glucose. WHO projects that diabetes will be the 7th leading cause of death in 2030.

Type 1 diabetes can occur at any age, but tends to develop in childhood, so it has long been called ‘juvenile diabetes’. As of 2014, an estimated 387 million people have diabetes worldwide, of which T1DM accounts for between 5% and 10%.

Pakistan ranks at number six in terms of number of people with diabetes worldwide. It was estimated that in 2000 there were 5.2 million diabetic patients and this will rise to 13.9 million by 2020, leading Pakistan to 4th most populous country for patients with diabetes mellitus. According to WHO prevalence of diabetes in Pakistan is 9.8%. According to diabetes international federation, there were over 7 million cases of diabetes in Pakistan in 2015.

RISK FACTORS:

Some known risk factors for type 1 diabetes include:

• Family history: Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition.
• Genetics: The presence of certain genes indicates an increased risk of developing type 1 diabetes.
• Race/ethnicity: Certain ethnicities have a higher rate of type 1 diabetes. In the United States, Caucasians seem to be more susceptible to type 1 than African-Americans and Hispanic-Americans. Chinese people have a lower risk of developing type 1, as do people in South America.
• Geography: The incidence of type 1 diabetes tends to increase as you travel away from the equator.
• Age: Although type 1 diabetes can appear at any age, it appears at two noticeable peaks. The first peak occurs in children between 4 and 7 years old, and the second is in children between 10 and 14 years old.

Many other possible risk factors for type 1 diabetes have been investigated, though none have been proved. Some other possible risk factors include:

• Exposure to certain viruses, such as the Epstein-Barr virus, Coxsackie virus, mumps virus and cytomegalovirus
• Early exposure to cow's milk
• Low vitamin D levels
• Drinking water that contains nitrates
• Early (before 4 months) or late (after 7 months) introduction of cereal and gluten into a baby's diet
• Having a mother who had preeclampsia during pregnancy
• Being born with jaundice

SIGN AND SYMPTOMS:

The symptoms include:

• Being very thirsty.
• Urinating a lot.
• Bedwetting in children who previously didn't wet the bed during the night
• Losing weight without trying.
• Being hungrier than usual.
• Blurry eyesight.
• Fatigue and weakness
• Irritability and other mood changes
• In females, a vaginal yeast infection

If you wait too long to get medical care, you may get diabetic ketoacidosis, which is very dangerous. Symptoms of this problem include:

• Flushed, hot, dry skin.
• Not feeling hungry.
• Belly pain.
• Nausea and Vomiting.
• A strong, fruity breath odor.
• Fast and shallow breathing.
• Restlessness, drowsiness, or trouble waking up.

HYPOGLYCEMIA:

This occurs when your blood sugar level drops below your target range. Ask your doctor what's considered a low blood sugar level for you. Blood sugar levels can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin.

Early signs and symptoms of low blood sugar include:

• Sweating
• Shakiness
• Hunger
• Dizziness or lightheadedness
• Rapid or irregular heart rate
• Fatigue
• Headaches
• Blurred vision
• Irritability

COMPLICATIONS:

Type 1 diabetes can affect major organs in your body, including heart, blood vessels, nerves, eyes and kidneys. Keeping your blood sugar level close to normal most of the time can dramatically reduce the risk of many complications.

• Increases your risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
• Increase risk of nerve damage (Neuropathy) especially in the legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward.
• Diabetes can cause Kidney damage (Neuropathy). Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which requires dialysis or a kidney transplant.
• Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness, cataracts and glaucoma.
• Diabetes can causenerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications.
• Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
• High blood sugar levels can be dangerous for both the mother and the baby. The risk of miscarriage, stillbirth and birth defects are increased when diabetes isn't well-controlled. For the mother, diabetes increases the risk of diabetic ketoacidosis, diabetic eye problems (retinopathy), pregnancy-induced high blood pressure and preeclampsia.

DIAGNOSTIC TEST:

Your doctor can diagnose diabetes with a physical exam, your medical history, and blood tests. Some people are diagnosed with type 1 diabetes because they have symptoms of diabetic ketoacidosis.

To diagnose type 1 diabetes, your doctor will ask for a following laboratory test:

• Glycated hemoglobin (A1C) test: This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes.

If the A1C test isn't available, or if you have certain conditions that can make the A1C test inaccurate such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant), your doctor may use the following tests to diagnose diabetes:

• Random blood sugar test: A blood sample will be taken at a random time. Blood sugar values are expressed in milligrams per deciliter (mg / dL) or millimoles per liter (mmol / L). Regardless of when you last ate, a random blood sugar level of 200 mg / dL (11.1 mmol / L) or higher suggests diabetes, especially when coupled with any of the signs and symptoms of diabetes, such as frequent urination and extreme thirst.
• Fasting blood sugar test: A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.

If you receive a diagnosis of diabetes, your doctor will also run blood tests to check for autoantibodies that are common in type 1 diabetes. These tests help your doctor distinguish between type 1 and type 2 diabetes. The presence of ketones  (by products from the breakdown of fat)  in your urine also suggests type 1 diabetes, rather than type 2.

TREATMENT OPTIONS:

Treatment for type 1 diabetes includes:

• Taking insulin
• Frequent blood sugar monitoring
• Healthy eating and monitoring carbohydrates
• Physical activity
• Investigational treatments
• Treatment of hypoglycemia

INSULIN: Anyone who has type 1 diabetes needs lifelong insulin therapy.
Types of insulin are many and include:

• Rapid-acting insulin
• Long-acting insulin
• Intermediate options

INSULIN ADMINISTRATION: Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action. Therefore, it must be given either through injections or an insulin pump.

• INJECTIONS: You can use a fine needle and syringe or an insulin pen to inject insulin under your skin. An insulin pump a device about the size of a cellphone worn on the outside of your body. A tube connects a reservoir of insulin to a catheter that's inserted under the skin of your abdomen.

There's also a wireless pump option. You wear a pod that houses the insulin reservoir on your body that has a tiny catheter that's inserted under your skin. The insulin pod can be worn on your abdomen, lower back, or on a leg or an arm. The programming is done with a wireless device that communicates with the pod.

Pumps are programmed to dispense specific amounts of rapid-acting insulin automatically. This steady dose of insulin is known as your basal rate, and it replaces whatever long-acting insulin you were using.

BLOOD SUGAR MONITORING:
Depending on what type of insulin therapy you select or require — twice daily injections, multiple daily injections or insulin pump — you may need to check and record your blood sugar level at least four times a day, and generally more often. The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and if you suspect you have low blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. Be sure to wash your hands before checking your blood sugar levels.

Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels, and may be especially helpful for preventing hypoglycemia.
HEALTHY EATING AND MONITORING CARBOHYDRATES
It's important to center your diet on nutritious, low-fat, high-fiber foods such as:

• Fruits
• Vegetables
• Whole grains

Your dietitian will recommend that you eat fewer animal products and refined carbohydrates, such as white bread and sweets. This healthy eating plan is recommended for everyone, even people without diabetes.

PHYSICAL ACTIVITY:
Everyone needs regular aerobic exercise, and people who have type 1 diabetes are no exception. But get your doctor's approval to exercise first. Then choose activities you enjoy, such as walking, swimming and biking. Make physical activity part of your daily routine. Aim for at least 30 minutes of aerobic exercise most days of the week. The goal for children is at least an hour of activity a day. Flexibility and strength training exercises are important, too. If you haven't been active for a while, start slowly and build up gradually.

Remember that physical activity lowers blood sugar, ou might need to adjust your meal plan or insulin doses to compensate for the increased activity.

INVESTIGATIONAL TREATMENTS:

• Pancreas transplant: With a successful pancreas transplant, you would no longer need insulin. But pancreas transplants aren't always successful — and the procedure poses serious risks.
• Artificial pancreas: An emerging treatment approach, not yet available, is closed-loop insulin delivery, also known as the artificial pancreas. It links a continuous glucose monitor to an insulin pump. The device automatically delivers the correct amount of insulin when the monitor indicates the need for it.
• Islet cell transplantation: Researchers are experimenting with islet cell transplantation, which provides new insulin-producing cells from a donor pancreas.
• Stem cell transplant: In a 2007 study, a small number of people newly diagnosed with type 1 diabetes were able to stop using insulin for up to five years after being treated with stem cells made from their own blood. Although stem cell transplants, which involve shutting down the immune system and then building it up again — can be risky, the technique may one day provide an additional treatment option for type 1 diabetes.

TREATMENT OF LOW BLOOD SUGAR (HYPOGLYCEMIA):  If you have a low blood sugar reading:

• Have 15 to 20 grams of a fast-acting carbohydrate, such as fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar. Foods with added fat, such as chocolate or ice cream, don't raise blood sugar as quickly because fat slows down the absorption of the sugar.
• Retest your blood sugar in about 15 minutes to make sure it's normal.
• If it's still low, have another 15 to 20 grams of carbohydrate from juice, candy, glucose tablets or other source of sugar, and retest in another 15 minutes.
• Repeat until you get a normal reading.
• Eat a mixed food source, such as peanut butter and crackers, to help stabilize your blood sugar.

Always carry a source of fast-acting sugar with you. Left untreated, low blood sugar will cause you to lose consciousness. If this occurs, you may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. Be sure you always have a glucagon emergency kit available — at home, at work, when you're out — and make sure it hasn't expired.

PRECUATIONS:

• Make healthy food choices: Eat lots of fruits, vegetables, whole grains, and low-fat dairy products. Limit the amount of meat and fried or fatty foods that you eat.
• Be active: Walk, garden, or do something active for 30 minutes or more on most days of the week. Take advantage of the many opportunities you have each day to set a good example for your child. Take the stairs instead of the elevator. If you live a short distance to shops, then opt not to drive and walk with your child instead. Go on a walk together after dinner.
• Stop smoking: Smoking increases the chance that you will have a heart attack or stroke, or develop cancer.
• Lose weight: Being overweight increases the risk of many health problems.
• Avoid alcohol: Alcohol can increase blood sugar and blood pressure.

BLOOD GLUCOSE AND PHYSICAL ACTIVITY: Physical activity can cause blood glucose to drop. If your child's blood glucose level falls too low, it can cause hypoglycemia.

Here are a few ways you can help lessen the effect of physical activity on your child's blood glucose level:

• Give your child extra carbohydrates before the activity.
• Check your child's blood glucose level before, during, and after the activity.
• Prepare a kit that contains snacks, glucose tablets, fruit juice, water, and any medications that your doctor recommends for your child to take to practices and games.
• Be sure to check blood sugar levels more frequently after the activity and overnight to assess if insulin doses need to be adjusted.

FOOT CARE:

Preventive foot care can significantly reduce the risk of ulcers and amputation. Some tips for preventing problems include:

• Inspect your feet daily and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers.
• When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward.
• Apply moisturizers, but NOT between the toes.
• Gently use pumice to remove corns and calluses (do not use medicated pads or try to shave the corns or calluses by yourself).
• Trim toenails short and file the edges to avoid cutting adjacent toes.
• Well-fitting footwear is very important. Make sure your shoe is wide enough. Avoid high heels, sandals, thongs, and going barefoot. Shoes with a rocker sole reduce pressure under the heel and front of the foot and may be particularly helpful. Custom-molded boots increase the surface area over which foot pressure is distributed. This reduces stress on the ulcers and allows them to heal.
• Change shoes often during the day.
• Wear socks, particularly with extra padding (which can be specially purchased).
• Avoid tight stockings or any clothing that constricts the legs and feet.
• Consult a specialist in foot care for any problems.

IMMUNIZATIONS:

Patients with diabetes should be given the following immunizations:

• All standard childhood immunizations, on a standard schedule.
• Annual influenza vaccine (also recommended for all individuals six months of age and older). Children with diabetes should receive the inactivated (injectable) vaccine rather than the live attenuated (intranasal) form of the vaccine.
• Pneumococcal vaccine: Children with diabetes should receive the pneumococcal conjugate vaccine, which is recommended for all children. They should also be given thepneumococcal polysaccharide vaccine because they are considered to be at high risk for invasive pneumococcal disease.

There is no evidence for an association between immunizations and the development of type 1 diabetes.

REFERENCES:

• Global report on diabetes. World Health Organization, Geneva, 2016. (http://www.who.int/diabetes/global-report/en/)
• Projections of global mortality and burden of disease from 2002 to 2030. Mathers CD, Loncar D. PLoS Med, 2006, 3(11):e442.
• Frese T, Sandholzer H. The epidemiology of type 1 diabetes mellitus. In: Escher S, Li A, eds. type 1 diabetes. InTech, 2013:1–22.
• International Diabetes Federation. Key findings 2014. http://www.idf.org/diabetesatlas/update-2014
• Melmed S, Polonsky SK, et al. Williams textbook of endocrinology. 12th edn. Philadelphia: Elsevier/Saunders, 2011.
• Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of Diabetes: estimates for year 2000 and projections for 2030. Diabetes Care 2004; 27: 1047-53
• http://www.who.int/diabetes/country-profiles/pak_en.pdf?ua=1
• http://www.idf.org/membership/mena/pakistan
• http://www.webmd.com/
• http://www.mayoclinic.org/