Diabetes type 1

Diabetes mellitus is a condition where the glucose in the blood is too high. It is due to no insufficient insulin production, insulin not working effectively, or a combination of both. In the case of type 1 diabetes, the issue is that insulin is no longer produced and therefore there is absolute insulin deficiency.

Insulin is a hormone made by the beta cells in the pancreas. The role of insulin is to lower blood glucose levels by carrying glucose from the blood to the muscles. Glucose is the body’s form of sugar which gives the body energy to function.

In a person without diabetes, glucose levels are always kept within the normal range because insulin and other hormones are perfectly balanced.

All people with type 1 diabetes need insulin therapy to manage their condition. Most people with type 1 diabetes inject insulin multiple times a day or deliver insulin via an insulin pump.

What is type 1 diabetes?

Type 1 diabetes is an autoimmune condition, which means that the body’s own immune system attacks the cells of the pancreas that produce insulin by mistake. This causes the pancreas to stop producing insulin.

As a result, glucose in the blood rises because it cannot enter the muscle cells without insulin. When the blood glucose rises above 15.0 mmol/L, a person will usually have signs and symptoms of high glucose levels (also known as hyperglycaemia).

What are the signs and symptoms of hyperglycaemia or diabetes?

Some signs and symptoms of type 1 diabetes are:

• Feeling very thirsty
• Urinating a lot more often, including overnight
• Feeling very tired
• Blurred vision
• Infections or thrush that reoccur
• Wounds that are slow healing or won’t heal
• Rapid weight loss.

If diagnosed and treated with insulin as soon as symptoms occur, a person with type 1 diabetes may not get to the point of feeling very unwell.

If signs and symptoms are missed, and the person does not get medical help early enough, glucose levels will begin to rise dangerously high. When this happens, and the body does not receive insulin, the body starts to break down its own fat stores for energy. The result of fat breakdown is ketones being produced. Ketones are seen in the urine with a urine dipstick test or in the blood via finger prick or a blood test via the vein.

Ketones are an acid. They are toxic when they rise above a certain level in the blood. This acidic state is called diabetic ketoacidosis, or DKA for short, and it results from a lack of insulin. The signs and symptoms of DKA include:

• Signs and symptoms of hyperglycaemia (as outlined above)
• Nausea and vomiting
• Abdominal cramps
• Severe dehydration
• Fast or unusual breathing
• Reduced consciousness
• Coma.

If DKA is not treated promptly it can lead to death.

DKA is preventable in most cases. Some people have DKA by the time they are diagnosed with type 1 diabetes because their symptoms have been mistaken for another condition such as gastroenteritis, causing a delay in treatment.

DKA can develop in people already diagnosed with type 1 diabetes when:

1. They have an illness or infection, but they don’t increase their insulin doses or don’t treat the underlying cause of their illness
2. They have omitted or forgotten to take their insulin
3. They take steroid therapy for a condition such as asthma or cancer but do not increase their insulin doses to manage high glucose or ketone levels

What causes type 1 diabetes?

The exact cause of type 1 diabetes is unknown and there is no cure.

We do know that people who develop type 1 diabetes have the genes for developing the condition. However, not all people with the genes develop type 1 diabetes.

Something in the environment, such as a virus, triggers the immune system to attack the beta cells of the pancreas.

The Rotavirus has been linked with the development of type 1 diabetes. Research has found that since the Rotavirus vaccine was developed in 2007, the incidence of type 1 diabetes in children under 5 has decreased.

Other research has shown that Vitamin D supplementation can be protective against developing type 1 diabetes and that Vit D deficiency may increase the risk of developing type 1 diabetes.

Most people diagnosed with type 1 diabetes have no other relative with the condition. However, if you have a mum or dad, brother or sister with type 1 diabetes, you do have a higher chance of developing type 1 diabetes. Also, if you or a family member has another autoimmune condition such as coeliac or thyroid disease your risk of developing type 1 diabetes increases.

Who develops type 1 diabetes?

Type 1 diabetes is usually diagnosed in childhood, teenage years (the peak age is 10-14 yrs old), or in early adulthood before the age of 30, but it can be diagnosed at any age.

Latent autoimmune diabetes in adulthood (LADA), also known as type 1.5 diabetes, is also autoimmune in nature. However, it develops more slowly than classic type 1 diabetes.

People with LADA often get misdiagnosed as having type 2 diabetes because they have some of the features of type 2 diabetes:

• do not usually need insulin at diagnosis
• are above the age of 30
• may be overweight.

People with LADA will usually need insulin therapy within 6 months to 6 years from diagnosis. 10% of people originally diagnosed with type 2 diabetes actually have LADA.

Diagnosis of type 1 diabetes

Although, diabetes is confirmed by a fasting or random blood glucose via a pathology blood test, it is likely to be detected with a urine test. Signs and symptoms of diabetes or hyperglycaemia (as listed above) should prompt a doctor to check the urine for glucose and ketones. If a blood glucose and ketone meter is available, a glucose and ketone check should be done via finger prick.

Children and teenagers with glucose in their urine or a high blood glucose result should always be sent to a major hospital for immediate and urgent management.

If the diagnosis isn’t clear, a blood test is performed to check for autoantibodies to distinguish type 1 from type 2 diabetes. Type 1 autoantibodies show that the body has created antibodies against its own insulin producing cells.

Management of type 1 diabetes

In a person without diabetes, insulin is released by the pancreas in 2 ways:

1. Continuously, 24 hours a day, to provide energy for all of the essential functions of the body such as breathing and digesting food.
2. In spurts, when meals are eaten

Normally, insulin levels increase and decrease to continually meet all the body’s needs, while also helping keep blood glucose levels in range.

Examples of when your body needs to make more insulin:

• carbohydrate food is eaten.
• the body is under stress such as during illness
• weight increases

Examples of when your body makes less insulin:

• carbohydrate food hasn’t been eaten for several hours
• exercising, because during exercise, muscles use more glucose.
• weight decreases

The goal of type 1 diabetes management is to copy the normal release of insulin that someone without diabetes has. This will keep blood glucose levels as close to the normal range as possible. To do this, many people with type 1 diabetes use a flexible insulin regimen.

A flexible insulin regimen can be achieved by insulin injections or an insulin pump and includes having:

1. Basal insulin that works 24 hours a day
2. A bolus or meal time insulin:

• To match carbohydrate eaten
• To correct or lower glucose levels that are above target

A flexible insulin regimen allows a person with type 1 diabetes the choice to:

1. eat at varying times, with as much or as little carbohydrate they want
2. fast for a blood test, medical procedure or religious festivity without causing unstable glucose levels
3. exercise and avoid hypoglycaemia (low blood glucose level)
4. lose weight safely

A person with type 1 diabetes needs to learn many self - management skills. This includes:

• injecting insulin multiple times a day or using an insulin pump
• rotation of injection sites to prevent lipohypertrophy (thickened or scarred area of fat under the skin where insulin is repeatedly injected). This can delay insulin absorption and cause unstable glucose levels.
• self-monitoring of glucose levels with a glucose meter
• hypoglycaemia management, including the prevention and treatment
• counting carbohydrate accurately in foods and drinks and matching quick acting insulin to the amount of carbohydrate eaten
• adjusting carbohydrates and insulin to manage exercise
• managing sick days, including checking for blood ketones and knowing how to adjust insulin, and carbohydrates, to manage illness
• learning how to adjust management when drinking alcohol.
• In addition, people with diabetes need to have an annual cycle of care and maintain regular checks to detect any diabetes complications early as well as have regular immunisations for influenza, pneumococcal disease and whooping cough.

Hypoglycaemia

Hypoglycaemia (also known as a hypo) is a glucose level of less than 4.0mmol/L. Hypos are a side effect of insulin therapy.

A person without diabetes does not experience hypoglycaemia because insulin and other hormones are always perfectly balanced to keep glucose in range.

A person with diabetes needs education and training to understand how to adjust insulin and carbohydrate to prevent hypoglycaemia, and to treat hypoglycaemia when it occurs.

Hypoglycaemia occurs when insulin injected outweighs insulin needed by the body. People with diabetes can have frequent and severe hypos if they do not have a flexible insulin regimen.

If a person uses a flexible insulin regimen and has their insulin doses assessed regularly and as needed, the risk of hypos is reduced.

Hypos are more likely to occur during or after exercise, and after alcohol intake.

Due to the limitations of the insulin injecting tools and insulins available, it is impossible to keep BGLs in target range all of the time. Almost everyone with type 1 diabetes will experience a hypo at some point.

Having 1 or 2 mild hypos per week is common for many.

For more information on hypoglycaemia, see the National Diabetes Services Scheme (NDSS) hypoglycaemia resources.

Diabetes complications in type 1 diabetes

Over time, high glucose levels can damage nerves, vessels, tissues and organs of the body.

Complications may be:

• kidney damage (nephropathy)
• eye damage (retinopathy)
• nerve damage to feet (peripheral neuropathy) which can lead to lower limb amputation
• heart and vessel disease and stroke
• gum and tooth disease
• sexual dysfunction in both men and women.
• damage to the nerves that control the automatic functions of the internal organs such as digestion and bowel function, blood pressure and heart rate (autonomic neuropathy)

Other complications

Many people with diabetes experience diabetes distress (a normal emotional response to the burden to caring for diabetes). Support groups are available, either in person or online for people with type 1 diabetes. Support groups can help people to feel less isolated or alone with their condition. Counselling can also be helpful.

Education programs

Structured diabetes education programs are considered the gold standard for achieving self-management skills and making long term behaviour change.

The OzDAFNE and FlexIT programs are examples of structured programs available to people with type 1 diabetes.

Advances in technology

Modern technology is providing different options for people with type 1 diabetes to manage their condition. Insulin pumps have allowed people to improve and fine tune their glucose levels.

New glucose monitoring devices such as flash glucose monitoring (FGM) and continuous glucose monitoring systems (CGMS) have allowed people to improve their overall management whilst reducing their risk of hypoglycaemia.

Combining pump and sensor technology allows for automatic suspension of insulin pumps if glucose levels fall too low or, in some systems, if glucose levels rise too high.

This technology can improve quality of life for some and reduce anxiety and fears surrounding hypos and long-term complications.

However, this technology may not be affordable for some. The NDSS (National Diabetes Services Scheme) has subsidies to help people with type 1 diabetes. There is an eligibility assessment form to obtain discounted CGMS and FGM and insulin pumps.

The JDRF Insulin Pump Program provides pumps to low income families.

Where to get help

• Your GP (doctor)
• Endocrinologist (Diabetes specialist)
• Credentialled Diabetes Educator
• Accredited Practising Dietitian
• Psychologist or counsellor

Type 1 support groups

• Juvenile Diabetes Research Foundation Australia Tel. 1300 363 126
• Diabetes Australia Victoria Tel. 1300 437 386
• Life! Helping you prevent diabetes, heart disease and stroke Tel. 137 475
• Baker Heart and Diabetes Institute Tel. (03) 8532 1111