Type 1 Diabetes

 

The Problem

Type 1 diabetes (T1D) is the most common type of diabetes occurring in childhood and adolescence. Most cases of T1D are due to destruction of the pancreatic B-cells (which make insulin) by T-cells (white blood cells concerned with the immune system). This is a type of autoimmune destruction, wherein the body destroys part of itself.

The B-cells are destroyed at a variable rate. Clinical symptoms of T1D occur when 90% or more of the cells are destroyed, so that sufficient insulin cannot be produced. In the absence of insulin, glucose in the blood is unable to move into the cells, and the blood glucose (BG) level rises while cells lack glucose to produce energy. This causes the person with diabetes to be tired, eat more, and yet lose weight.

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Global Scenario of T1D

Prevalence estimates indicate that there are almost 500,000 children (<15 years) with T1D worldwide, the largest numbers being in Europe (129,000: 78%) and North America (108,700), and the lowest in countries in sub-Saharan Africa (8%). Countries with the highest estimated numbers of new cases annually are the United States (13,000), India (10,900) and Brazil (5,000).

Monogenic diabetes (due to a gene defect) is increasingly being recognized among those with clinical features of T1D or T2D, as genetic studies become available, but population-based data show wide variation in incidence and prevalence due to lack of standardization in the studies. Similarly, studies on T2D in childhood suggest increased incidence and prevalence in many countries, but detailed population-based studies are limited.

 

Type 1 Diabetes: The Indian Context

The incidence of T1D in India is found to be rising by 3% per annum, especially in younger children, with about 70,000 children newly diagnosed every year. A report from Chennai city (urban area) in 1996 reported an incidence of 10.5/100,000 population. Another report from Karnal (Haryana), found a prevalence of 26.6/100,000 in urban and 4.27/100,000 in rural areas of the district, with an average prevalence of 10.20/100,000 population.

Type 1 Diabetes: Causes

The pancreas is an organ about the size of a hand, located behind the lower part of the stomach. It makes hormones (endocrine function) and digestive juices (exocrine function). The endocrine cells are arranged in groups called the islets of Langerhans, and include the ß-cells (they make insulin, which controls BG and fats in the body), a-cells (they make glucagon, which increases BG), and d-cells (they sense BG and inform the a- and ß-cells). T1D occurs when the body’s immune system attacks and destroys the ß-cells, so the production of insulin is reduced greatly. Insulin allows the glucose in the blood stream to move into cells throughout the body, so it can be used for energy. When insulin is not made, the glucose stays in the blood stream, where it causes serious damage to all the organ systems of the body.

People with T1D must take insulin in order to stay alive. Because insulin is a peptide which gets digested when it reaches the intestine, it must be injected into the body. Because insulin is needed to handle the glucose absorbed after food is eaten, it must be injected multiple times daily, or delivered multiple times through an insulin pump, before each major meal. In order to know how much insulin is needed, BG must be tested multiple times a day, by pricking a finger for a drop of blood. People with diabetes must also carefully balance their food intake and their exercise to regulate their BG levels, so that they avoid hypoglycemic (low BG) and hyperglycemic (high BG) reactions, which can be life threatening.
 

Type 1 Diabetes: Symptoms

Symptoms may develop suddenly over a few days, or gradually over days to weeks, and can vary from person to person.

Classic symptoms include:

  • Excessive thirst and water intake (POLYDIPSIA)
  • Excessive urination (POLYURIA)
  • Excessive food intake (POLYPHAGIA)

T1D symptoms can surface quickly and may include:-

  • Unexplained weight loss
  • Dry month
  • Frequent urination
  • Fatigue
  • Blurred vision
  • Sweet, or wine-like odor on breath
  • Labored breathing; stupor; and unconsciousness

Type 1 diabetes is generally diagnosed in children, teenagers, or young adults, but can occur at any age. Scientists know that autoimmune, genetic, and environmental factors are involved, but do not yet know what exactly triggers the process off.

 

Prevention and Cure

Widespread research is underway worldwide to find a sustainable cure for T1D. Many advances have been made since insulin was discovered in 1922, which enable persons with T1D to live normal, productive lives. However, for now, there is no curative treatment available.

The types of Insulin are available for managing diabetes are:

The Rapid Acting Insulin is used as bolus (given before each meal). Its’ action starts in 5-15 minutes, peaks in 30-60 minutes, and is over in 2-4 hours.

Short acting insulin (also known as ‘regular’ or ‘plain’ insulin) starts acting in 30 minutes, peaks at 2-3 hours, and lasts for 5-6 hours.

Intermediate acting insulin is a cloudy looking liquid, since insulin is in suspension: it starts in 2-4 hours, peaks at 4-8 hours, and lasts for 10 to 18 hours.

Long acting insulin has a relatively peak-less action profile, lasting for about 12-24 hours. This is use to provide the basal needs of the body.

The amount and frequency of dosage is determined by the frequency of meals and the BG level. The child and family must learn how to monitor BG, how to load and inject insulin, and how to decide the dose of insulin. The doctor guides the family how to regulate the insulin doses based on the BG reading, the type and quantity of the meal to be taken, and the activity levels. Insulin can be taken by a syringe, a smaller convenient pen device, or by continuous subcutaneous insulin infusion (CSII) through a portable pump.

Precautions

  • 1Insulin being a peptide, gets spoilt at temperatures below 2°C or above 25°C. Insulin should be kept in a cool environment, and never left in a vehicle or in the hold baggage of an aircraft.
  • 3Excessive sweets and oily food are harmful: not just the BG but also the blood pressure, and blood cholesterol levels increase with such foods.
  • 2Predictable eating habits and activity levels make it easier to manage the BG well.
  • 4Fasting, e.g. during Ramzan and Navratri should be avoided by persons with T1D, as hypoglycemia can lead to coma, and even death.
  • 5To avoid coma caused by hypoglycemia, persons with T1D should always carry an identity card and some sugar/ sweet candies in their pockets.