Type 1 is the less common type of diabetes in which our pancreas stops making insulin quite suddenly. We get symptoms very quickly, and we need insulin treatment right from the start. Type 1 used to be called insulin-dependent diabetes.
Type 1 diabetes arises from damage to the pancreas caused by our immune systems. The system makes a mistake, attacking our own cells as if they were an invading bacteria. This auto immune reaction may be triggered by infection of some sort. As the islet cells (the ones which make insulin) are destroyed, we produce less insulin and the blood glucose rises. Glucose spills into the urine, and because glucose will form crystals if it is very concentrated, the kidneys can't concentrate it and we end up going to the toilet a lot more, just to get rid of all the glucose.
Insulin helps glucose get into cells, that then use it for energy. Without insulin, cells can't use glucose even though there is lots around, because it can't get into cells, so they turn to other sources of energy. We burn up fat instead, and ketones are a by-product of using that energy source. That's why we get ketones in the urine, and 'keto-acidosis' when our blood glucose is very high.
In type 1 diabetes glucose control alone is the name of the game, at least for the first 10 years. Insulin is the treatment, along with healthy eating, plenty of exercise and not smoking of course. In the first couple of years, most people can control their blood sugars easily because they still make a little insulin. Eventually, it gets more difficult. The aim of treatment is to reduce the symptoms of high blood glucose and prevent diabetes complications, keeping blood glucose as near to normal as possible without causing excessive hardship or unacceptable risk from hypos.
People who get type 1 diabetes today do not have to face the condition for life, because we are now very close to a choice of cures. By cure, I mean ways to control blood sugar without having to test or plan, inject or worry about ups and downs. These might be islet cell transplants, which are used in some countries but are not yet ready for general use, or an insulin pump driven by a long-term implanted glucose sensor. Another aim is to get to this cure in the best condition possible, so we can put the future risk of complications behind us.
In the past, insulin was administered in a glass syringe using a steel needle. Glucose meters weren't available. Test-tube kits were used for urine testing. Now there is a range of small syringes, pens, pumps, and fancy meters with downloadable memories – so there is no excuse for not taking care of yourself.
The 1993 Diabetes Control and Complications Trial (DCCT) followed a total of 1,400 teenagers and adults with type 1 diabetes over seven years. It compared usual care (once or twice daily injections and once a day glucose monitoring) with intensive insulin therapy, including the use of multi-dose therapy and insulin pumps. The intensive group did far better. The downside was a two to three-fold increase in serious hypos.
Here are some principles of good care (and self-care) to get you started:
Remember, the aim is to try for good control, but only as far as we can while leading a full, normal life.
A healthy diet with diabetes is a healthy diet for anyone (this will be covered in a later article).
Glucose rises when we eat, and it rises faster and further if we eat purified sugars (sweets, sweet minerals, table sugar).
It also rises when we get ill, because we then make hormones which make insulin less effective. That's why we still need plenty of insulin even if we are vomiting.
Ketones are a sign that our glucose is too high, for too long. We should all have strips to test our urine or blood for ketones.
Hypos are a natural consequence of trying for good control. They can be managed.
Exercise and alcohol lower blood glucose as well as insulin. Being tipsy and hypo at the same time is dangerous!
Busy people of any age need flexibility in their insulin regime, ie. twice daily insulin mixes mean you cannot miss lunch.
Flexibility comes from using multiple-dose insulin therapy or pump therapy.
Convenience comes from using a pen. Syringes are pretty much out of date now.
Protection from hypos at night comes from using new very long-acting insulin such as insulin glargine (Lantus]), and from testing morning and evening or even using a Minimed CGMS sensor from the clinic, or the Glucowatch to check overnight patterns occasionally.
Protection during the day comes from using shorter-acting analogue insulins like Novorapid or Humalog, and from testing regularly and thinking about how much insulin to take with each meal, based on what you are eating, your blood glucose level and any planned activity.
In summary, type 1 diabetes is all about insulin and can be managed with modern insulins and devices. Science and technology are making huge strides in defeating the condition, and life will continue to get easier over the next few years.
Written by Dr Tony O'Sullivan, chairman of the Diabetes Federation of Ireland
Copyright Diabetes Ireland
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