Type
1 Diabetes Or Juvenile Diabetes (Type I DM)Overview: This
form of diabetes mellitus occurs mostly in patients who are younger than 30 years
of age. Most of the time it happens in children or teenagers. A large number of
these patients have autoimmune antibodies in the blood directed against the beta
cells of the pancreas (in the Langerhans islets). The antibodies kill these
insulin producing cells until there is a severe shortage of insulin production.
This can lead to a sudden crisis, particularly when the metabolism is so much
out of control that the patient goes into a diabetic coma. Many research papers
have shown that type 1 diabetes is due to a combination of genetic factors and
environmental factors.
The
genetic factors are from susceptibility genes near the HLA-D
locus on chromosome 6. The environmental factors are due to various
viruses such as rubella, mumps or coxsackie B, which leads to a T lymphocyte stimulation,
but can in susceptible individuals overreact causing an autoimmune reaction against
the beta cells of the pancreas as shown in the link above. There might be other
factors from the environment such as a cross reaction between cow's milk protein
and beta cell protein resulting in the induction of autoantibodies. But there
are also possible other environmental factors as in certain European countries
there is a high incidence of type 1 diabetes, but in others there is not.
Type 1 diabetes requires insulin therapy, oral diabetes medication is not helping.
This makes sense in view of the fact that eventually there are no more insulin
producing cells left in the pancreas and one has to replace the missing insulin
with injections.
Juvenile
diabetes symptoms: With type 1 diabetes the symptoms may be those
of symptomatic hyperglycemia (high blood sugar), in which case the symptoms described
below would present over a longer period of time (weeks and months). Alternatively,
the patient might present with symptoms of severe metabolic derangement ending
up with mental confusion followed by a diabetic coma. With this latter presentation
the symptoms would come on extremely suddenly (within hours) and lead to a coma,
if untreated. This condition is called diabetic ketoacidosis
(see below). Symptoms from hyperglycemia: As
the blood sugar is significantly elevated, the kidneys are working under the pressure
of "osmotic diuresis", which means that there is increased urine output
from glucose that leaks into the urine. Normally there should
be no sugar in the urine and this is one of the first screening tests the doctor
would do. With juvenile diabetes the sugar in urine test would be positive. The
patient also gives a history of urinating large amounts of urine very frequently
(polyuria). The patient even may have noticed that urine drops around the toilet
have dried by leaving white spots of sugar behind. A lot of fluids are consumed
(polydipsia)
to keep up with the fluid loss through the kidneys and the
doctor may notice a significant weight loss when the present weight is compared
to the records (diabetes weight loss). Fatigue and nausea are common as are mouth
yeast infections, vaginal yeast infections or yeast infections of the buttock
creases. There are the same late complications as with type 2 diabetes and these
will be dealt with there.
Diabetic
ketoacidosis In the case of a newly diagnosed type 1 diabetic
this serious metabolic derangement occurs because of the acute lack of insulin.
Often, in patients who know that they have type 1 diabetes this episode is triggered
by them not taking insulin. Alternatively, there might be an acute infection,
acute trauma or a heart attack, which leads to a high blood sugar because there
was a discrepancy between supply and demand with regard to insulin. There
is severe dehydration from a strong osmotic diuresis with loss of electrolytes
(sodium and potassium loss) and water loss. The deranged liver metabolism also
feeds into the forced urine output because of strong diabetes ketones, which are
excreted in the urine as well. However, the kidneys can only work so hard and
the blood is getting more and more acidy (acidosis diabetic), which makes the
patient breathe deeper and harder in a typical pattern (Kussmaul breathing). The
mentation is slow with lethargy and sleepiness, which is a sign of impending disaster.
The next step could be a complete unconscious state as the ketones including acetone
causing brain anaesthesia. At this point the patient goes into a diabetic coma.
Often at this stage the blood pH is 7.0 or less when normal would be 7.36 to 7.44.
In other words the blood is very acidy, which increases mortality. Juvenile
diabetes diagnosis: Most of the diagnosis can be done by a history
and by a quick examination at the bedside with testing of a urine sample with
the dip stick method. This is a conveninet way of checking for glucose in urine
and urine ketones. However, later the physician will want to check for the three
elements that make the diagnosis: 1. High glucose level in the blood
2. High levels of ketone bodies in the blood (the lab will report these as acetoacetic
acid and beta-hydroxybutyric acid) 3. Metabolic acidosis (determined by
blood test): this is an accumulation of acids in the blood because of the uncontrolled
diabetes. ADVERTISEMENT
All
of these elements are connected : number 1 above shows that there is uncontrolled
diabetes due to a lack of insulin, number 2 shows that this has lead to a deranged
liver metabolism. And number 3 shows the results of the deranged liver metabolism,
which has lead to metabolic acidosis with various degrees of severity. Associated
with the metabolic acidosis are often severe electrolyte abnormalities such as
hyperkalemia (high potassium count) and high blood nitrogen urea levels (indicating
signs of kidney failure). High amylase levels are often present as well. An infection
is not uncommon as the high glucose levels in all the tissues are an ideal breeding
ground for bacteria and the physician will check for this.
| Diabetes, the
silent killer: | Unfortunately
diabetes is often not apparent to the patient until suddenly a serious course
such as a diabetic ketoacidosis sets in with a sudden coma. Here is a list
of symptoms that tell the patient that it is time to see a physician to be checked
out change of mental alertness with forgetfulness, memory and concentration
problems frequent urination and weight loss despite a hunger
for food with sugar content ("osmotic diuresis")frequent
yeast infections in mouth cavity, vagina and buttock creaseschanges
of prescriptions for people with glasses or contact lenses, but the optometrist
might get different corrective lens readings on different days (the lens of the
eye is very sensitive to blood sugar changes in the blood). Others will experience
blurred vision for no apparent reasonfoot ulcers or wounds that
do not want to heal |
| Juvenile diabetes treatment: As the
patient with type 1 diabetes is usually not overweight, a weight loss program
is not necessary. However, the physician will likely consider a brief hospitalization
for the newly diagnosed mild to moderate case. This will allow to do all
the blood tests in quick succession and carefully restore the metabolism to normal.
The patient is started on insulin injections and an educational program on juvenile
diabetes information
is started at the same time. Depending on the response
to the injections shots are needed once, twice or three times per day. It is important
that reactive hypoglycemia from an inadvertent insulin overdose is avoided. On
the other hand the patient needs to learn how to use the home glucometer,
where initially daily blood sugars are measured fasting, and 30 minutes before
meals. All of these values are recorded so that the physician can check these
values at a future date. Newer data has shown that a close control of the blood
sugars will prevent damage to the arterial walls, to the target organs like heart,
kidneys, brain and retinas of the eyes.
Here is a brief
overview regarding the complex topic of insulin injections:
- The majority of adults patients will require around 40 IU (international units)
of insulin per day. This is given divided into 3 doses, 20 IU before breakfast,
10 IU before dinner and 10 IU before bedtime. Glucometer readings of blood sugar
are initially done 4 times per day and later, when things are stabilized about
2 or three times per day. Depending on the glucosometer readings of the blood
sugars the insulin dosages are customized to bring the sugars in line with what
is normal.
- Insulin comes in different types, the short acting insulin(or
Toronto insulin), the intermediate acting insulin(also NPH insulin or lente insulin)
and the long acting insulin (or ultralente insulin). On top of that there are
various mixtures where a smaller percentage of intermediate acting and a larger
percentage of long acting insulin is mixed into one bottle, Novolin ge 10/90 or
Humulin 30/70 for instance, which are brand names. The advantage of such fixed
mixtures is that the patient does not have to mix two separate insulins and this
way less mistakes are made.
- The patient must work closely together
with knowledgeable therapists such as trained nurses with experience in diabetes
or doctors. It is important to go slow and check glucometer readings frequently.
Somebody needs to check the technique of the patient from time to time until it
is a routine.
- The patient must know how to recognize a hypoglycemic
reaction. This can occur because the patient may have mixed up insulins
and inadvertently have given too high a dosage. Alternatively the patient may
have exercised and used up glucose in the process of the increased metabolism
thus leading to a net loss of the glucose pool with resulting hypoglycemia. Or
the patient may have skipped a meal, but carried on with the same dose of insulin.
The diabetics are taught in diabetes classes to always carry pieces of sugar or
candies with them, just in case of a hypoglycemic reaction. For emergencies when
a patient passes out, some physicians train the immediate family members how to
inject glucagon, the natural body hormone to counteract insulin. The diabetic
patient should carry a diabetes Medical Alert bracelet. This will clarify his
condition to emergency personel.
- Never freeze insulin! Some, if not all
of the activity would be lost. Insulin should be stored in the fridge for a longer
shelf life, but most insulin preparations now are stable at room temperature for
several months. Check with the pharmacist about the particular brand you are using. It
would be beyond the scope of this summary to be more detailed about insulin injections.
See your family doctor or specialist for more details regarding your own situation.
Ask your physician for a repeat hemoglobin A1C blood test every
3 months to monitor how well the blood sugar is controlled.
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