Type 1 diabetes mellitus (DM type 1) is the second most common form of diabetes. The blood sugar level rises due to the chronic disturbance of the sugar metabolism. DM type 1 is caused by an autoimmune reaction: instead of fighting hostile, foreign cells, the immune system attacks the body's own structures. It destroys the cells in the pancreas that make insulin, a hormone that controls blood sugar levels. Type 1 DM often first appears in childhood or adolescence. This is why the disease used to be called “juvenile diabetes”. But DM type 1 can also break out in adults. Symptoms usually appear early in the course and are distinct. Those affected have to inject insulin or so-called insulin analogues throughout their lives to replace the hormone that is missing in their body.
By far the most common form of diabetes is type 2 diabetes mellitus (DM type 2). In addition, gestational diabetes (type 4 diabetes mellitus) is common among women.
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| Treatment of type 1 diabetes mellitus |
Type 1 Diabetes Mellitus Causes And Risk Factors
In type 1 DM, an autoimmune reaction destroys the cells in the pancreas that make insulin. One speaks of an autoimmune reaction when antibodies of the immune system are not directed against foreign substances, but against those from the own body. Why the immune system makes this mistake in DM type 1 is only partially known. Specialists know that several genes play a role. Children of parents with type 1 DM have a higher than average risk of also developing it. However, the connection with heredity is weaker than with DM type 2, and other factors probably also have an influence. Exactly which one is uncertain. Among the possible candidates, the experts include some viral diseases, certain foods in childhood, toxins and too short a breastfeeding period.
Risk factors
Genes, nutrition during infancy and infections influence the risk of developing the disease. However, it is still uncertain how much influence they have on individual foods and viral diseases.
- Genetic predisposition: About 20 genes are known to play a role in type 1. Children of fathers with type 1 DM are at higher risk than those of affected mothers. The influence of the genes is not as strong as in DM type 2.
- Infections: Respiratory diseases in infancy, infections with viruses (e.g. by Coxsackie B, mumps, measles and rubella viruses) are suspected of supporting the development of DM type 1.
- Diet: There is preliminary evidence that certain foods and deficiencies favor the development of DM type 1. These include vitamin D deficiency, cereals containing gluten in infancy and cow's milk in the first three months of life if breastfeeding is too short. Some chemical substances (e.g. toxins from rotten spots on root vegetables such as potatoes and carrots, nitrosamines) may also influence the risk of disease.
- Intestinal flora, hygiene, caesarean section: recent studies have indicated that an intestinal flora that contains many types of bacteria reduces the risk of immune diseases such as type 1 DM. Excessive hygiene and caesarean births reduce the diversity of species in the intestine, as does antibiotic therapy.
Symptoms of Type 1 Diabetes Mellitus
Are you constantly thirsty and drink a lot?
Are you urinating unusually often?
Is your skin very dry and sometimes itchy?
These symptoms are considered typical of DM type 1. They appear as soon as the immune system has destroyed around 80% of the cells that produce insulin. In young people, this usually happens quickly, so that insulin production stops quickly. Accordingly, the typical symptoms often start suddenly and clearly. The first sign of the disease can even be a complication (ketoacidosis). DM type 1 is mostly noticeable in childhood, adolescence or young adulthood, which is why the disease used to be called “juvenile diabetes” or “juvenile diabetes”. These terms are considered obsolete. DM type 1 can also break out at an advanced age. Then the symptoms are often quite mild at first, but soon intensify. Typically, DM type 1 manifests itself through symptoms such as these:
- Excessive thirst (polydipsia)
- Increased urination (polyuria)
- Dry skin, itching
- Weight loss for no reason
- Weakness, tiredness, exhaustion, poor performance, dizziness
- Visual disturbances
- Increased tendency to infections, poor wound healing
- Nausea, abdominal pain, vomiting
- Acetone odor on breath (similar to the smell of overripe fruit, varnish, or nail polish remover)
Diabetic ketoacidosis and ketoacidotic coma
Diabetic ketoacidosis is often the first sign when DM type 1 appears. In addition, ketoacidosis occurs as a frequent complication over the course of the disease. They appear annually in up to 5 out of 100 people affected. The cause is a sharp rise in blood sugar (acute hyperglycemia). Type 1 DM lacks insulin, so the body cells cannot absorb glucose from the blood. The blood sugar level rises. At the same time, the cells lack energy in the form of sugar. In order to create a balance, the metabolism adjusts. Among other things, this means that many substances with a certain chemical form get into the blood – so-called ketone bodies. They acidify the blood. When the blood becomes too acidic, doctors generally speak of acidosis, here of (diabetic) ketoacidosis. Acidification disrupts other processes in the metabolism. It gets completely out of whack or "derails". Diabetic ketoacidosis can present with symptoms such as:
- Those affected compulsively breathe more frequently and deeply. The body tries to release more carbon dioxide with the air we breathe so that the blood becomes less acidic.
- Breath smells of acetone, as does urine.
- Those affected often suffer from nausea, severe abdominal pain and vomiting.
- You have a strong feeling of thirst, but pass so much urine that the body loses a lot of fluid. This can lead to new problems.
- Drowsiness, listlessness and disturbances of consciousness up to unconsciousness (ketoacidotic coma) can occur.
Call an ambulance immediately!
Patients with diabetic ketoacidosis or diabetic coma must be hospitalized immediately. The events can be life-threatening: Between 5 and 10 out of 100 people affected die as a result of a ketoacidotic coma!
Type 1 diabetes mellitus with a later onset
Sometimes DM type 1 does not become established until later adulthood, usually between the ages of 25 and 50. Then insulin production often slows down. The typical symptoms also appear slowly and are comparatively mild at first. Those affected initially respond to medication (oral antidiabetics) and not just to insulin alone. This form is similar to DM type 2. However, those affected have exactly those antibodies in their blood that are characteristic of the autoimmune disease DM type 1. That is why experts refer to this unusual form as "late onset autoimmune diabetes in adults" or LADA (late onset autoimmune diabetes in the adult). The oral antidiabetics lose their effect within a short time, those affected will soon have to switch to insulin - like all other type 1 diabetics. LADA and the early Type 2 are often confused because they are superficially similar. Distinctive features for LADA can be:
- Strikingly young age for DM type 2, i.e. 50 years or younger
- Slim figure, not overweight or low body mass index (BMI)
- Medications to be taken (antidiabetics) lose their effectiveness quickly.
- Patients respond well to insulin administration.
- Patients have other autoimmune diseases.
- There are or have been other cases of autoimmune diseases in the family.
- Doctors can also find other clues in the blood (e.g. low insulin levels, typical antibodies).
Treatment of Type 1 Diabetes Mellitus
In order to recognize DM type 1, the typical and usually severe symptoms are usually sufficient. Subsequent measurements of blood sugar and other substances (e.g. autoimmune antibodies) confirm the diagnosis of the disease and the type.
Various measurements of blood sugar
Four different blood sugar values appear in connection with diabetes mellitus. Your units of measurement (mmol/l or mg/dl) and the level of the limit values can differ - depending on whether the blood sample comes from a fingertip (capillary blood) or a vein (venous blood).
- The fasting blood sugar (fasting glucose, fasting plasma glucose) is measured after a fasting phase of at least eight hours. During this time, test subjects are not allowed to consume any calories – i.e. neither food nor sweet or nutritious drinks. Therefore, the measurement almost always takes place in the morning before breakfast.
- The occasional blood sugar (blood glucose, occasional plasma glucose) can be determined at any time during the day.
- For the two-hour blood sugar value (two-hour glucose, two-hour plasma glucose), a measurement takes place two hours after the ingestion of a precisely defined amount of glucose. It is an oral glucose tolerance test (OGTT) in which the test person drinks a solution containing 75 grams of glucose. After that, usually several blood sugar measurements are taken over a period of two hours at specific time intervals. Test subjects must be sober at the beginning of the test, i.e. they must not have eaten any calories for eight to twelve hours beforehand.
- Doctors refer to the HbA1c value as average blood sugar (blood sugar memory, long-term blood sugar, saccharified hemoglobin). This is a form of the red blood pigment hemoglobin (Hb) to which a sugar has attached itself. The higher the blood sugar level, the more hemoglobin is saccharified - the more red blood cells contain saccharified Hb, i.e. HbA1c. Since this connection is stable and red blood cells live for an average of eight weeks, doctors can use the HbA1c value to see how much sugar was in the blood over the past few weeks: The HbA1c value corresponds to the average blood sugar level over the past eight to twelve weeks. It is mostly used in treatment to adjust blood sugar, the measurement can take place regardless of the time of day. Incorrect results can be caused by certain blood diseases, heavy blood loss, blood transfusions, liver diseases (e.g. cirrhosis, insufficiency), kidney weakness, iron deficiency and pregnancy. Most often, HbA1c values are expressed as a percentage, although the official unit is millimoles per mole (mmol/mol).
The following measured values apply as limit values for diabetes:
- Fasting blood glucose: ≥ 7.0 mmol/L (126 mg/dL)
- Casual blood glucose: ≥ 11.1 mmol/L (200 mg/dL)
- Two-hour blood glucose (OGTT), capillary: ≥ 11.1 mmol/L (200 mg/dL)
- Average blood glucose (HbA1c): ≥ 6.5% (48 mmol/mol)
Diabetes therapy - goals and drugs
The goals of the therapy are determined individually and jointly by the doctor and patient. On the one hand, the treatment must lower the elevated blood sugar to such an extent that symptoms subside, the patient's quality of life improves, there are no complications and the risk of secondary diseases is reduced to a minimum. At the same time, it is important to prevent blood sugar from falling too low and dangerous hypoglycaemia from occurring. The therapy must therefore avoid values that are too high or too low: The blood sugar may only fluctuate within a certain range. Therefore, the amount of insulin must also be individually matched to the amount of carbohydrate intake and consumption.
As a rule, doctors recommend that patients take part in training. It provides comprehensive information on what negatively influences the disease, what needs to be considered during therapy, what mistakes many patients make and how everyday life with diabetes can be made as uncomplicated as possible. Through training, the patients themselves become experts in their disease. The imparted knowledge and practical tips enable them to take more responsibility for the therapy and their own health.
- Oral antidiabetics are only used in exceptional cases in DM type 1, for example at the beginning of LADA. The drugs require the body to produce at least a little more insulin. Most drugs either promote insulin production or improve the action of insulin. The drug group includes numerous active ingredients for oral administration from different substance families such as the biguanides, sulfonylureas, glinides, glitazones, alpha-glucosidase inhibitors and DDP-4 inhibitors.
- Insulins and insulin analogues are the drugs of choice in type 1 DM. They replace the body's own insulin when it can no longer produce it. Treatment is either with bioengineered human insulin (which is chemically identical to the natural human hormone), insulin of animal origin (usually porcine insulin, which differs in one component from human insulin) or insulin analogues. The latter are very similar to human insulin and have a comparable effect. Insulins are classified according to their duration of action. Short-acting insulins or insulin analogues work immediately or after a few minutes. They reach their greatest effect in one to two hours, the duration of action is four to eight hours. This group includes the chemically unmodified insulin without retarding additives, also known as normal insulin or old insulin, since it was the first insulin used to treat diabetes. With long-acting insulins or insulin analogues, the effect occurs slowly and runs evenly without peaks. Some remedies work for more than 40 hours. Insulin analogues achieve their longer effect through a slightly different chemical structure. Added substances (e.g. zinc, certain proteins), on the other hand, delay the effect of insulin. Such active ingredients are also called delayed insulin, depot insulin, basal insulin, basic insulin, long-term insulin or intermediate insulin. Combinations of short-acting and long-acting insulins are also called mixed insulin. The insulin preparations are almost exclusively injected into the subcutaneous fatty tissue, mostly on the abdomen. Unfortunately, it is impossible to take insulin orally because the gastric juices would destroy the hormone. Too little insulin gets into the blood with sprays. Inhalation powders are currently being tested, as are bioreactors with cells that produce insulin. Patients could receive the bioreactors in small containers as implants. An alternative to syringes and pens are currently jet injectors that force insulin through the skin.
Treatment of type 1 diabetes mellitus
Patients with type 1 DM have to replace insulin throughout their lives because their bodies lack it. There are basically two therapy concepts for this. In addition, the experts recommend patient training so that those affected get to know all the circumstances that affect their illness favorably or unfavorably.
Most patients with DM type 1 undergo intensified insulin therapy. They inject insulin preparations with an insulin pen or, more rarely, with disposable syringes. Insulin pens are injection tools the size of a thick ballpoint pen. The devices that are most common in our country work with interchangeable ampoules. The amount of preparation can be adjusted before the injection. Compared to disposable syringes, pens are considered to be easier and less conspicuous to use. For basic care, patients inject themselves with a long-acting preparation once or several times a day. In addition, they inject short-acting preparations as needed, i.e. at meals or to compensate for increased sugar levels.
Insulin pump therapy works exclusively with short-acting insulins or insulin analogues. A programmable pump constantly supplies the body with the required amount of insulin. If there is a special need, such as at mealtimes, patients can increase their dose using a small keyboard. As a result, and thanks to precisely coordinated programming, the dosage can be adjusted more precisely and according to requirements than with syringes. Usual insulin pumps are about the size of mobile phones. Patients wear them all the time, but can temporarily take them off if necessary. The insulin enters the body from the pump via a type of tube (catheter) and an injection needle. There are smaller disposable models that do not require a hose.
Patients with DM type 1 do not need to follow any diets, i.e. they do not have to do without sugar or certain other foods. But they have to adjust their insulin dosage to the carbohydrate intake. Physical activity cannot have a positive effect on the disease either, but it does improve general health. Sufficient exercise and a healthy diet are therefore by no means unimportant. In addition to DM type 1, many patients have other risk factors for cardiovascular disease, the most common cause of death in diabetics.