Diabetes - Type 1

Introduction

Diabetes is a disease that affects how the body uses glucose, a sugar that is used as a source of fuel for the body.  Normally, the hormone insulin helps glucose enter the cells where it is used for energy.  People with diabetes do not produce insulin, do not produce enough insulin, or the insulin does not work like it should.  As a result, glucose does not get into the body’s cells and stays in the bloodstream.  Too much sugar in the blood makes people ill and can result in medical complications. 

There are different types of diabetes.  Type 1 diabetes is an auto-immune disorder.  During the disease process, the body mistakenly recognizes the cells that produce insulin as foreign and kills them off.  As a result, people with type 1 diabetes do not produce insulin.  There is no cure for type 1 diabetes, and it cannot be prevented.  It is a lifelong condition.  Type 1 diabetes must be treated with insulin.  In the case of type 1 diabetes, a person’s diet or lifestyle does not contribute to the development of the disease.

Type 1 diabetes usually appears before the age of 20, although people older than this may be diagnosed with the disease.  It was formerly called “juvenile diabetes” or “insulin dependent diabetes”.  People with diabetes need to diligently manage their disease to remain healthy and reduce the risk of medical complications.  Many people with type 1 diabetes can lead long healthy lives with proper management and blood sugar control.  Technology and improvements in insulin therapy have greatly improved the management of this condition.

Anatomy

Your body is composed of millions of cells.  The cells need energy to function.  One way the cells receive energy is from the food that you eat.  Whenever you eat or drink, some of the food is broken down into glucose.  Glucose is a sugar that is released into your blood.  It is a major source of energy for your body's cells and is transported from your bloodstream and into your cells with the help of insulin.

Insulin is a hormone that’s made in the pancreas.  Your pancreas is a gland located near your stomach that produces chemicals for food digestion.  Insulin is produced by the beta, or islet cells inside your pancreas and works continuously to regulate the amount of glucose in your blood.  When you eat, the amount of glucose in your bloodstream rises.  In response to the elevated blood glucose level, your islet cells produce insulin.  The insulin moves the glucose out of the bloodstream and into your cells.  In turn, a lower level of glucose is left in the blood stream.  To prevent your blood glucose level from getting too low, your body signals you to eat.  This starts the process again so that your body’s cells continually receive the energy that they need.

Causes

The exact cause of type 1 diabetes is not clear.  Type 1 diabetes is triggered when islet cells of the pancreas are destroyed by the immune system and insulin is no longer produced.  Researchers do not know why this happens.  They suspect it may be an inherited genetic condition or triggered by a toxin or virus.

Without insulin, glucose remains in the blood and cannot get into the body’s cells for energy.  The glucose accumulates and makes the blood sugar levels high.  High blood sugar causes both immediate and long-term problems and requires patients to take insulin by injection to help regulate the blood sugar levels and keep them normal or as close to normal as possible.

Symptoms

The symptoms of type 1 diabetes tend to develop rapidly.  Even after diagnosis, it is important to know the signs of elevated blood sugar.  It is especially important that parents or guardians of children with diabetes pay close attention to the warning signs.  Here are some specific signs to look for:

• Frequent urination
• Extreme thirst and dry mouth
• Extreme hunger
• Unexplained weight loss
• Fruity smelling breath
• Abdominal pain
• Nausea or vomiting
• Urinary tract/vaginal infections
• Blurred vision
• Headaches
• Drowsiness, lethargy
• Stupor, unconsciousness

The symptoms of type 1 diabetes are usually prominent before a person is diagnosed.  While each of the symptoms alone might not signal diabetes, it is important to be aware of changes in routines, behaviors or habits and to address them if they occur.

As the blood sugar rises, the symptoms become more pronounced.  The ones usually noticed first are frequent urination, constant thirst, a voracious appetite and rapid weight loss.

The body tries to over-compensate by removing the excess blood sugar by passing it out of the body in urine.  If you notice your child or loved one urinating more frequently and feeling extremely thirsty and drinking more, this may be a sign.  Because the body is not getting energy from blood sugar, it increases the appetite.  However, even though the person is eating more and drinking enough, they may actually lose weight.  This is because the body starts to use fat and muscle for fuel when it cannot access the blood sugar.  People may also feel tired and weak because the body's cells cannot use glucose for energy. 

If diabetes goes undetected or untreated, the symptoms may get worse and more dangerous and the person may experience abdominal pain, nausea, and vomiting and could go into ketoacidosis.  Ketoacidosis is a serious condition that can lead to diabetic coma and even death.

 

Understanding Blood Sugar Swings and Management

Once someone is diagnosed and on proper insulin therapy, the treatment for type 1 diabetes can prevent symptoms from happening.  However, even with treatment, some problems associated with type 1 diabetes may occur.  These conditions include ketoacidosis, hyperglycemia (high blood sugar), and hypoglycemia (low blood sugar). 

 

Ketoacidosis

Ketoacidosis is extremely dangerous.  Ketones are acids that accumulate in the blood when your body breaks down fats.  Your body releases ketones through urine.  Ketones appear in urine when the body does not have enough insulin.  Ketoacidosis occurs when all of the ketones cannot be released through urine and the amount of ketones remaining in the blood becomes high enough to poison the body.  Ketoacidosis usually develops slowly, but when vomiting occurs, the condition can develop in just a few hours.   

The first symptoms of ketoacidosis are similar to those for diabetes itself and include thirst, dry mouth, frequent urination, high blood glucose levels, and high levels of ketones in the urine.  However, if ketoacidosis is present these symptoms can be severe.  These symptoms are followed by:  dry or flushed skin, continual tiredness, nausea, abdominal pain, or vomiting; difficulty breathing, impaired attention span or confusion, and fruity smelling breath.  If your child or loved one has any of these symptoms contact your doctor immediately, call emergency services, usually 911; or go to the nearest emergency room.  Treatment for ketoacidosis usually involves a hospital stay and is a serious and sometimes life-threatening condition. 

You can help prevent ketoacidosis by monitoring for warning signs and checking the urine and blood regularly.  Follow your doctor’s instructions if you detect high levels of ketones.  If there is a high level of ketones, do not allow exercise.  Exercise increases ketone levels.  It is also important to note that extra monitoring is required whenever a diabetic is sick or has an infection.  Infection can lead to high blood glucose and if left unchecked, ketoacidosis can occur.

 

Hyperglycemia (High Blood Sugar)

Hyperglycemia, the term for high blood glucose, happens to people with diabetes.  A number of factors can affect the blood sugar and even those whose disease is properly managed may experience bouts of high blood glucose levels.  People with type 1 diabetes may experience hyperglycemia if they did not administer enough insulin, ate more than planned, exercised less than planned, or were sick or stressed.  Fluctuating hormones in teenagers, pregnant women and women whose bodies are preparing for menopause can also cause problems with blood sugar.

Some medications will cause hyperglycemia. Cortisone and other steroids are a good example.  It is critically important that individuals with type 1 diabetes check or have their blood sugar checked several times daily.  Knowing what blood sugar levels are at various times throughout the day will go a long way to detecting patterns of low or high blood sugar levels.

The warning signs and symptoms of hyperglycemia include high blood glucose levels, high levels of sugar in the urine, frequent urination, and increased thirst.  It is important to understand however, that a single spike in blood sugar may not always produce overt symptoms in someone who is well controlled.  This is why regular blood sugar monitoring is critical in maintaining good control and avoiding those high blood sugar levels.  You should follow your doctor’s instructions for treating hyperglycemia as soon as you detect high blood sugar levels or ketones in the urine—this is very important.  If you fail to do so, ketoacidosis could occur.

 

Hypoglycemia (Low Blood Sugar)             

Hypoglycemia or low blood sugar occurs when the body has too little food/glucose and too much insulin.  It is a very common condition for many people with type 1 diabetes.  Very low blood sugar may lead to insulin shock, which can be life threatening if not promptly treated.

The following are all reasons that a person with type 1 diabetes might have low blood sugar:

• Taking too much insulin
• Not eating enough
• Eating later than usual
• Waiting too long between the time an insulin injection is taken and the time one eats
• Insulin was given at a site on the body where the absorption rate is faster than usual
• Taking insulin after forgetting about a previous dose
• More exercise than normal or planned
• Illness or injury
• Other hormonal issues
• Medication interaction

Symptoms of hypoglycemia include shakiness, dizziness, sweating, hunger, nervousness, blurry vision, headache, pale colored skin, sudden moodiness and irrational behavior, erratic responses to questions, crying, clumsiness, seizure, poor attention span, confusion, and tingling sensations around the mouth.  Check blood sugar levels if you suspect that the blood glucose level is low.  You should treat hypoglycemia immediately.  The quickest way to treat hypoglycemia is to raise the blood sugar level with some form of sugar—glucose tablets, fruit juice, or hard candy.  Ask your doctor for a list of appropriate foods.  Be sure to give the body enough time to recover and for the blood sugar to rise to normal levels before testing again.  It is important not to over-treat the symptoms as this can cause a rebound effect and turn into a high blood sugar.

It is important to treat hypoglycemia immediately to avoid unconsciousness.  If the person passes out, they will need immediate treatment.  For this rare occasion, you should always have glucagon available.  Glucagon is a hormone that raises blood glucose levels by causing the release of glycogen (a form of stored carbohydrate) from the liver.  Glucagon does not contain any sugar.  It is administered through an injection into the thigh, buttocks or upper arm muscle.  Be sure you know how to use it and be sure your child’s teachers and coaches and even baby sitters know how to use it.  It is advisable to give a glucagon kit to any insulin dependent child’s school to be kept by the school nurse.  If glucagon is not available, seek emergency medical assistance by either going to the emergency room of a hospital or calling emergency medical services, usually 911.  You should never try to force food or drink into anyone’s mouth if they are experiencing severe hypoglycemia, because choking can occur.

 

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a serious condition that most frequently occurs in older persons and those with type 2 diabetes.  However, it can also occur in individuals with type 1 diabetes.  An illness or infection usually brings on HHNS.  HHNS can cause severe dehydration and lead to seizures, coma, and death.

For people with HHNS, dehydration occurs as the body tries to remove excess blood sugar by passing it out of the body in urine.  The rate of urination may be frequent at first, but then decrease.  Unquenchable thirst and dark urine are both symptoms.   Warning signs and symptoms of HHNS include a blood sugar level of over 600 mg/dl.  Other symptoms include a dry parched mouth, extreme thirst that may gradually disappear, warm dry skin that does not sweat, a high fever, over 101° Fahrenheit, sleepiness or confusion, vision loss, auditory or visual hallucinations, seeing or hearing things that are not there, and weakness on one side of the body.  Call your doctor immediately if your child or loved one experiences any of these symptoms. 

HHNS can be avoided by checking blood glucose levels regularly.  You need to check blood glucose levels more often when sickness occurs or an infection is present.  You should work with your doctor and health care professionals to develop a monitoring plan for when a loved one or child becomes sick.

Diagnosis

There is no test to screen for type 1 diabetes.  If you are the parent of a child, keep track of your child’s symptoms and report them to your doctor.  Your doctor can diagnose type 1 diabetes by testing urine and blood. 

 

Urine Tests for Diabetes

Your doctor will test the urine for glucose and ketones.  Ketones are acids that accumulate in the blood and appear in urine when the body does not have enough insulin.  The tests are simple to conduct.  Test strips are simply placed in your urine sample.  Your doctor will read the results after a short period of time.

 

Blood Tests for Diabetes

Your doctor can also determine if diabetes is present by conducting blood glucose tests.  The Fasting Plasma Glucose Test (FPG) and the Oral Glucose Tolerance Test (OGTT) are commonly used.  The FPG measures blood glucose levels after you have fasted or not eaten for a period of time, usually 6-8 hours.  A normal fasting blood sugar is 70 to 100 milligrams per deciliter.  The OGTT test measures blood glucose levels after fasting and again a few hours after you drink a high-glucose beverage.  The FPG and the OGTT test indicate your blood glucose level for one time on a given day. 

Because blood glucose levels fluctuate from day to day, your doctor can also test how your blood glucose levels have been over a period of three months.  To do so, your doctor will use a Hemoglobin A1c test, also called a glycated hemoglobin or HbA1c test.  The A1c test measures your average hourly blood sugar during the past 90 days.  For someone who doesn't have diabetes, a normal A1C level can range from 4.5 to just below 6 percent.  Someone who has had uncontrolled diabetes for a long time might have an A1c level at 9 percent or above.

When the A1c test is used to diagnose diabetes, an A1c level of 6.5 percent or higher on two separate tests indicates you have diabetes.  A result between 5.7 and 6.4 percent is considered pre-diabetes, which indicates a high risk of developing diabetes.

For most people who have previously diagnosed diabetes, an A1c level of 7 percent or less is a common treatment target.

Treatment

There is no cure for Type 1 diabetes but it can be treated and managed.  Type 1 diabetes must be treated with insulin.  Treatment can help prevent swings in blood sugar and may prevent or delay the development of medical complications associated with diabetes.  Your doctor and health care team will teach you how to keep your blood glucose levels as near to normal as possible with medication, nutrition, and exercise.

You should carefully follow your doctor’s instructions for monitoring your blood glucose levels.  A normal blood sugar ranges from 70-100 mg/dl.  You will need to check your blood glucose levels throughout the day as it fluctuates based on eating habits, exercise levels and stress to the body.  To test your blood glucose level, you will prick your finger with a needle or lancet.  Some newer monitoring devices allow you to prick your forearm or other sites on your body, which may be less painful.  You will place a small amount of blood on a test strip and then insert it into a glucose meter.  The meter will display your results. 

Your doctor will help you establish a schedule for checking your blood glucose.  Make sure that you write down the time that you tested your blood and the result.  Bring your logbook to each of your doctor appointments.  It is recommended that you keep a written log even if your glucose meter can store your results. 

There are also sensors that can be worn on the body that instantly deliver blood sugar results every five minutes without the need for a finger stick.  These sensors are small and are generally used in conjunction with blood glucose monitoring machines to allow doctors to see what blood sugars are doing in the overnight hours when patients are sleeping.

 

Understanding Insulin

Depending on the results of your blood glucose test, you may need to inject yourself with insulin.  The insulin will help lower your blood glucose level.  Your doctor will let you know how much insulin to use.  It will depend on your weight, what you eat, and how active you are.  Most people with type 1 diabetes need insulin injections two to four times a day.

There are different types of insulin that differ in onset, peak time, and duration.  Onset refers to how long it takes the insulin to reach the bloodstream and begin lowering the blood glucose level.  The peak time indicates when the insulin is at its maximum strength.  Insulin duration describes the length of time that the insulin works to lower blood glucose levels. 

Some types of insulin may be used alone or with another type of insulin for maximum effect.  Additionally, there are new types of medications that enhance the way that insulin works.  Medications may require mixing or they may be purchased in a convenient premixed pen.  Ask your doctor about which medications are right for you.

Before meal rapid-acting insulins should be injected 15 minutes before a meal.  These types of insulins work about 15 minutes after they are injected, peak in an hour, and continue to work for 2 to 4 hours.  Before meal rapid-acting insulins leave the bloodstream quickly and reduce the chance of hypoglycemia after meals.  After meal rapid-acting insulins are well-suited for children because it can be difficult to predict how many calories a child will eat prior to a meal.  After meal rapid-acting insulins are also useful for people with delayed stomach emptying.

Short or regular-acting insulins reach the bloodstream within 30 minutes after they are injected, peak in 2 to 3 hours, and continue to work for 3 to 6 hours.  Short-acting insulin is often used with another type of insulin, intermediate-acting insulin.  Intermediate-acting insulins reach the bloodstream 2 to 4 hours after they are injected, peak 4 to 12 hours later, and continue to work for about 12 to 18 hours. 

 

Insulin Delivery Methods

Insulin can be administered in a variety of ways that are easy and relatively painless.  Insulin delivery methods include small needles, a pen, or a pump.  Needles are smaller than ever before and have special coatings that make injecting easy and nearly pain-free. 

An infuser may be used to reduce the number of daily injections.  An infuser or a portal is a catheter device that is placed into your skin.  Insulin injections are given into the infuser instead of your skin.  An infuser can remain in place for 48 to 72 hours.

The insulin pump is a small device that you can wear on your belt or carry in a pocket.  Insulin travels through soft plastic tubes to a catheter that is placed in the skin.  Some insulin pumps allow the catheter to remain in place while only needles are removed.  The insulin pumps hold a pre-set amount of insulin and are generally changed every three days or so.  They are completely computerized to deliver steady doses of insulin and surge (or bolus) doses, per your instructions when you eat.  Essentially it counts carbohydrates for you and calculates the dosage of insulin based on a formula set by your doctor.  This continual release with boluses is most like the normal insulin production your body would make on its own.  You will need to check your blood glucose levels more frequently than with other delivery methods.  However, many people prefer the pump because it allows them to have a more flexible lifestyle.  Newer pumps now offer a wireless version which can be worn directly on a body part such as the thigh, belly or arm.  This pump also holds a pre-set amount of insulin and stays in place for athletics, and even swimming.  Many diabetics enjoy the freedom a wireless pump gives.

Jet injectors deliver insulin without using needles.  Jet injectors force insulin through the skin with pressure.  In some cases, this method may cause bruising. This method is used less often than injections or pumps.

 

Counting Carbs for Better Control

Blood sugar management is further improved with carbohydrate counting and bolus insulin doses at meals.  This method works best for type 1 diabetics who use an insulin pump or take several injections throughout the day.  Most diabetics will have a basal dose of insulin that is released steadily around the clock, but will also require bolus doses at meal time.  Carbohydrate counting gives diabetics more flexibility at meal time by counting the carbs in the meal and then giving a bolus or extra dose of insulin for it.  This prevents blood sugar highs and lows and gives steadier blood sugar management.

Carbohydrates are the component of food that contribute most to the post-meal blood sugar reading and are the main factor that determines how much insulin should be taken.  For some patients, a nutritionist or other medical provider will establish a ratio of insulin to carbohydrate to follow for meals.  Based on blood sugar readings over time, ratios may be adjusted by your doctor but can range from 1 unit per every 5 carbohydrates consumed to 1 unit for every 30 units consumed or anything in between.  Diabetics will base their insulin dose on the number of carbohydrates in the meal.  To count carbohydrates, diabetics must use the nutritional information on the food’s package or carry a reference to determine the number of carbohydrates in a particular food paying close attention to portion sizes.   Books may be purchased for this, or you may even purchase an app for your phone.

 

Diabetes Supplies and Tools

Purchasing diabetes care supplies can be confusing.  You should select the products that you are most comfortable with and that you will use.  The American Diabetes Association has an extensive list of diabetes care supplies in their Resource Guide.  The Resource Guide provides detailed information that allows you to compare the features of various products.  You should also talk to your health care professionals for product advice, demonstration, and trial.

Blood glucose meters have advanced over the past 20 years.  They have become easier to use and there are many types.  Some meters are easier to use than others.  Most meters provide results in less than a minute.  Some of the newer meters display results in just five seconds.  “Talking” meters are helpful for people with visual impairments.  The talking meters provide verbal instructions and results.  Some of the units are available in Spanish and other languages.

You should take your time when deciding on a glucose meter.  You should select the one that you are the most comfortable with because you will be using it regularly.  When purchasing a blood glucose meter, check to see if your insurance company covers the meter and the care supplies, such as the test strips.  You should compare prices for items not covered by insurance. 

For many years, insulin was given with a syringe and needle, but newer alternatives offer delivery with an insulin pen.  Insulin pens are convenient for active people or those with visual or coordination problems.  The pens contain accurate pre-measured doses of insulin.  The insulin is easy to deliver.  Simply “dial up” your dose, and with the push of a button, a spring-loaded device quickly inserts the needle into your skin and delivers the correct does of insulin.

Data management systems are an alternative for storing the results of your glucose monitoring.  Data management systems are a convenience, but not a requirement.  You may keep your own records in a written log.  Some of the newer blood glucose meters have a built in data management system that can store the results of 500 blood glucose checks.  Data management systems vary.  They can record such variables as when you checked your blood glucose, the type and dose of insulin used, your meals and exercise.

There are several things to consider if purchasing a data management system.  You should talk to your doctor to see if your unit is compatible with the doctor’s computer.  You should also ask your doctor what type of records he or she would like the data management system to track.  As always, try the equipment before you purchase it.  Data management systems can be expensive.

 

Scheduled Screenings and Maintenance

Every few months, you will need to have your doctor check your blood glucose average with the A1c test.  The A1c test measures your blood glucose level average for the course of about three months.  Your doctor will use this information to alter your course of treatment, if necessary.

You will also need to test your urine per the guidelines set by your doctor.  People with type 1 diabetes should test their urine for ketones when their blood glucose level is high.  Urine testing involves placing test strips in your urine sample and reading the results after a short period of time.   

A microalbuminuria kit is used to measure the amount of protein in your urine.  The presence of microalbuminuria in the urine can be an indicator of kidney disease.  People with type 1 diabetes are at risk for kidney damage.  The American Diabetes Association recommends that people with diabetes be tested for microalbuminuria every year.  Some people may need to perform the test more frequently to monitor the progression of kidney disease.  Microalbuminuria tests may be done in your doctor’s office or are now available in home testing kits.  You apply your urine sample to the test kit and mail it to the company.  A physician must interpret your test results.  The home testing kit allows you the convenience of testing your urine at home.

 

Healthy Lifestyle Tips

Managing type 1 diabetes also includes a nutritional component.  Your doctor or a registered nutritionist can help you plan what to eat to help regulate your blood glucose levels, cholesterol, and blood pressure.  A balanced meal plan includes a wide variety of foods, particularly vegetables, whole grains, non-fat dairy products, beans, lean meats, poultry, and fish.  Your health care professional can help you learn to read nutrition labels, measure portion sizes, and plan balanced meals.

Exercise is another important element for managing type 1 diabetes.  Exercise may help to lower your blood glucose level, blood pressure, and cholesterol.  It also may help your body use insulin better.  You should strive for a combination of aerobic activity, strength training, and stretching.  Ideally you should exercise aerobically for 30 minutes a day, five days per week.  You can break the time period into three ten minute segments throughout the day or exercise for the entire 30 minutes.  Aerobic exercise includes physical activities that work your heart, lungs, and vascular system, such as quick walking, riding a stationary bike, or running.

Prevention

Type 1 Diabetes cannot be prevented. There is no test to screen for type 1 diabetes.  You should contact your doctor if you experience the symptoms of type 1 diabetes. 

Because the medical complications associated with diabetes can be very serious and life threatening, people with diabetes need to diligently manage their disease to remain healthy.  The following are suggestions for preventing complications from diabetes.

 

Preventing Complications

Wear a Medic Alert bracelet and carry a Medic Alert card in your wallet.  In the case of an emergency, the Medic Alert information will be helpful to the healthcare professionals treating you.

Monitor your blood glucose levels carefully, and treat yourself with insulin daily, as instructed by your doctor.  Make sure that your write down the time that you tested your blood and the result.  Take your logbook to each of your appointments.  See a physician regularly to prevent and stay on top of any problems that might develop.

Eat a balanced diet and consult a nutrition expert for help with meal planning.  Exercise regularly and reduce your weight if you are overweight.  Even losing small amounts of weight is helpful for diabetes management.

Monitor your blood pressure.  Ask your doctor what your blood pressure should be, and contact your doctor when it is out of range.  You should also keep your cholesterol within normal limits.  Have regular cholesterol checks throughout the year, and follow your doctor’s instructions for lowering cholesterol. 

People with diabetes should have an eye exam at least once a year.  The eye examination should include screening for glaucoma, cataracts, and diabetic retinopathy. 

Attend all of your scheduled medical appointments.  Your feet should be inspected at every visit.  Discuss any concerns about depression with your doctor as well.

 

Am I at Risk

The risk factors for Type 1 diabetes are unknown.  It appears to develop more frequently in Caucasians and people younger than 20 years old, although it may occur at any age.

Researchers have also found some patients to be at a higher risk based on family history.  If there is a parent with type 1 diabetes, the risk for their children is higher.  Other more complicated causes including changes in specific genes and the presence of immune system disorders like adrenal or thyroid disease may also play a role.

There is advanced testing that can be done for siblings of type 1 diabetics to look for antibodies to insulin, or antibodies to islet cells of the pancreas to help determine if they are at risk.  Some school age children may have a test to evaluate how the body responds to glucose but none of these tests is guaranteed to detect type 1 diabetes and provides no prevention for the disease.

Complications

In addition to managing your blood sugar, eating smart, and exercising, you should also maintain appropriate cholesterol and blood pressure levels.  It is also important to not smoke.  Smoking increases blood sugar and can contribute to the development of medical complications.  It is important that you take care of yourself daily and keep all of your doctor appointments.  Type 1 diabetes is a lifelong condition; however, people with type 1 diabetes can live healthy, happy, and long lives with good care.  

Many people with diabetes also have high cholesterol and high blood pressure.  These three factors combined—diabetes, high cholesterol, and high blood pressure, increase the risk of developing a variety of serious medical complications.  Some of the symptoms may be obvious, while others may be subtle and develop over time.  It is important that you monitor yourself for signs and symptoms of medical complications and complete all screenings recommended by your doctor.  Report any concerns to your doctor promptly.  The following paragraphs describe some of the medical complications associated with type 1 diabetes. 

 

Heart and Cardiovascular System

Type 1 diabetes is associated with an increased risk of coronary artery “heart” disease, heart attack, and stroke.  Heart disease is the leading cause of diabetes related death in the United States.  Coronary artery disease causes the vessels that carry blood to your heart to narrow.  They can also become completely or partially blocked by fatty deposits.  A heart attack occurs when the heart does not receive blood or does not receive enough blood.  A stroke occurs when the brain does not receive blood or does not receive enough blood.  A heart attack or stroke can be fatal.  They can also cause permanent or temporary impairments and disability.

 

Kidney and Renal System

Kidney disease, also called nephropathy, can also be caused by diabetes.  Your kidneys remove waste products from your blood.  Diabetes can damage the filtering system in the kidneys resulting in kidney disease or kidney failure.  Persons with kidney failure need dialysis, a process in which a machine filters the blood.  Some people may even need a kidney transplant.

 

Eye Health

People with diabetes have a higher risk of eye problems and blindness than people without diabetes.  A long history of diabetes and older age are factors associated with developing glaucoma.  Glaucoma occurs when pressure builds up in the eye and causes gradual vision loss.  People with diabetes tend to develop cataracts at a younger age and at a quicker rate than people without diabetes.  Cataracts cause the clear lens in the eye to become cloudy, diminishing vision. 

Diabetic retinopathy or retinal disorders can also be caused by diabetes.  The retina is the part of your eye that receives images.  Nonproliferative retinopathy is a condition that affects the capillaries in the retina.  Retinal swelling can cause vision loss.  In some people, retinopathy progresses to a more serious condition called proliferative retinopathy.  The blood vessel damage caused by proliferative retinopathy causes scarring and eventual retinal detachment destroys vision.

 

Nerves and Neurologic System 

Nerve damage caused by diabetes is called diabetic neuropathy.  Nerves carry messages between your brain and body about pain, temperature, and touch.  They also control your muscle movements and organ systems, such as the processes for food digestion and urination.  Sensorimotor neuropathy and autonomic neuropathy are two common types of nerve damage.

Sensorimotor neuropathy affects sensation and movement.  It may cause your feet and hands to feel weak, tingly, numb, or painful.  Autonomic neuropathy affects the nerves that regulate involuntary functions or actions that you cannot directly control, such as your heartbeat.  Of great concern, it can cause a loss of the typical warning signs of a heart attack or low blood glucose levels.  Autonomic neuropathy can cause dizziness or faintness.  It can also create problems with digesting food; vomiting, diarrhea, or constipation; bladder function; sex; increased or decreased sweating; and changes in the way the eyes function in the dark or light.

 Diabetes can often lead to nerve damage called peripheral neuropathy.  Peripheral neuropathy is a condition in which nerve function deteriorates in the limbs.  This leads to a gradual loss of feeling in the hands, arms, legs, and feet.  This is often problematic because pain is what enables you to know when something is wrong.  Without pain, you may not realize that you have bruises, cuts, blisters or burns and seek medical treatment.  It is important that people with diabetes receive medical treatment for foot sores because diabetes-related circulation problems can lead to more medical conditions.

 

Conditions of the Feet

The feet are very vulnerable to diabetes-related complications.  There are a variety of foot problems that can occur.  Foot problems are the leading reason for diabetes-related hospitalization.  Further, diabetes is the leading cause of lower leg and foot amputation.  Diabetes-related foot conditions are most frequently caused by poor blood circulation, infection, and nerve damage that can result in ulcers or sores, deformities, and trauma.

Peripheral vascular disease is a common diabetes-related circulation disorder.  Poor circulation results in reduced blood flow to the feet.  It can restrict the delivery of oxygen and nutrients that are required for normal wound maintenance and repair.  As a result, foot injuries, infections, and ulcers may heal slowly or poorly.  Minor skin problems on the feet can become worse and lead to infection.

Wounds and injuries can be difficult to heal if diabetes is uncontrolled.  This can be especially true of wounds in the feet.  Infections tend to get worse or remain undetected, especially in the presence of diabetic neuropathy or vascular disease.

Neuropathy can cause you to be unaware of wounds.  Additionally, the increased pressure from the feet carrying the body weight aggravates foot wounds.  Further, shoes can cause skin friction, rubbing, and tearing. The hot moist environment of shoes is favorable to infection and foot ulcers.  Foot ulcers are sores caused by skin breakdown.  They can be exacerbated by infection.  Foot ulcers tend to develop over areas of high pressure, such as bony prominences or foot deformities.

Foot deformities are another common problem associated with diabetes.  They occur when the ligaments and muscles that stabilize the foot bones deteriorate.  This can cause the bones to shift out of position or an arch to collapse. 

A hammertoe deformity is a common condition that occurs most frequently in the second toe, although it can be present in more than one toe.  Increased pressure on the tips of the toes and the lack of muscle stability causes a joint in the toe to become permanently flexed with a claw-like appearance.  The toe deformity and pressure displacement makes the toe susceptible to skin ulcers.

Charcot foot is another common foot deformity associated with diabetic neurogenic arthropathy.  Neurogenic arthropathy is a progressive degenerative arthritis that results from nerve damage.  Charcot foot most frequently affects the metatarsal and tarsal bones located in the midfoot and forefoot.

Charcot foot causes the foot muscles, ligaments, and joints to degenerate or break down.  Without support, the foot becomes wider and deformed.  Without joint stability, the foot becomes unstable, making walking difficult.  Inflammation and pressure eventually can cause bone dislocation. 

People with Charcot foot have impaired or absent abilities to feel pain, temperature, and trauma.  They may not be able to sense the position of their foot.  This makes them vulnerable to injury, such as fractures, sprains, joint dislocation, bone erosion, cartilage damage, and foot deformity.  They may even continue to walk on a broken bone without knowing it, because they cannot feel it.

 

Skin Conditions

People with diabetes are generally more prone to skin infections and skin disorders than people without diabetes.  People with diabetes have a greater tendency to get bacterial infections, fungal infections, and itchy skin.  Some skin problems happen mostly to or only to people with diabetes. 

Bacterial infections tend to manifest as sties on the eyelid, boils, infected hair follicles, deep infections under the skin, and nail infections.  Bacterial infections cause the skin to become hot, swollen, red, and painful.  Fungal infections are caused by yeast-like organisms that can grow and spread in diabetics whose sugar levels are uncontrolled.  They create itchy rashes in moist areas of the skin.  Common fungal infections include jock itch, athlete’s foot, ringworm, and vaginal infections.  Both bacterial infections and fungal infections can be treated with prescription medication.

Diabetic dermopathy and necrobiosis lipoidica diabeticorum (NLD) are similar skin disorders caused by changes in the blood vessels.  Both conditions cause brown spots to appear on the skin.  Diabetic dermopathy is harmless, but NLD can cause the skin to crack and bleed.  NLD is a rare condition affecting mostly adult women.  Open sores need to be treated by a doctor.

People with diabetes tend to get atherosclerosis at a younger age than people without diabetes.  Atherosclerosis causes the arteries to thicken, narrowing the route for blood flow.  It results in skin changes.  The skin becomes hairless, thin, cool, and shiny.  The toes become cold, and the toenails thicken and discolor.  Atherosclerosis can also cause wounds to heal slower or become infected because of lack of blood flow.

Eruptive xanthomatosis usually occurs among young men with type 1 diabetes.  It typically develops when diabetes is not controlled, in conjunction with high cholesterol and fat in the blood.  Eruptive xanthomatosis causes firm, yellow, pea-sized bumps in the skin.  The bumps may have a red ring and itch.  They occur most often on the backs of the hands, feet, arms, legs, and buttocks.  The condition usually resolves when the diabetes is controlled. 

 

Digestive System

People with type 1 and type 2 diabetes can experience gastroparesis, a stomach disorder in which the movement of food is slowed or stopped.  Gastroparesis occurs when high blood glucose levels damage the vagus nerve and the nerves that regulate stomach functioning over a period of time.  The muscles in the stomach and intestines stop working properly.  Signs and symptoms of gastroparesis include heartburn, nausea, vomiting, feeling full early when eating, weight loss, bloating, erratic blood glucose levels, lack of appetite, reflux, and stomach spasms. 

If food stays in the stomach too long it can be dangerous.  Delayed stomach emptying can lead to bacterial overgrowth and stomach or intestinal obstructions.  Medications and nutritional changes can treat gastroparesis.  In severe cases, a feeding tube may need to be inserted to deliver nutrients to the small intestine. 

 

Mental and Psychological

Finally, people with diabetes have a greater risk of depression than people without diabetes.  Depression is a real medical condition that can be treated.  Depression is not a “normal part” of everyday life.  Symptoms of depression include continually feeling sad, irritable, tired, and uninterested in activities that you used to find enjoyable.  Other common symptoms of depression include changes in appetite, having difficulty getting a good night’s sleep, moving the body at a much slower pace, and not being able to remember things or concentrate as easily as before.

Doctors are not exactly sure why people with diabetes are at risk for developing depression.  They suspect that people cope with diabetes management differently.  Additionally, some of the symptoms of low or high blood sugar can cause symptoms that look like depression.  You should discuss your concerns with your doctor in order to receive appropriate diagnosis and treatment.

Advancements

Prevention, technology, and research have greatly improved the management of diabetes and lengthened the lives of diabetes patients.  In fact, results of a 30-year study released by the American Diabetes Association show that people living with diabetes between 1965 and 1980 lived 15 years longer than the generation before them.  As advancements improve, these numbers will likely improve even more.  Diabetes is no longer the limitation that it used to be many years ago. 

Sugar-free foods, new types of insulin, and easy-to-use insulin delivery methods have made diabetes management more convenient.  The American Diabetes Association’s Resource Guide is a great resource for new products. 

Wireless insulin pumps are offering diabetics more freedom than ever before.  Easily hidden under clothing or even a swimsuit, there are no wires to manage or see.  Some wireless pumps are also waterproof and can be worn for swimming or other water activities without worrying about damage to the electronics inside.  The pump communicates with a remote handheld device that looks a bit like a small cell phone where diabetics can calculate insulin doses, program insulin delivery and even check their blood sugar. 

New technology like continuous glucose monitoring systems (CGMS) may also help you monitor and track your blood sugar readings over time.  This can give your doctor a better idea of how you are managing your blood sugar.  A CGMS has a sensor that is placed under your skin to read your blood sugar every few seconds.  This information is then transmitted to a control module where the information is stored.  These systems can work with some types of insulin pumps, provide real-time readings, and signal an alarm when levels get too low or too high.

Pancreatic transplants are an option for select people with type 1 diabetes.  In some people, transplanting the pancreas can “cure” type 1 diabetes.  However, there are high risks involved with pancreatic transplantation; some people do not survive.  The transplanted pancreas is at risk for being rejected by the body.  Further, people must take anti-rejection medications that have their own risks.  Researchers are studying the effects of transplanting just the islet or beta cells from the pancreas, in hopes that it is more effective.