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Type 1 diabetes is a chronic autoimmune condition in which the immune system attacks the insulin-producing beta cells of the pancreas, causing them to degenerate. Due to this, the body is unable to produce insulin.
Insulin is a hormone required for blood glucose (sugar) control. Normally, after a meal, blood glucose rises. This is because the carbohydrates from the food are broken down into glucose and released into the bloodstream.
Insulin is then released from the pancreas to control blood glucose levels by allowing glucose to enter the cells from the bloodstream. Little to no insulin release in type 1 diabetes means that glucose can’t enter the cells, so blood glucose levels remain high, and the cells starve.
The first ever case of diabetes was described around 3,000 years ago by the Egyptians. They noted frequent urination, excessive thirst, and weight loss.
Other known symptoms include:
tingling or numbness in the hands and feet
The precise cause of type 1 diabetes remains unknown. Currently, it’s understood as an autoimmune disorder — meaning that the body’s own immune system mistakenly attacks and destroys the beta cells of the pancreas. Why this occurs is yet to be determined.
Genetics, environmental conditions, and viruses are thought to play a role in their genesis.
Currently, research¹ has identified 50 different loci that produce susceptibility to type 1 diabetes. However, the points don’t directly cause type 1 diabetes, and the extent to which they contribute to diabetes is unknown.
Many individuals with the gene don’t develop type 1 diabetes, so it’s suspected that something is required to trigger the gene to begin developing type 1 diabetes.
Some viruses, particularly enteroviruses, have been associated with type 1 diabetes as they’ve been detected in the pancreas of recently diagnosed individuals. Enteroviruses, including poliovirus and coxsackievirus, are more likely to have occurred in children with type 1 diabetes than those without.
More research is required to understand how exposure to such viruses puts the pancreas at risk, and it’s hoped that the development of additional vaccinations will provide adequate protection.
Environmental triggers that are thought to contribute to type 1 diabetes include pollutants, diet, stress, infectious agents, drugs, and gut microflora.
One hypothesis is that these environmental factors alter gene expression and consequently change immune cell function.
Hypothyroidism and celiac disease have been found to have a high prevalence among individuals with type 1 diabetes. Pernicious anemia and autoimmune gastritis have also been identified as having a 3 to 5-fold prevalence² in type 1 diabetics compared to the general population.
It is thought that these diseases share common genetic factors and immune processes.
Antibody testing is currently one of the more popular ways to confirm type 1 diabetes. This test will look for various antibodies, including insulin antibodies (IA) and islet cell cytoplasmic autoantibodies (ICA).
A doctor will undertake a random blood glucose test in the presence of typical symptoms. Typically, blood glucose levels should sit between 4 and 8mmol/L. A random blood glucose level of 11.1mmol/L or more indicates diabetes.
Your doctor can also carry out an HbA1c test. This measures your average blood glucose levels over the past three months. You will be diagnosed with type 1 diabetes if you have an HbA1c of ≥48mmol/mol.
Another option is to take a fasting blood glucose test.³ This test can be carried out after an overnight fast. A fasting blood glucose level of over 126mg/dL on two separate tests suggests diabetes.
Type 1 diabetes is managed by:
taking regular injections of insulin
consistently monitoring blood glucose levels
eating regular meals
keeping up physical activity
Four types of insulin can be used to control type 1 diabetes. Some are short-acting and are known as bolus insulin. Others are long-acting and are called basal insulin.
This insulin generally acts within 10–20 minutes, so it is injected with or before eating food. This insulin peaks at 1–3 hours and lasts as long as 5 hours.
This insulin begins to lower blood glucose levels in around 30 minutes. It peaks at 2–5 hours and lasts as long as 6–8 hours.
This insulin begins to work 60–90 minutes after injection. It peaks at 4–12 hours and lasts for a maximum of 16–24 hours.
This insulin generally has no apparent peak and lasts around 24 hours. This is generally administered once or twice a day.
Insulin needs to be injected into the fatty tissue under the skin. The stomach and thighs are common injection points. Changing injection sites is important — otherwise, the skin can become lumpy. This can also impact how insulin is absorbed.
Insulin pumps are also available to ease insulin administration. These are small electronic devices that mimic the role of the pancreas by delivering a continuous basal rate of insulin, as well as a bolus of insulin during meals.
The advantage of these is that they are convenient and require fewer needles. Only one injection is needed every few days when the infusion set (the tube and needle that delivers the drug) is changed. Insulin pumps also deliver more accurate doses, making it easier to manage blood glucose levels.
Consistently monitoring blood glucose levels is necessary to keep the levels within a healthy range and to delay or prevent complications. Diabetics should check their blood glucose levels at least four times per day.
Typical times to do this are before meals, before exercising, before bed, or when feeling too high or low. This is partly because of how unpredictable blood glucose can be — even with consistent meals and insulin administration, other factors can cause variation.
To avoid constant finger pricking, continuous glucose monitors are also available. These insert a needle directly under the skin that checks blood glucose every few minutes. While this is convenient, it’s not always as accurate as finger pricking.
A doctor will also help a person manage A1C (glycated hemoglobin). This test indicates your average blood glucose level over the previous three months. It achieves this by looking for hemoglobin in the blood, as when sugar enters the blood, it binds hemoglobin to produce glycated hemoglobin.
If the A1C is high, a greater chance of diabetes complications exists. When this occurs, it’s useful to look at your current diabetes management plan. With the help of a health professional, you may be able to implement changes that can help you maintain your ideal A1C goal.
People can still exercise and participate in sports with type 1 diabetes. However, understanding how different types of activity impact blood glucose levels is important. Low and moderate-intensity exercise, such as walking or biking, can cause blood glucose levels to drop gradually.
By contrast, high-intensity exercise such as football or sprinting can cause blood glucose levels to spike due to catecholamine production. Adrenaline, noradrenaline, and epinephrine are all catecholamines acting as hormones and neurotransmitters.
it’s important to monitor blood glucose before, during, and after exercise. Staying hydrated and eating the right carbs before and after exercise can help regulate blood glucose levels.
Over time, the person will begin to understand how their body reacts to different forms of exercise and how to best manage this, as it varies from person to person. Regardless, staying physically active is important as it has a profoundly positive impact on one’s mental well-being.
Eating regular healthy meals may help to maintain better blood glucose levels and prevent comorbidities, such as kidney or heart disease, in people with type 1 diabetes. A diet rich in whole grains, fruits, and vegetables is encouraged.
Avoid potato chips, candy, and other foods high in sugar or highly processed — these are high in carbohydrates yet offer little nutritional value.
Counting carbohydrates⁴ is encouraged to measure an appropriate dose of insulin. Generally, food labels make this process relatively straightforward, and over time, this becomes much easier.
One unit of insulin covers around 12–15g of carbohydrates, so the dose should be adjusted accordingly.
Generally, people with type 1 diabetes who keep their blood glucose levels under control have cholesterol levels that are comparable to controls. However, people who are overweight or obese are more likely to have high cholesterol.
Too much cholesterol in the blood can lead to heart disease. Generally, this can be treated with cholesterol-lowering statins, and exercise will also help with weight loss.
Yearly screening of both the eyes and feet is recommended for type 1 diabetes. This is to prevent the potential for blindness or limb amputations. Diabetes can result in foot numbness, pain, ulcers, and other foot complications due to blood vessel and nerve damage. Regular eye screening can help to detect changes in the retina before you become aware of them.
Having a regular check-up with your doctor, annually or more frequently, depending on your specialist’s recommendations, is important to check whether you’re meeting your target levels. This might include measuring your weight, blood pressure, HbA1c, and cholesterol levels, as well as carrying out an eye and foot check. These targets should be individualized and may change over the course of your diabetes care.
While insulin has been the treatment of choice since 1922, new and emerging therapies are undergoing trials to work alongside insulin and boost its effects.
Even with correct insulin doses, the unpredictability of blood glucose levels and unwanted weight gain are frustrating. Consequently, therapies that supplement insulin therapy have potential. These supplemental therapies help people with type 1 diabetes maintain tighter control of their blood glucose levels long-term, reducing the potential for diabetic-related complications.
Amylin is a peptide secreted alongside insulin from the pancreatic beta cells in response to a meal. In healthy people, this lowers glucose levels following the meal by decreasing glucagon release, increasing satiety, and slowing gastric emptying.
Pramlintide⁵ is a synthetic form of amylin that can be administered to type 1 diabetic patient to mimic amylin release. Clinical trials have demonstrated that administering pramlintide helps people with type 1 diabetes have more normal and predictable glucose levels.
Metformin is a common oral medication for type 2 diabetes. However, it was recently introduced as a potential treatment for type 1 diabetes.
A one-year trial⁶ of metformin decreased glucose concentrations, lowering insulin requirements and decreasing metabolic syndrome in patients with type 1 diabetes. Metformin could be highly beneficial for individuals having trouble controlling their blood glucose levels or experiencing insulin resistance.
Empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, has shown promise in clinical trials,⁷ demonstrating improvements in A1C, body weight, glucose management, and total daily insulin requirements in people with type 1 diabetes. It’s already being used as a treatment for those with type 2 diabetes.
It’s used alongside insulin and works by eliminating glucose via the urine. It helps manage diabetes by reducing variations in glucose levels and also contributes to weight management. The reduction in blood pressure following healthy weight loss contributes to reducing the risk of cardiovascular events.
A pancreas transplant is an option carried out in only a few diabetes patients because it’s a relatively high-risk procedure. This operation can lead to organ rejection, infection, and blood clots, among other risks, so it is only reserved for patients with significant complications. Insulin injections remain effective and low-risk by comparison.
Vertex, a pharmaceutical company, was conducting clinical trials to investigate the efficacy of stem cell therapy. This treatment works by injecting differentiated cells into a diabetic patient. The stem cells are differentiated into mature pancreatic cells before being injected.
The first patient in the trial showed very promising results, with treatment reducing the need for exogenous insulin by up to 90%.⁸ Unfortunately, the FDA halted the study as they determined there was insufficient evidence to test higher doses of the therapy.
It is hoped that Vertex can negotiate with the FDA to resume the study as soon as possible – hopefully resulting in a life-changing cure for people with type 1 diabetes.
Insulin currently remains the main therapeutic avenue for type 1 diabetes. However, a large body of research investigates supplemental therapies and potential cures.
This will help to minimize the significant burden of type 1 diabetes and increase the quality of life for people diagnosed with type 1 diabetes.
A doctor can help people with trouble regulating their blood glucose levels and determine if additional medications could be beneficial.
If left untreated, uncontrolled blood glucose levels can lead to several other health complications. Around 50%⁹ of patients with type 1 diabetes develop significant comorbidities over their lifetime.
These can include complications such as neuropathy, nephropathy, foot disease, ketoacidosis, retinopathy, and cardiomyopathy. Poor blood glucose control can also lead to premature death.
Currently, type 1 diabetes can’t be prevented. As research elucidates what causes the condition, this direct cause may become clearer and open up potential avenues for prevention. Until such time, the onset of type 1 diabetes can potentially be delayed but not prevented.
Type 1 diabetes can be identified in the preclinical phase, where initial pancreatic beta cell loss is in its early phases. While type 1 diabetes can’t be prevented at this point, its impacts can be limited. During the preclinical phase, blood glucose levels are still under control, and the disease can be detected through testing for autoantibodies.
A trial was conducted on relatives of patients with type 1 diabetes who were also at high risk of developing type 1 diabetes because of its genetic component. It identified that administering an anti-CD3 monoclonal antibody (teplizumab) could delay the onset of diabetes for three years.
This was following a two-week course of administration of the antibody, enabling it to slow the body’s destruction of its own beta cells. This highlights the potential benefits of immunotherapy, and research is continuing to determine if these results can be extended beyond three years.
This is beneficial as it can delay the onset of the clinical phase of the disease, meaning the person has a longer period without continuous monitoring of blood glucose, and chances of longer-term complications are decreased. It also may allow the person to preserve limited beta cell function.
Above all, individuals diagnosed with type 1 diabetes need support networks provided as a part of their diabetes care. Receiving a significant diagnosis without a cure in sight can be challenging.
Doctors, friends, family, schools, and other organizations should be encouraged to stay well-educated to provide appropriate support and guidance.
While studies on mental health alongside type 1 diabetes are limited, some research¹⁰ has identified that adolescents with type 1 diabetes are three times more likely to develop depression than those without diabetes.
Depression then puts youth at further risk as it can impact the body’s response to insulin and is commonly associated with poorer metabolic control, which leads to further long-term complications.
Being diagnosed with type 1 diabetes is a significant, life-changing event. However, treatment is available, and people with the disease can still live well and participate in the activities they love. It may be some time before a cure becomes safe and accessible, so until then, understanding how to best manage this condition is important.
A doctor will prescribe insulin based on the needs of the person’s body, and doses may be subject to change over time. Doctors can advise about any additional medicines and remain informed about new treatment options as research progresses.
Genetics of type 1 diabetes (2018)
Diabetes tests | Centers for Disease Control and Prevention
Vertex announces positive day 90 data for the first patient in the phase 1/2 clinical trial dosed with VX-880, a novel investigational stem cell-derived therapy for the treatment of type 1 diabetes (2021)
Diabetes mellitus type 1 | NIH: National Library of Medicine
All about your A1C | Centers for Disease Control and Prevention
Guide to HbA1c | Diabetes.co.uk
Diabetes and exercise (2014)
Nutritional recommendations for individuals with diabetes | NIH: National Library of Medicine
Type 1 diabetes | Vertex
Diabetes | World Health Organization