Diabetes mellitus, type 1 part one

Diabetes Mellitus type 1
Patient information:
Diabetes mellitus, type 1
David K McCulloch, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on August 31, 2006. The next version of UpToDate (15.2) will be released in June 2007.
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INTRODUCTION — Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin (show figure 1).see figure below.

Insulin is a hormone that helps the body to absorb and use glucose and other nutrients from food, store fat, and build up protein. Without insulin, blood glucose (sugar) levels become elevated.
Elevated blood glucose levels (called hyperglycemia) cause a person to urinate more frequently, causing loss of body water and dehydration. A person can also feel tired and lose weight. In addition, a serious and potentially life-threatening complication known as diabetic ketoacidosis can develop (see "Symptoms" below). Long term complications associated with hyperglycemia can affect the eyes, nerves, kidneys, and cardiovascular system, leading to blindness, loss of sensation in the feet, the need for amputation of toes or a foot, kidney failure, and an increased risk of heart attack and stroke.
Type 1 diabetes requires regular blood glucose monitoring and treatment with insulin. Treatment, lifestyle adjustments, and self-care can effectively control blood glucose levels and minimize a person's risk of ketoacidosis and other disease-related complications.
Type 1 diabetes usually begins in childhood or young adulthood, but can develop at any age. In the United States, Canada, and Europe, type 1 diabetes accounts for 5 to 10 percent of all cases of diabetes. It is relatively more common in Caucasians than in persons of African or Asian descent.
THE IMPACT OF DIABETES — Being diagnosed with type 1 diabetes can be a frightening and overwhelming experience for some patients, and it is common to have questions about why it developed, what it means for long-term health, and how it will affect everyday life. For most patients, the first few months after being diagnosed are filled with emotional highs and lows. Persons with newly-diagnosed diabetes, as well as their families, can use this time to learn as much as possible so that diabetes-related care (eg, self-blood glucose testing, medical appointments, daily insulin) becomes a "normal" part of the daily routine. (See "Patient information: Self-blood glucose monitoring").as below
Patient information: Self-blood glucose monitoring
David K McCulloch, MD
INTRODUCTION — People with diabetes have an important role in their own medical care, and self-glucose monitoring is an opportunity for people with diabetes to take control of their health.
Although diabetes is a chronic condition, it can usually be controlled with lifestyle changes and medication. The main goal of treatment is to keep blood glucose levels in the normal or near-normal range. Monitoring blood glucose levels is one of the best ways of determining how well a diabetes treatment plan is working. (See "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Insulin treatment in type 1 diabetes").
A healthcare provider will periodically order laboratory blood tests to determine blood glucose levels and hemoglobin A1c (A1C). The results of these tests gives an overall sense of how blood glucose levels are controlled (show figure 1). However, fine-tuning of blood glucose levels and treatment also requires that patients monitor their own blood glucose levels on a day-to-day basis.
Self-blood glucose monitoring allows patients to know their blood glucose level at any time and helps prevent the immediate and potentially serious consequences of very high or very low blood glucose. Monitoring also enables tighter blood glucose control, which decreases the long-term risks of diabetic complications.
HOW TO TEST — The following steps include general guidelines for testing blood glucose levels; specific details for individual blood glucose monitors should be obtained from the package insert or a healthcare provider.

Wash hands with soap and warm water. Dry hands.

Prepare the lancing device by inserting a fresh lancet. Lancets that are used more than once are not as sharp as a new lancet, and can cause more pain and injury to the skin.

Prepare the blood glucose meter and test strip (instructions for this depend upon the type of glucose meter used).

Use the lancing device to obtain a small drop of blood from the fingertip or alternate site (like the skin of the forearm) (show picture 1). Alternate sites are often less painful than the fingertip. However, results from alternate sites are not as accurate as fingertip samples when the blood glucose is rising or falling rapidly (show picture 2).

Patients who have difficulty getting a good drop of blood from the fingertip can try rinsing the fingers with warm water, shaking the hand below the waist, or squeezing ("milking") the fingertip.

Apply the blood drop to the test strip in the blood glucose meter. The results will be displayed on the meter after several seconds.

Dispose of the used lancet in a puncture-resistant sharps container (not in household trash).

FREQUENCY OF TESTING — Studies have proven that patients with type 1 and 2 diabetes who maintain normal or near normal blood glucose levels have a lower risk of diabetes-related complications. The frequency of monitoring will depend upon the type of diabetes (1 or 2) and treatment used (insulin versus oral medications).
Type 1 diabetes — For patients with type 1 diabetes, frequent testing is the only way to safely and effectively manage blood glucose levels. (See "Patient information: Diabetes mellitus, type 1").
The recommended frequency of testing varies from patient to patient, though most patients need to test at least four times per day. Patients using intensive insulin therapy and women with type 1 diabetes who are pregnant may need to test as many as seven times per day.
Patients who test frequently, especially those using intensive insulin therapy, may consider purchasing several blood glucose monitors to keep at home, work, school, or in a purse or backpack. This allows a patient easier access to testing equipment, which can increase testing frequency and therefore improve blood glucose control. However, patients who like to track data using meters with a memory function may have difficulty if some blood glucose results are on one meter and others are on a different meter.
Type 2 diabetes — Blood glucose monitoring is also important for patients with type 2 diabetes. The recommendations for frequency of testing varies from one patient to another based upon individual factors such as type of treatment (diet versus oral medication versus insulin), level of hemoglobin A1c (A1C), and treatment goals. A healthcare provider can help a patient know how frequently they should test. (See "Patient information: Diabetes mellitus, type 2").
INTERPRETING RESULTS
Blood glucose testing — The results of blood glucose testing indicate if diabetes treatments are on target. However, blood glucose results can be affected by activity levels, foods eaten, and medications (include insulin and oral diabetes medications). To interpret results, patients must consider all of these potential factors.
Patients should discuss their blood glucose results and the best way to interpret them with a healthcare provider. Patients should understand how to record results (either with paper and pen or electronically) and how to use them to optimally control blood glucose levels. Many meters have a memory function that allows results to be stored and downloaded to a computer. Results can then be analyzed and printed for a healthcare provider to review. All patients who monitor their blood glucose levels should bring their blood glucose records to each visit with a healthcare provider.
Patients should generally record blood glucose results, the time and date, and dose of medication used; additional notes about food intake, exercise, and difficulties with illness or stress can also be helpful but are not generally required every day.
Several days of monitoring are usually needed to identify daily patterns, which can be used to make lifestyle or medication adjustments. Patients who use intensive insulin therapy should adjust their insulin dose before meals based upon the blood glucose readings (ie, give a higher dose of very-rapid or rapid acting insulin when blood glucose levels are high).
Need for urine testing — People with type 1 diabetes should perform urine testing for ketones if their blood glucose level is above 240 mg/dL ((13.3 mmol/L), during periods of illness or stress, or if there are symptoms of ketoacidosis, such as nausea, vomiting, and abdominal pain. Ketones are acids that are formed when the body does not have enough insulin to break down glucose, causing the body to break down fat for energy. Ketones can also develop during illness, if an inadequate amount of glucose is available (due to skipped meals or vomiting). Ketoacidosis occurs when high levels of ketones are present, which can lead to serious complications such as diabetic coma.
Urine ketone testing is done with a dipstick, available in pharmacies without a prescription. Urine can be collected and then tested with the dipstick, or the dipstick may be held in the urine stream. A color change occurs if ketones are present, indicating a trace, small, moderate, or large concentration of ketones. If a moderate to large concentration of ketones is present, the patient should consult with a healthcare provider immediately to determine the best treatment. An additional dose of insulin may be required, or the provider may instruct the patient to go to the nearest emergency room.
ADJUSTING TREATMENT — Home blood glucose monitoring can provide useful and motivating information. However, patients should make slow and careful changes to their treatment, allowing the body time to respond to changes. Most patients will need to consult with their provider frequently as they learn to make adjustments in treatment, especially with insulin. However, with time and experience, most patients are able to learn how to make adjustments on their own.
Patients should avoid making multiple treatment changes at the same time unless instructed to do so by a healthcare provider. Changing one aspect of treatment at a time allows for more careful evaluation of the effects of that change on blood glucose levels. Furthermore, it can take several days before changes are reflected in blood glucose results.

Dr. Abdul Hadi Aljuraisy

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