Insulin-dependent diabetes mellitus (IDDM)
Alternative names:
diabetes mellitus - type I; IDDM; juvenile onset diabetes; type I diabetes mellitus
Treatment:
At diagnosis, the immediate goals of treatment are to stabilize the metabolism and eliminate the symptoms of high blood-glucose. Because of the sudden onset of symptoms in insulin dependent diabetes, treatment for newly diagnosed people will involve hospitalization to stabilize the high blood glucose level.
The ultimate goals of treatment are to prolong life, improve the quality of life and prevent long-term complications through education, medication, meal planning and weight control, exercise, self testing of blood glucose, foot care and careful monitoring.
INSULIN:
Insulin lowers blood sugar by allowing it to leave the blood stream and enter the body cells. Everyone needs insulin. People with Type I diabetes can't make their own insulin, and therefore must take insulin injections every day to survive. Insulin must be injected under the skin using a syringe, or in some cases, an infusion pump is used to deliver insulin continuously. It is not available in an oral form.
Insulin preparations differ in how fast they start to work and how long they work. The health care professional measures blood glucose to determine the appropriate type of insulin to use. More than one type of insulin may be mixed together in an injection to achieve the best control of blood glucose. The injections are needed, in general, from 1 to 4 times a day. People requiring insulin injections are taught how to give themselves injections by their health care provider, or a diabetes educator referred by their provider. Initially, a child's injection should be given by an experienced individual. By age 14, children can be expected, but not required, to give their own injections.
GLUCAGON EMERGENCY KIT:
Glucagon is a medication that is injected and raises blood sugar. Every person who takes insulin should have glucagon on hand. It is indicated when the blood sugar gets so low that the person is unable to swallow or loses consciousness. People in close contact with the diabetic should be instructed on how administer glucagon in an emergency, since the person needing it may be unable to do so.
CURRENT RESEARCH:
Transplantation of a donor pancreas to treat diabetes has been used with varied success due to the need for long-term immunosuppression to fight rejection. Studies are currently underway to evaluate the success of islet and beta-cell transplantation procedures.
Current research efforts are aimed at development of an artificial closed-loop insulin pump that can sense glucose levels and release appropriate insulin amounts, similar to the function of the pancreas.
EDUCATION:
You are the most important person in managing your diabetes. Diabetes education is therefore a crucial part of the treatment plan. Diabetes education basically involves learning how to live with your diabetes. Knowledge of disease management is imperative to avoid developing short term complications (hypoglycemia, hyperglycemia) and to delay or slow the onset of long term complications of the disease (diabetic retinopathy, nephropathy,...). See also diabetes- diabetic education.
You should be knowledgeable about the basic principles (survival skills) of diabetes management. Basic "survival skills" include: - how to recognize and treat low blood sugar (hypoglycemia)
- how to recognize and treat high blood sugar (hyperglycemia)
- meal planning (refer to DIABETIC DIET)
- how to administer insulin or how to take oral hypoglycemic agents
- how to test and record blood glucose (see blood glucose monitoring) and urine ketones (see urine ketone monitoring)
- how to adjust insulin and/or food intake during exercise (see EXERCISE AND WEIGHT CONTROL FOR DIABETICS)
- how to handle sick days (see DIABETIC SICK DAYS)
- where to buy diabetic supplies and how to store them
DIABETIC DIET:
Diabetic diet management for insulin-dependent diabetes (Type I) requires consistency in meal time and the amounts and types of food eaten to allow food and insulin to work together to regulate blood glucose levels. If meals and insulin are out of balance, extreme variations in blood glucose can occur. The American Diabetes Association and the American Dietetic Association developed 6 food exchange lists for planning healthy, balanced meals. Consultation with a registered dietitian or nutrition counselor is an invaluable tool for meal planning and dietary control for diabetics. See diabetes- diabetic diet.
PHYSICAL ACTIVITY:
Regular exercise is especially important for the person with diabetes. It helps control the amount of sugar in the blood and helps burn excess calories and fat to achieve optimal weight. Before people with diabetes begin any exercise program, they should obtain medical approval. Diabetic's, especially, insulin dependent diabetics, must take special precautions before, during and after participation in intense physical activity or exercise. See diabetes- exercise and weight control.
Support groups:
The stress of illness can often be helped by joining a support group where members share common experiences and problems. For this condition, see diabetes - support group.
SELF-TESTING:
Blood-sugar testing or self monitoring of blood glucose is done by checking the glucose content of a small drop of blood. The testing is done on a regular basis and will inform the person with diabetes how well diet, medication, and exercise are working together to control diabetes. The results can be used to adjust meals, activity, or medications to keep blood-sugar levels within an appropriate range. It will provide valuable information for the health care provider to suggest changes to improve care and treatment. Testing will identify high and low blood-sugar levels before serious problems develop. See diabetes- blood glucose monitoring.
FOOT CARE:
People with diabetes are prone to foot problems because of complications of the diabetes. Diabetes cause damage to the blood vessels and nerves. These changes can result in a decreased ability to sense trauma or pressure on the foot. A foot injury could go unnoticed until severe infection develops. Additionally, diabetes alters the bodies immune system, thus decreasing the bodies ability to fight infection. Small infections can rapidly progress to death of the skin and other tissues (necrosis), necessitating amputation. To prevent injury to the feet, diabetics should adopt a daily routine of checking and caring for the feet. See diabetes - diabetic foot care.
MONITORING: - Visit your physician and/or diabetes educator at least 4 times a year.
- Have your glycohemoglobin (HbA1c) measured 4 times a year to evaluate your level of glucose control.
- Have your cholesterol and triglyceride level, and kidney function evaluated yearly.
- Visit your ophthalmologist (preferably one that specializes in diabetic retinopathy) at least once a year, more frequently if signs of diabetic retinopathy.
- Every 6 months have a throughout dental cleaning and examination. Inform your dentist and hygienist that your are a diabetic.
- Daily, monitor your feet for early signs of injury or infection. Make sure that your health care provider inspects your feed at each visit.
- Get a flu shot every year in the fall.
Expectations (prognosis):
The outcome for diabetes mellitus varies. Usually insulin-dependent diabetes mellitus is more severe, and the potential for development of complications is greater than with other types of diabetes. Even with good control by diet and medication of both types of diabetes, complications may result.
Complications:
EMERGENCY COMPLICATIONS: In a person with diabetes, if insulin is not present for the body to use glucose as a fuel source, body fat is used as fuel. The by-products of fat metabolism are ketones. Ketones build up in the blood and "spill" over into the urine. A condition called ketoacidosis develops when the blood is more acidic than body tissues.
Hypoglycemic coma can occur when the balance between insulin, food intake and exercise is disturbed. If blood glucose levels drop too low, lose or consciousness and coma may occur.
LONG-TERM COMPLICATIONS:
People who have had diabetes for several years are likely to develop long-term complications. A recent study called the Diabetes Control and Complications Trial (DCCT), sponsored by the National Institutes of Health, showed that a program of tight glucose control, with frequent self glucose monitoring, can actually delay or slow the progression of complications caused by insulin dependent diabetes (Type I). These serious complications include:
Diabetics develop atherosclerosis at an accelerated rate and it tends to appear earlier in life than in non-diabetics. Additionally, diabetics have a higher rate of developing hyperlipidemia, hypertension, and coronary artery disease. It is very important for diabetics to take measures to reduce their risk of coronary heart disease by not smoking, maintaining a normal blood pressure, and keeping lipid and cholesterol level within normal limits.
Microvascular changes occur in capillaries of every organ of the body. There is a thickening of the basement membrane of the small blood vessels. These microvascular changes are responsible for many of the diabetes complications.
Changes in the basement membrane of the retina (also known as diabetic retinopathy) with blockage of some vessels and dilation of others predispose the diabetic to several eye disorders. After 15 years of diabetes, 80% of diabetics will have some diabetic retinopathy. If bleeding and scarring has developed, a retinal detachment may occur, causing blindness. Vascular changes in the iris may cause obstruction of the flow of vitreous fluid leading to development of narrow-angle glaucoma. Diabetics are also more likely to develop senile cataracts, although the exact rationale is unclear.
Kidney abnormalities may be noted early in the disease. Also poorly controlled diabetes may accelerate the development of kidney failure. Urinary tract infections in diabetics tend to be more severe and may result in kidney damage. Also, diabetics are more susceptible to kidney damage as a result of drug toxicity and uncontrolled high blood pressure.
People with diabetes may develop temporary or permanent damage to nerve tissue. Injury to the nerves is caused by decreased blood flow and high blood sugar levels. Neuropathies are more likely to develop if blood-glucose levels are poorly controlled. Some diabetics will not develop neuropathy, while others may develop this condition relatively early. On average, the onset of symptoms occurs 10 to 20 years after diabetes has been diagnosed.
The feet of diabetics are very susceptible to infection and injury. Studies have shown that 20% of all hospital admissions in diabetics are for foot problems, and half of all non-accident related leg amputations are performed on diabetics. Several foot problems are common in people with diabetes, including skin changes (loss of hair, loss of ability to sweat, dry, cracked skin), arterial insufficiency (impaired blood supply to feet), neuropathy (decreased ability to feel pressure or injury), and specific foot deformities (hallux valgus, bunion, hammertoe, calluses).
- SKIN AND MUCUS MEMBRANE PROBLEMS
People with diabetes are more likely to develop infections. Hyperglycemia (high blood sugar) predisposed a person to vulvovaginitis, fungal infections of the skin, and urinary tract infections. Additionally, diabetics are especially susceptible to developing periodontal disease.
- COMPLICATIONS OF INSULIN THERAPY
Diabetics who take insulin to control their blood sugar are at risk for several complications. Acute complications include hypoglycemia and hyperglycemia which may be related to improper balance of insulin with diet and activity level. Chronic complications may include development of scar tissue at the injection sites and allergic reaction to the insulin.
Calling your health care provider:
Medical follow-up for a person newly diagnosed with insulin-dependent diabetes mellitus will probably occur weekly until good control of blood glucose is achieved. The health care provider will want to review results of home glucose monitoring, urine testing, and a diary of meals, snacks, and insulin injections. As the disease becomes more stable, follow-up visits will be less frequent. Periodic evaluation is very important for the evaluation of long-term complications associated with diabetes.
Call your health care provider if symptoms of ketoacidosis are present: Go to the emergency room or call the local emergency number (such as 911) if symptoms of hypoglycemic coma or insulin reaction are present: Early signs of hypoglycemia may be treated at home by ingesting a sugar source or injecting glucagon. If the signs of hypoglycemia are not relieved by the above action or if blood glucose levels remain below 60 mg/dl go to the emergency room.
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