DIABETES MELLITUS PART 1: TYPE 1 DIABETES AND DIABETIC KETOACIDOSIS

Energy is one important requirement needed for the body to function normally. The most common source of energy is carbohydrates - glucose. This is found in various types of food, such as grains, cereals, bread, and dairy products.

With the help of digestive enzymes, carbohydrates from food are broken down into simple sugars (like glucose and fructose) in the mouth and small intestine and transported into the blood. It becomes free to be used by various organs and tissues of the body. The body uses insulin, a hormone that functions like a built-in mechanism to regulate the amount of glucose in the blood. Insulin is the key that allows glucose in the blood to be transported inside cells, for use as an energy source.

Prediabetes

When blood glucose levels remain too high, this is called hyperglycemia, which may be a sign of prediabetes. This means that the body is unable to regulate blood glucose levels, putting the patient at risk for diabetes.

There are certain criteria for prediabetes. These include:

• blood sugar level: 100-125 mg/dl after an 8-hour fast
• blood sugar level: 140-199 mg/dl 2 hours after an OGTT test
• glycosylated hemoglobin level: 5.7-6.4%

Prediabetes may be associated with metabolic syndrome. This involves obesity, too high or low blood lipid levels, hypertension, and problems with insulin levels in the body.

Diabetes Mellitus

If the level becomes too high, or there are certain accompanying symptoms, diabetes mellitus may develop. In general, there are four types of diabetes: type 1 diabetes mellitus, type 2 diabetes mellitus, monogenic diabetes, and gestational diabetes mellitus. This article will focus on Type 1 diabetes mellitus.

Prediabetes can lead to diabetes mellitus when these occur:

• blood sugar level: 126 mg/dl or higher, after an 8-hour fast
• blood sugar level: 200 mg/dl or higher, 2 hours after an OGTT test
• glycosylated hemoglobin level: 6.5% or higher
• excessive intake of water or food, excessive urination, unexplained weight loss
• high amount of sugar or ketones in the urine

Types of Diabetes Mellitus

Type 1 Diabetes Mellitus

Type 1 diabetes mellitus used to be known as insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes. It’s the most common type of endocrine-metabolic disorder in children. Although it is frequently seen in children 7-15 years old, it can happen at any age. Up to 10% of people with diabetes mellitus in the world are children; in the United States, as much as 1 in 300 children have diabetes.

In Type 1 diabetes, there isn’t enough insulin produced by the body because of autoimmune damage to the pancreatic cells that produce this hormone. In some cases, insulin is not produced at all. This may be inherited or due to environmental factors, such as viral infections, diet, drugs or chemicals, radiation, and psychological stress. People who have undergone pancreatectomy may also develop this condition.

Common symptoms of children with Type 1 diabetes are weight loss, fatigue and weakness, increased thirst or hunger, and increased urination. Sometimes, there can be flu-like symptoms, such as weakness, fatigue, and fast breathing. There are children who are diagnosed with diabetes despite having no symptoms at all; commonly, high blood glucose levels are discovered through routine examination or during screening for other diseases.

Children with this condition will need to change their diet and have daily insulin injections to help keep a normal blood glucose level. Unfortunately, there can be acute and chronic complications from Type 1 diabetes. Long-term complications include heart disease and obstruction of blood vessels that can affect the eyes (retinopathy), kidney (nephropathy), and nervous system (neuropathy). The most severe acute complication is ketoacidosis, which can be life-threatening.

Diabetic Ketoacidosis

In diabetic ketoacidosis (DKA), excess blood glucose levels bring more fluids into the blood vessels, eventually leading to increased urination. A lot of water and glucose is excreted with urine, so patients often feel thirstier and hungrier. Eventually, this leads to weight loss and dehydration. Because the body is unable to use the glucose in the blood, it compensates by breaking down free fatty acids as an alternative energy source. The by-products of this process are ketoacids, which start to accumulate in the blood and cause nausea, vomiting, and abdominal pain. Eventually, this affects the functions of the heart, lungs, and brain. If left untreated, a child could further deteriorate and end up in a coma.

As much as 20-40% of children with Type 1 diabetes are diagnosed because they developed DKA. Other than symptoms, DKA is also diagnosed through various laboratory tests, such as electrolyte levels and blood and urine ketones.

Children who develop DKA are typically admitted to the hospital for treatment. This includes intravenous (IV) fluid, insulin, and careful monitoring with regular blood tests. Extra medications are given for children who show signs of increased pressure in the brain (intracranial pressure). Electrolytes are also replenished through IV fluids. Once the acidosis is resolving, patients may start having regular insulin injections through the fatty layer beneath the skin (subcutaneously), while attempting to adjust their diet through a nutrition care plan. Proper patient and family education about the medical condition should also be done, to ensure that the child is cared for even after hospital discharge. Regular exercise is also highly recommended. In certain situations (on a case-to-case basis), a healthcare provider may include certain medications to help control blood sugar levels.

Takeaway

Diabetes mellitus can also affect children. Among the various types of diabetes, Type 1 is usually diagnosed in children as compared to adults. This condition is not easily diagnosed because it can mimic other illnesses; hence, some children are diagnosed with Type 1 diabetes when they develop diabetic ketoacidosis. This is a life-threatening complication that should be urgently treated at a well-equipped hospital or institution. Although symptoms can be managed and prevented, Type 1 diabetes has no cure at the moment.

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References:

• Kliegman, R.M. et al. (2020). Section 6 Diabetes Mellitus in Children. Nelson Textbook of Pediatrics 21st edition. Elsevier.
• Canadian Sugar Institute. Carbohydrate Digestion and Absorption. Taken from: https://sugar.ca/sugars-health/carbohydrate-digestion-and-absorption
• Stanford Children’s Health. Type 1 Diabetes Mellitus in Children. Taken from: https://www.stanfordchildrens.org/en/topic/default?id=type-1-diabetes-in-children-90-P01977
• Gosmanov, A.R., & Kitabchi, A.E. (Last update 28 Apr 2018). Diabetic Ketoacidosis. Endotext [Internet]. Taken from: https://www.ncbi.nlm.nih.gov/books/NBK279146/

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