Type 1 Diabetes: Risk Factors & Symptoms

• 1.25 million people in America have Type 1 Diabetes (T1D)
• Most common in people under 20
• Most common metabolic disease in children
• Represents 1 in 400-600 children

Risk Factors

• Genetic susceptibility from the presence of HLA haplotypes on chromosome 6: DR4-DQ8 or DR3-DQ2
• History of T1DM or T2DM in a first degree relative
• Viral infections
• Immunization
• Diet
• Higher socioeconomic status
• Obesity
• Vitamin D deficiency
• Perinatal factors like maternal age and low birth weight

Clinical Manifestations

• Classic new onset of chronic polydipsia, polyuria, and polyphagia
• Weight loss with hyperglycemia and ketonemia or ketonuria
• Diabetic ketoacidosis
• Dehydration
• Decreased energy level
• Confusion
• Fruity odor to breath
• In young children or infants, failure to grow and gain weight

Physical Examinations and Screenings

• Check vital signs and BMI
• Fundoscopic and visual examination to screen for diabetic retinopathy look for neovascularization, microaneurysms.
• Auscultate heart for rate, rhythm, murmur, clicks or extra heart sound
• Palpation of thyroid to rule out thyroid disorders
• Skin examination for signs for dehydration
• Neurological examination for neuropathy
• Feet examination for pulses, swelling, nail thickness, gangrene
• Psychosocial screening for depression

Diagnostic Criteria

• C-peptide insulin level (normal 0.5 to 2 ng/mm): Below normal in T1DM and normal or above normal in T2DM
• Insulin level: little or no insulin T1DM
• Presence of autoantibodies: anti-glutamic acid decarboxylase, insulin autoantibodies, and islet-cell antibodies

Treatment: Pharmacologic

• Intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion
• Rapid acting insulin: Lispro, Aspart (15 mins before meal)
• Short acting insulin: Regular (HumilinR/Novolin R) (30 mins before meal)
• Intermediate acting insulin: NPH (HumilinN/Novolin N) (works for about 16 hrs) taking between meals and at bed time
• Long acting insulin: Gargline(Lantus, Levemir, Toujeo) works (20-24 hrs)

Calculations of Daily Insulin Requirements

• Initial Total Daily Dose (TDD): 0.4 to 0.5 u/kg/day
• Usual Total Daily Dose (TDD): 0.4 to 1 u/kg/day in divided doses
• Dosing broken down to 50% basal and 50% prandial
  • Basal insulin: intermediate (NPH)- or long-acting (eg, glargine, degludec, detemir) in 1 to 2 daily injections
  • Bolus or prandial insulin: administered before or at mealtimes as a rapid-acting (eg lispro aspart glulisine insulin for inhalation) or short-
• Example for a 60 kg person with 0.4u/kg/day:
  • TDD = 60 kg x 0.4u/day = 24 units/day
  • 50% basal insulin = 12 units
  • 50% prandial insulin = 12 units in divided doses or 4 units with each meal

Dose Adjustment

• Basal or/ and prandial insulin must be titrated to achieve glucose control and avoid hypoglycemia
• Prandial insulin correction factor for elevated blood sugar >150:
  • Subtract 100 from blood sugar and divide by 50
  • Administer resultant number of units of insulin
  • Example: blood sugar = 200 mg/dL, so 200-100 = 100 and 100/50 = 2 units of insulin to correct elevated blood sugar

Treatment: Non-Pharmacological

• Diabetes self-management: self-monitoring of glucose multiple times daily
• Nutrition management: Individualized and culturally sensitive
• Exercise: 150 min of moderate-to-vigorous intensity aerobic activity daily activities at least 3 days per week
• Education: periodic, culturally sensitive, and developmentally appropriate regarding maintaining ideal body weight, daily exercise, smoking avoidance/cessation, insulin, and foot care

Complications

• Include hypoglycemia, hyperglycemia, and diabetic ketoacidosis
• Other complications include diabetic retinopathy & nephropathy and diabetic neuropathy
• Skin ulcerations and gangrene of lower extremities can also occur
• Chronic or acute infections can occur secondary to hyperglycemia
• Cardiovascular disease and dyslipidemia risks increase

Hypoglycemia

• It includes abnormally low plasma glucose concentration with or without symptoms
• No specific glucose level defines it, as glycemia thresholds may vary. It usually occurs at levels less than 65 mg/dl or 3.6 mmol/lit
  • Neurogenic symptoms consist of tremors, palpitation, anxiety, sweating, hunger and paresthesia
  • Neuroglycopenic symptoms include dizziness, weakness, drowsiness, delirium, confusion and seizures/coma

Hypoglycemia Management

• Asymptomatic Hypoglycemia: if glucose level ≤70 mg/dL (3.9 mmol/L), retest in15 to 60 minutes.
• Symptomatic hypoglycemia:
  • Take 15 to 20 grams of fast-acting carbohydrate like 3-4 glucose tablets, ½ cup (4 oz) orange juice, 1 tbsp sugar, or 6-8 hard candies, and retest in 15 mins
  • If glucose < 70 mg/dl, repeat treatment; follow by long-acting carbohydrates, like from a meal or snack
• Severe Hypoglycemia:
  • Requires assistance to administer carbohydrate, glucagon, or resuscitative actions
  • GlucaGen HypoKit or Glucagon Emergency: IM, IV, SubQ: 1 mg; may repeat after 15 min
  • Intranasal: 3 mg (one actuation) into a single nostril; if no response, may repeat

Follow Up

• Physical examinations every 3 months focused on growth and development
• Assess for psychological issues and family stress that could impact diabetes management
• Screen for additional autoimmune diseases like thyroid dysfunction and celiac every 2-3 years
• Hypertension screenings at every visit
• Dyslipidemia screening annually
• Screen for micro and macrovascular complications like nephropathy (annually) and retinopathy (every 2-5 years)
• Neuropathy screening: comprehensive foot exam annually

Referrals

• Endocrinologist
• Diabetes educator
• Dietitian
• Mental health professional for newly diagnosed and/or initiation of insulin pump
• Obstetrician during pregnancy

Explore the risk factors and clinical manifestations of Type 1 Diabetes (T1D), a common metabolic disease, especially in children. Identify genetic predispositions, lifestyle factors, and key symptoms like polydipsia and weight loss. Learn about physical exams for early detection.