Definitive Guide for Type 1 Diabetes

Written by Dr Katie Stephens, GP

Dr Katie graduated from the University of Manchester in 2007 (MBChB) and completed her GP training in the West Midlands in 2012 (MRCGP). 

Keywords/Abbreviations 

What is Type 1 Diabetes? 

Type 1 diabetes occurs when the pancreas stops producing insulin. The pancreas is an internal organ, roughly the size of your hand, located in the top left of your abdomen, tucked just below your stomach. Insulin is a hormone that lowers the amount of sugar (glucose) in the blood. Without it, the sugar level can rise above what is healthy. If it rises very high, it can lead to life-threatening emergencies. It can also cause long-term damage to multiple organs in the body even at more modestly raised levels. 

In the UK, someone is diagnosed with Diabetes every 2 minutes, with an estimated 4.7 million people now affected. This includes both type 1 and type 2 Diabetes, although most of these people have the latter. Additionally, the NHS spends £25,000 a minute on Diabetes, and every hour someone has an amputation because of it.

How are sugar levels normally controlled?

The cells in our body use sugar (glucose) as an energy source to help them function. Usually, the amount of glucose being carried around in our bloodstream can vary by a reasonable amount within a ‘normal range’. It is affected by factors such as how long ago someone has eaten, or how active they have been.

When the sugar level fluctuates above or below where it should be, this is sensed by our pancreas, which then responds by releasing a hormone to bring the level back towards normal. The pancreas is an internal organ, roughly the size of your hand, located in the top left of your abdomen, tucked just below your stomach.

When the blood sugar rises too high, the pancreas normally responds by secreting a hormone called insulin, which lowers the blood sugar levels in the following ways:

• Telling our cells to open up and pull in some of the glucose from the bloodstream. (This is important as it means the cells then have the energy they need to work properly.)
• Telling our liver to store more glucose, thereby taking it out of circulation.
• Using glucose to make and store fats and cholesterol.

How does Type 1 Diabetes happen? 

In Type 1 Diabetes there is no insulin in the body. In 90% of cases of type 1 diabetes, this is because the body’s own immune system attacks the pancreas, specifically the β (beta) cells, which are responsible for making insulin. As the β cells become damaged, the amount of insulin they can make reduces, until they eventually become destroyed and are unable to make any insulin at all. For the remaining 10% of people where this does not happen, they too have no insulin, but the underlying cause for this isn’t known. 

When the body mistakenly attacks its own healthy cells, this is referred to as an auto-immune disease. There are many other well-known conditions apart from Type 1 Diabetes that are auto-immune diseases: Rheumatoid Arthritis, Inflammatory Bowel Disease (e.g., Crohn’s Disease), Hashimoto’s Disease (causing an underactive thyroid, or hypothyroidism), Coeliac Disease and Multiple Sclerosis, to name just a few. 

It is thought that people who have one auto-immune disease already are at an increased risk of developing a second. There are certain genetic syndromes which involve people having multiple auto-immune conditions all at once (for example, Autoimmune Polyglandular Syndrome Type 2 is a combination of type 1 diabetes, hypothyroidism and Addison’s Disease – a type of underactive adrenal gland). Apart from these more severe syndromes though, there is also a recognition that simply having one autoimmune condition can increase the chances of getting a second. 

What’s the difference between Type 1 and Type 2 Diabetes? 

As described above, type 1 diabetes happens when the pancreas becomes so badly damaged that it stops making insulin altogether. People with Type 1 Diabetes tend to have symptoms younger and get diagnosed as children or young adults. The old name for this is Insulin-Dependent Diabetes Mellitus, or IDDM. 

With Type 2 Diabetes, there is still insulin in the body, just either not enough of it, or what is present does not have the desired effect, as the body stops responding normally to it (a phenomenon known as insulin resistance). It tends to come on later in adult life and is caused by carrying excess fat, although with the trend towards obesity occurring at younger ages, people are getting diagnosed younger and younger these days. The old name for type 2 diabetes is Non-Insulin Dependent Diabetes Mellitus, or NIDDM. This can be a bit misleading, however, as there are some people with Type 2 Diabetes who do need insulin (just not everyone). 

What is Pre-Diabetes? 

Pre-Diabetes is the diagnosis used for people whose blood sugar levels are higher than they should be, but not quite high enough to be diagnosed as Diabetic. It is worth identifying these people as they have a risk of progressing to develop Diabetes (usually Type 2). However, if they can make lifestyle changes and lose excess fat, they may potentially never develop Type 2 Diabetes and could even have their blood sugars drop back down into a normal range. 

Usually, Pre-Diabetes is discovered when someone is tested for Type 2 Diabetes using the HbA1c test. This test gives an average sugar level reading, taking into account what the sugars have been for the previous 3 months. 

While an HbA1c of 48 mmol/mol or higher is classed as Diabetic, 42 – 47 mmol/mol is considered Pre-Diabetic. 

Other types of diabetes?  

Gestational Diabetes 

When pregnant women have Diabetes only during pregnancy and resolving soon after delivery, it is known as Gestational Diabetes. Women who have had Gestational Diabetes are known to be at increased risk of progressing to have a longer lasting type of Diabetes later in life. For those who do, the vast majority will have type 2 diabetes, although some may develop type 1 diabetes.  

The other Diabetes: Insipidus 

The full name of the Diabetes we are discussing in this guide is ‘Diabetes Mellitus’. It helps to explain first that there is a second type of Diabetes that you may not have heard of, a rare condition known as Diabetes Insipidus (DI).  

Both types of Diabetes involve excess urine being made, when they are in an untreated, severe state. In fact, ‘diabetes’ comes from the Greek term for siphon – meaning passing through, (referring to the large volumes of urine). In the case of Diabetes Mellitus, the urine has excess glucose in it, hence the name Mellitus, which is Latin for ‘sweet’. 

With Diabetes Insipidus, there is no excess sugar involved, and the underlying cause is instead a malfunctioning of either the brain or the kidneys. With the urine of people with DI therefore not being sweet, it earned the ‘insipidus’ label, which is Latin for ‘tasteless’.  

Now that I’ve explained the difference between the two Diabetes conditions (and you may be wondering about early doctors’ urine tasting!), it’s worth clarifying that this article is only addressing DM and not DI, so any time I use the word ‘Diabetes’, I am referring to Diabetes Mellitus. Also, as DM is very common, and DI is quite rare, when you see the word ‘Diabetes’ on its own elsewhere, the writer is likely referring to the former.  

Risk Factors 

The only definite known risk factor for type 1 diabetes is a positive family history, although even this is only present in about 10 – 15 % of cases. However, it is still significant: twins have a 50% risk, children of parents with type 1 diabetes have a 6% risk (the risk is higher if the father has type 1 diabetes than the mother), and siblings have a 5% risk, compared to just 0.4% risk for the general population. 

There is a great deal of research being done into other potential causes, though. For instance, the TEDDY Study (The Environmental Determinants of Diabetes in the Young) is an international study following over 8,000 children who have a genetic risk of developing  type 1 diabetes right from birth to age 15y. It is looking at the potential role of infections, diet, and other environmental factors such as prenatal supplements, in triggering type 1 diabetes. The current average age of the children is 9 years, so while there will likely be significant discoveries revealed in the next few years, there are already interesting developments now, such as the link found between certain childhood respiratory infections and damage to pancreas cells, and the association of lower Vitamin D levels with developing type 1 diabetes. 

Symptoms 

General Symptoms of Type 1 Diabetes 

Two of the classical symptoms of diabetes are weeing more (polyuria) and excessive thirst (polydipsia). The raised sugar level in the blood that occurs with Diabetes eventually translates to a raised sugar level in the urine. This has an osmotic effect in the kidneys, pulling in extra fluid from nearby areas to become urine as well, resulting in the volume of urine increasing. 

The excessive thirst likely occurs in part due to losing more fluids in the urine, as well as a direct result of the raised blood sugar levels themselves. Our body has some fantastic and complex ways of making us feel thirsty if we need to dilute things like a too-high sugar or salt level down. I won’t get into the details here, but I am guessing you may have experienced the effects of this yourself if you have ever woken up feeling particularly thirsty the morning after a salty pizza dinner. 

Other symptoms include recurrent infections (e.g., thrush that is hard to treat), fatigue, unexpected weight loss, poor-healing wounds, blurry vision, and fruity-smelling breath. 

As previously mentioned, type 1 diabetes tends to come on at a young age, (in fact, another interesting finding from the TEDDY study is that the damage to the pancreas seems to begin most often in just the second year of life). If you suspect your child may have type 1 diabetes, we will normally recommend getting urgent medical attention. You could access this by contacting your NHS GP or ringing 111. If your GP tests your child’s urine or blood, and it looks like they have diabetes, they would advise you attend the hospital immediately. 

Symptoms of Type 1 Diabetes Emergencies 

Things can get serious quickly if the blood sugar rises very high or very low. 

DKA, Diabetic Ketoacidosis 

A very high sugar level can cause an emergency known as DKA. A quick fact about insulin: not only does it lower the sugar level in the blood, but also it must be present for your body’s cells to use glucose as energy. If there is not enough insulin, the body needs to find an energy source other than glucose. It then turns to fats instead: in the liver, fats get broken down into molecules called ketones, which can be used by cells for energy even when there is not any insulin around.  

While this seems like a good solution, in people with Diabetes, the quantity of ketones can go unchecked, which gets dangerous. Ketones are acidic by nature, and if there are enough of them, they can bring down the pH balance of the blood (hence ‘ketoacidosis’), which can have disastrous knock-on effects on basic body functioning. 

Symptoms and signs of DKA include: 

• High blood sugar levels  
• Ketones present in the blood or urine 
• Excessive thirst and weeing 
• Blurred vision 

• Altered mental state – confusion, drowsiness 
• Nausea and/or vomiting 
• Abdominal pain 
• Sweet or fruity-smelling breath 
• Fainting 

DKA is a potentially life-threatening medical emergency. If you think someone with you might have DKA, they need urgent medical help. If they have any of the above symptoms, please ring 999 or take them to A&E immediately. Or, if they know their ketones are only slightly high (0.6 – 1.5 mmol/L), and they are not too unwell, you can ring 111 or their diabetes care team for urgent help instead.

Hypoglycaemia (‘hypo’) 

There are a few reasons why the blood glucose level may drop too low, such as the insulin dose being too high, not eating enough, exercising or drinking alcohol. Usually, a cut-off of less than 4 mmol/L is used to diagnose hypoglycaemia officially – also known as having ‘a hypo’.  

Symptoms can be similar to what you may have felt yourself when you’ve been particularly hungry, but in an accentuated way: shakes, nausea, dizziness, sweating, confusion, fatigue and drowsiness. 

If you are with someone you think is having a hypo but is conscious, get them something that has sugar it in to eat or drink quickly (pure fruit juice, a few sweets, or a sugar tablet or gel) and stay with them, making sure they feel better soon. If they faint, ring 999. If you know how to give a glucagon injection, this would also be a helpful thing to do. In this case, you can give the injection first and ring 999 if they haven’t recovered within 10 minutes. For more details, check out our page from St John Ambulance, or Diabetes UK. 

Investigations 

Generally, if a GP is suspecting that you (or your child) might have Type 1 DM, they would typically send you in to hospital the same day to be assessed and managed. This is because, unlike with Type 2 DM, it would be essential to start insulin treatment immediately if you are diagnosed. Any delay in diagnosing and treating type 1 diabetes may increase the risk of something serious happening. 

The following tests therefore are only referring to ongoing monitoring of someone who has already been diagnosed with type 1 diabetes and is on appropriate treatment and are not recommended for home-use for initial diagnosis. 

HbA1c 

This is a measure of how much haemoglobin has sugar attached to it (known as glycated haemoglobin). Haemoglobin is the part inside the red blood cell that carries oxygen. We all have some sugary haemoglobin but knowing how much there is tells us what the sugar levels in the blood are like generally. As red blood cells live around 3 months, this test gives us an average sugar level over the last 3 months. 

There are certain instances where this test may not be appropriate. Other conditions that affect red blood cell or haemoglobin levels may interfere with the interpretation. Examples include:  

• Age <18 years old 
• Pregnancy or testing within 2 months of being pregnant 
• If symptoms have lasted <2 months 
• Haemoglobinopathies (eg thalassaemia), anaemia 

• Having had a recent blood transfusion 

The HbA1c is one of the Home Health Tests that we offer at Kinetik Wellbeing. A normal range is 20 – 41 mmol/mol. 42 – 47 Mmol/mol is usually considered Pre-Diabetic, and 48 mmol/mol is usually used as the cut off for diagnosing Diabetes. Again, this test should not be used at home for diagnosing Type 1 DM as this would not be safe. 

If you are already known to have type 1 diabetes, your GP, Diabetes Nurse or Endocrinologist should be arranging regular HbA1c tests with you and following up the results with you. If you are interested in keeping a closer eye on your HbA1c more often than is offered, this test may come in handy. If this is the case, I’d recommend discussing this use of the home tests with your doctor or nurse and agreeing a plan together of what action should be taken depending on your results. It is also important to remember that you should wait at least 3 months since your last test to repeat the HbA1c, due to the red cell lifespan. 

Blood sugar level 

The advantage of this test is it does not rely on a normal haemoglobin, so it can be useful if one of the above conditions applies. The disadvantage is that it truly only gives a snapshot picture of what the blood sugar is in that very second that the test is taken. As sugar levels can go up and down, it can be falsely reassuring if the sugar level is tested in a moment when it is normal, even if that person actually has diabetes. It can also be falsely worrying as other conditions such as infection and trauma can raise sugar levels temporarily. 

Saying all of that, for someone diagnosed with type 1 diabetes, this is a very useful test for monitoring blood sugars in response to fasting, eating, and insulin doses. The quick result that is given allows the tester to take immediate action when appropriate, in response to a result out of range. The Kinetik Wellbeing range includes a clinically validated blood glucose monitor here(36), equipped with a ketone warning. 

The cut-offs for a raised blood sugar level depend on when the test is done. If it is done at a random time (as opposed to after fasting overnight, for instance), then over 11 mmol/L is considered significantly raised, or hyperglycaemic. Under the Monitoring section you can find target sugar levels for other testing times. 

Diagnosis 

As mentioned earlier, if your GP suspects that you or your child may have Type 1 Diabetes, they would usually send you in to be seen the same day in the hospital. This is because of the importance of quickly starting insulin treatment if type 1 diabetes is present. If treatment is delayed, the patient may come to serious harm.  

Diagnosis in adults is generally made on the basis of a raised blood sugar level (again, >11 mmol/L for a random test) in the presence of other factors that suggest type 1 diabetes, such as: 

• Ketones being present (see the DKA section for more information on ketones). 
• Rapid weight loss (remember, we need insulin for our cells to actually use sugar. Without it, we must break down fats for energy instead.). 
• Age of onset younger than 50y. 
• Body Mass Index (BMI) below 25 kg/m2. 
• Personal and/or family history of autoimmune disease. 

These factors help differentiate type 1 Diabetes from type 2 when diagnosing an adult. Symptoms also tend to come on a bit more slowly with type 2 and there may be a history of weight gain, as opposed to weight loss. Nine out of ten people with diabetes have type 2. 

The story is different when it comes to diagnosing children, however. Generally, any child found to have Diabetes is more likely to have type 1 than type 2. The clinician assessing the child will still of course consider the possibility of a diagnosis of type 2. Features that could point towards this include: 

• A strong family history of type 2 diabetes. 
• Obesity. 
• Black or Asian ethnicity. 

• Minimal/zero insulin requirement. 
• Signs or symptoms of insulin resistance (such as acanthosis nigricans – the occurrence of darker, velvety skin in the underarms, neck and/or groin) – remember, in type 2 diabetes, the body becomes more resistant to insulin and insulin levels may drop, whereas in type 1 diabetes, there isn’t any insulin at all. 

Management 

Lifestyle Changes 

Unlike type 2 diabetes, type 1 diabetes is not something that can be reversed by lifestyle changes and weight loss. However, lifestyle management still has an important role to play when it comes to optimising control, and reducing the risk of harm, with type 1 diabetes. 

Diet 

Somewhat confusingly, the dietary advice for someone with type 1 diabetes is not the same as for someone with type 2. For instance, NICE specifically advises against recommending a low Glycaemic Index diet for adults. This is due to research (albeit fairly low-quality) suggesting that there is no benefit to a low GI diet in type 1 diabetes. While this advice may change in the future in light of new research, while it stands, it may prevent adults on insulin feeling overly limited in their life-long diet choices. (Even more confusingly, NICE does recommend a low GI diet for young people, on the basis of evidence from a Cochrane review of adults with Type 2 Diabetes.) 

In this vein, there is a national educational course called DAFNE (Dose Adjustment for Normal Eating) which I highly recommend. It aims to enable adults with type 1 diabetes to ‘live their life with as few restrictions as possible and still achieve blood glucose results within healthy targets’. It is backed by NICE and offers both remote and in-person courses. Find a centre near you. 

Diabetes UK also has some handy dietary advice for those with type 1 diabetes: 

• Enjoy a healthy, balanced diet, including all the food groups (fruit, vegetables, grains, protein, dairy and alternatives). 

• Ideally include some carbs with each meal, to reduce the risk of a hypo. Choose healthier carbs where possible (wholegrains, fruit, vegetables, pulses, nuts, seeds, etc). 
• Avoid sugary drinks and fruit juices (unless using this to treat a hypo). 
• Avoid foods labelled as Diabetic – these can still have similar energy values and affect blood sugar, while potentially being more expensive and causing a laxative effect. 
• A low-carb diet is not recommended but carbohydrate counting is. 

Exercise 

First the disclaimer: exercise lowers blood sugar levels. Because of this, it is important to be aware of any adjustments needed to insulin or dietary intake during or after exercising, in order to avoid triggering a hypoglycaemic attack. 

Then, the good news: exercise (especially when combined with a healthy diet) can help with optimising body weight and reducing the risk of complications from diabetes.  

In fact, there is evidence that, specifically in people with type 1 diabetes, exercise improves blood sugar control, physical fitness, and well-being, while reducing lipids, Cardiovascular Disease (e.g., strokes, heart attacks), blood pressure and mortality. 

It is well known that many people with type 1 diabetes actually exercise less, due to a fear of triggering a hypoglycaemic attack. If this is you, please reach out to your diabetic care team to talk through your concerns with them. Getting equipped with the knowledge of how to avoid a hypo, then utilising this to exercise more, could really make a difference to not only lifespan but quality of life as well. You can read more about Diabetes and exercise here.

Alcohol 

Alcohol affects how your body manages blood sugar levels and can make getting a hypo more likely, especially for anyone taking insulin (which is an essential medication for all people with type 1 diabetes).  

For this reason, and because having a hypo can sometimes look a bit like being drunk, NICE recommends wearing some sort of bracelet or carrying a card that identifies you as having Diabetes when drinking somewhere outside of your own home. Of course, eating a snack before and after having a drink can also help reduce the risk of getting a hypo and is strongly recommended. 

It is also important to remember that alcohol does still have calories and carbs that can interfere with weight loss plans and blood sugar control, so it is vital to monitor blood sugar regularly when having a drink. 

So, while Diabetes doesn’t need to stop you from enjoying a drink, it’s important to be wise about what this looks like for you, and what you can do to reduce the risk of harm from alcohol. Diabetes UK has a great resource that looks at this topic in more detail here. 

Smoking 

You may be surprised to learn that smoking actually increases blood sugar levels, by making blood cells less responsive to insulin. For people with type 1 diabetes, this may translate to larger doses of insulin being needed. 

Smoking and Diabetes are both independent risk factors for serious medical conditions like strokes and heart attacks. If you have Diabetes, you are even more likely to develop one of these serious conditions if you smoke than if you don’t. 

Smoking also makes it more likely that some of the other complications from Diabetes will happen, such as kidney failure, visual loss and nerve damage. If you smoke and are contemplating one day quitting, please visit the NHS’s Smoke Free webpage for further information and support. 

Recreational Drug Use 

The main thing to be aware of here is that using recreational drugs when you have Diabetes may affect your ability to keep your blood sugar levels in a safe range. For instance, if you are so sedated as a direct result of the drugs, or indirectly through them affecting your mental health, that you don’t eat or take medication when you should. Or if you become so stimulated and over-active that you consume more energy than normal, causing your blood sugar levels to drop.  

Diabetes UK, while advising against recreational drug use, recommends that you ensure that you are with a friend who knows both about your Diabetes and how to treat a Diabetic Emergency, should you decide to use them. 

Medication 

Medication choices are much simpler in type 1 diabetes compared to type 2 diabetes. As there aren’t any low levels of insulin in the body to try to augment, and no insulin resistance to try to overcome, the only treatment option is to replace insulin. Anyone who has type 1 diabetes must take insulin. 

Insulin 

Insulin is always injected and cannot be taken in tablet form. Most insulin is created using DNA technology to match human insulin as it exists in the body normally. When a slight change in the insulin is designed in order to alter a facet of how it works (e.g., making it last longer), it is termed an insulin analogue.  

We tend to define insulin by how long it takes to start working and how long it lasts. Rapid and short-acting insulins tend to kick in quickly and, as the name implies, only act for a short while. They are useful in particular at mealtimes, with the option of adjusting the dose based on the amount of carbohydrates consumed. 

Intermediate and long-acting insulins take longer to have an effect but also last longer in the body. They are useful to have as a basic foundation of background insulin throughout the day (remember our cells need insulin in order to use glucose as an energy source). 

The type, combination, and amount of insulin that any one person uses should be jointly decided by both the healthcare professional and of course, the individual. Common treatment regimens include: 

• Separate fast and slow injections. The person has one or more injections of intermediate- or long-acting insulin daily, to provide that important background insulin the cells need. They can then vary the amount of rapid- or short-acting insulin injected before meals. 

• Mixed fast and slow injections. This has a similar strategy to the above, but the insulin is pre-mixed with both fast and slow types in a single injection. This may involve fewer injections, but also offer less flexibility than the above. 
• Insulin pumps. This is where a device is attached to the body through a small tube (cannula) that is inserted under the skin. The device continuously releases small amounts of fast-acting insulin into the body, and the dose can be increased at mealtimes. Insulin pumps are free on the NHS for many children and adults. To see if you may be eligible for one, check here. 

Taking too much insulin can lead to a hypoglycaemic attack and it is important that you feel you understand all of the information offered, including how to adjust a dose during intercurrent illnesses, prior to starting, as well as what to do in the event of a hypo. 

Complications 

We discussed the acute emergency situations that can arise when a blood sugar level is dangerously high or low in the Symptoms section. However, Diabetes also poses risks to the body through damage done slowly over time, even with less severely raised sugar levels. This damage tends to come about somewhat indirectly, through the effect of the raised sugar level on blood vessels themselves.  

The cost of treating the complications of Diabetes accounts for about three quarters of the total cost of Diabetes to the NHS, the latter being about £14 billion pounds per year. 

We can categorize the complications from Diabetes in terms of the size of the blood vessels affected. 

Microvascular Complications 

When smaller blood vessels are damaged due to Diabetes, it can cause problems with the eyes, the kidneys, and the nerves. The risk of the damage happening is linked to both how high the blood sugars get, and how long someone has Diabetes for. 

Eye Damage (Diabetic Retinopathy) 

When the blood vessels of the eyes become damaged (Diabetic Retinopathy), this can not only cause visual changes and blurring but can even result in blindness. In fact, Diabetic Retinopathy accounts for 10,000 new cases of blindness in the US each year.  

When eye damage is found early enough, it can be treated before it gets severe. Therefore, it is so important to attend regular eye screening appointments, and also to get medical attention in between appointments if you notice any changes to your vision. The NHS arranges regular eye screening for people who have Diabetes. 

Kidney Damage (Diabetic Nephropathy) 

Damage to the kidneys reduces their ability to filter the blood properly. Some components of the blood, like proteins, should stay in the bloodstream. However, damaged kidneys tend to leak this protein out into the urine. Testing for protein in the urine is therefore one of the best ways of assessing how well the kidneys are working. 

If there is protein found, new medication may be started to try to protect the kidneys from further damage as much as possible, as well as checking for other risks to the kidneys such as raised blood pressure. 

Other medication may need to be reviewed, to make sure it is still safe to keep taking the same doses. (If the kidneys are the medication’s Exit Door from the body, and the traffic moving through is slow, the medication can accumulate, which may cause further serious complications.) 

Nerve Damage (Diabetic Neuropathy) 

This is estimated to affect up to half of all people with Diabetes. Typically, the feet and/or hands are involved (in which case it is termed a peripheral neuropathy). Symptoms may vary but often include experiencing numbness/loss of feeling, pins and needles or burning/stabbing pain. At the start, it may occur only at night but may then progress to become more persistent. 

When the nerves affected are more central in our body, this is termed an autonomic neuropathy. There are many different symptoms that this may cause. Two examples include erectile dysfunction and postural hypotension, which is when the blood pressure drops when someone stands, causing dizziness.  

Macrovascular Complications 

These tend to occur as a result of atherosclerosis – the process by which the inner aspects of artery walls become damaged and can clog up with fatty plaques, narrowing the amount of blood getting through. If these clogs burst, they can block off the whole vessel, causing whatever is downstream to go without the essential oxygen and nutrients in the blood supply (infarction). 

Heart Attacks (Coronary Artery Disease) 

People with type 1 diabetes are four times more likely than non-Diabetics to have a heart attack and 4.5 times more likely to develop heart failure. Each day in the UK, diabetes causes about 75 heart attacks and 275 cases of heart failure, on average (27,000 and 100,000 respectively, per year) 

Strokes (CVA, Cerebrovascular Accident) 

Diabetes causes approximately one in five strokes, equivalent to over 35,600 per year in the UK. Someone with type 1 diabetes is three and a half times more likely to have a stroke than someone without Diabetes. 

Peripheral Arterial Disease 

When the arteries in the legs get damaged by Diabetes and atherosclerosis, it can cause multiple problems, including a condition known as Intermittent Claudication. This is where very painful cramps can occur on walking, which can limit mobility. 

It can also cause problems with one’s feet. A poor arterial supply can impact how well the foot can heal after trauma. Combine this with the risk of not being aware of an injury due to numbness from nerve damage, and it is no surprise that people with Diabetes are at risk of quite serious foot ulcers and long-term problems here. A non-healing ulcer or deep bone infection (osteomyelitis) can sometimes even lead to the need to amputate.

Monitoring 

Once someone is diagnosed with type 1 diabetes, aside from discussing the above important points with regards to lifestyle advice, insulin therapy and risk of complications, there is usually a plan put in place for monitoring. The main objectives for monitoring are: 

1. Monitoring current blood glucose levels 

Sugar levels carry an obvious immediate importance, especially with the considerable risk of emergencies from a too-high or too-low level inherent in both having type 1 diabetes and in using insulin. It is important that anyone with type 1 diabetes, or caring for someone with type 1 diabetes, is aware of the signs and symptoms of these emergencies, and knows how to manage them, including when to get help. There are a few different ways to monitor current blood sugar levels: 

• Finger prick tests. Using a home blood glucose monitor, or ‘glucometer’, a lancet, and a blood glucose test strip. The finger is pricked and the sugar level in the small collection of blood is measured by the device. 
• Continuous glucose monitoring. A small electrode is inserted under the skin and communicates with a phone or other device using Bluetooth, giving constant feedback on what the blood sugar level is. It is possible to have a ‘closed loop system’ where the continuous glucose monitor communicates with an insulin pump, allowing the pump to adjust the dose of insulin given in response, without the need for manual action by the user. 
• Flash glucose monitoring. Similar to the above, an electrode is worn under the skin. The difference here is that the results do not automatically transfer constantly, but only when the device is scanned over the sensor. 

Diabetes UK has a helpful article explaining if you might be eligible for a free Continuous or Flash glucose monitor on the NHS here. 

NICE recommends the following optimal targets for adults with type 1 diabetes: 

• Fasting plasma glucose level of 5–7 mmol/L on waking. 
• Plasma glucose level of 4–7 mmol/L before meals at other times of the day. 
• For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating. 

They also recommend that a bedtime target should be agreed, taking into account when the last meal is. 

2. Monitoring HbA1c 

As well as monitoring the daily sugar levels multiple times, there is added benefit from regularly checking the HbA1c. As you may recall from earlier, this is a blood test that gives an average sugar level from the previous three months. This can provide a helpful overview to general blood sugar trends and give insight as to how well controlled the condition is. As many of the complications of Diabetes are more likely with higher sugar levels, it is sensible to agree a treatment target to aim towards, in order to reduce the chance of these complications occurring. 

NICE recommends a standard target HbA1c of 48 mmol/mol for both young people and adults with type 1 diabetes. If an adult has chronic kidney disease but does not require dialysis, it suggests a target range of 48 – 64 mmol/mol. However, NICE also recognises that setting an individual target is ideal. This is important as some people may be prone to having more hypoglycaemic attacks when aiming for a target that is too low for them. We know that having too many hypo’s can put a strain on the heart and lead to other complications, so an ideal individual target will strike a balance between having a low enough target to effectively reduce the risk of complications from Diabetes, while avoiding damage from excessive hypoglycaemia. 

NICE also recommends checking the HbA1c every 3 – 6 months to start with for adults. In children and young people, it advises checking this 4 times per year minimum. 

3. Monitoring for complications 

This would include regular eye checks, foot checks and kidney health checks, all done through the NHS. These are so important, as they can pick up and treat issues before they get worse. Some, such as eye damage, may only be treatable if it is detected early enough. If you are overdue an NHS health check, please contact your GP. 

4. Monitoring other risk factors for complications 

Diabetes is not the only condition that can lead to some of the above complications. High blood pressure, raised cholesterol and smoking can all be linked with the Macrovascular Complications (e.g., heart attacks, strokes), as well as damage to the kidneys and sexual function. Hypertension can also cause eye damage. For this reason, it is worth assessing the blood pressure and cholesterol levels of someone with Diabetes regularly, and for anyone who does have Diabetes and smoke, to seriously consider quitting smoking as soon as possible. 

If someone with Diabetes is found to also have high blood pressure, because of the significant damage that can occur with both conditions, usually more aggressive treatment is used to aim to get the blood pressure lower than in someone without Diabetes. 

Conclusion 

Type 1 Diabetes is a serious condition affecting tens of thousands of people in the UK. It poses real threats both in terms of emergency situations and long-term damage in the body. There are ways of minimising harm through regular monitoring and treatment, and new technologies that can make this easier.  

There is also ground-breaking new research being done into what triggers Type 1 Diabetes to develop in children and young people and we will likely know even more about this in the coming years. 

If you think you or someone you care about might have Type 1 Diabetes, it is vital that you speak to your NHS GP urgently, or alternatively ring NHS 111 for appropriate medical attention and advice. 

For more info, please visit Diabetes UK, which has some fantastic resources that explore all the ins and outs of living with Diabetes in great detail.