What ICMR Guidelines Say About Management Of Type 1 Diabetes

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The Indian Council of Medical Research (ICMR) recently issued guidelines for the management of type 1 diabetes in India. This is the first time the ICMR has released guidelines for type 1 diabetes.

The ICMR's 'Guidelines For Management Of Type-1 Diabetes' is a comprehensive document providing advice on care of diabetes in children, adolescents and adults with type 1 diabetes, and chronicles information on advances in scientific knowledge and clinical care. 

The ICMR's guidelines on management of type 1 diabetes come at a time when the Covid-19 pandemic has disproportionately affected people with diabetes, increasing the risk for severe illness and mortality. 

According to the ICMR, India is home to the second largest diabetes population in the world. Every sixth person with diabetes in the world is an Indian. In the past three decades, there has been a 150 per cent increase in the number of people with diabetes in India. 

According to recent estimates from the International Diabetes Federation, India has the highest number of incident and prevalent cases of type 1 diabetes in the world. A person who has been newly diagnosed with diabetes is an incident case, whereas a person who has had diabetes for several years is a prevalent case. 

What Is Type 1 Diabetes?

Type 1 diabetes, earlier known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone which helps blood sugar enter the cells in the body for use as energy. Without insulin, glucose cannot enter the cells and builds up the bloodstream, as a result of which the person suffers from different symptoms and complications of diabetes. 

Diabetes occurs when blood glucose, also called blood sugar, is too high. 

The immune system of a person with type 1 diabetes attacks and destroys the cells in the pancreas that make insulin, as a result of which the organ stops making the hormone. 

Type 1 diabetes is less common than type 2 diabetes, and about five to 10 per cent of people with diabetes have type 1, according to the Centers for Disease Control and Prevention (CDC). 

Type 1 diabetes is thought to be caused by an autoimmune reaction which destroys the cells in the pancreas that make insulin, called beta cells. Genetic factors can also make some people more likely to develop type 1 diabetes. Exposure to viruses and environmental factors may also contribute to type 1 diabetes. All these factors may cause the immune system to destroy the insulin-producing islets of Langerhans in the pancreas. 

There is no cure for type 1 diabetes, and people with this condition can prevent complications by changing their diet and lifestyle, and monitoring their insulin levels.

Type 1 diabetes usually appears during childhood or adolescence, but can develop in adults. 

According to American academic medical centre Mayo Clinic, the symptoms for type 1 diabetes may include increased thirst, frequent urination, extreme hunger, weight loss, irritability, fatigue, weakness, and blurred vision. 

Diabetes is of two types: diabetes mellitus and diabetes insipidus. In diabetes mellitus, the level of glucose in the blood is too high, as a result of which the kidneys try to remove the extra glucose by passing it in the urine. Meanwhile, in diabetes insipidus, the blood glucose levels are normal, but the kidneys cannot properly concentrate urine. 

Diabetes mellitus is classified into three categories, namely, type 1 diabetes, type 2 diabetes, and gestational diabetes.

Gestational diabetes occurs when pregnant women without a previous history of diabetes develop high blood sugar levels. 

Thus, type 1 diabetes mellitus is an autoimmune disease characterised by insulin deficiency and hyperglycemia in people with underlying genetic susceptibility, and can be diagnosed through tests such as fasting plasma glucose, oral glucose tolerance test, glycated haemoglobin, or random plasma glucose.

The incidence of type 1 diabetes mellitus in India is 4.9 cases per 100,000 persons per year. Though type 1 diabetes mellitus can affect an individual at any age, the incidence of the condition is seen between 10 to 14 years of age. 

What Is The Difference Between Type 1 And Type 2 Diabetes?

The main difference between type 1 and type 2 diabetes is that type 1 diabetes is a genetic condition which often shows up early in life, or can develop due to environmental factors, whereas type 2 diabetes is mainly a lifestyle-related condition and develops over time. 

According to Diabetes UK, type 1 diabetes occurs when the body attacks the cells in the pancreas, while type 2 diabetes happens when the body is not able to make enough insulin or the insulin produced does not work properly. Diabetes UK is a British-based research charity described as "one of the foremost diabetes charities in the UK". 

While the exact cause of type 1 diabetes is not known, factors such as weight and ethnicity put a person at risk for type 2 diabetes. 

The symptoms for type 1 diabetes appear quickly, while those of type 2 diabetes appear slowly.

Therefore, when one has type 1 diabetes, it means they have an autoimmune condition. Meanwhile, if one has type 2 diabetes, it means their body does not make enough insulin, or the insulin does not work properly, a mechanism known as insulin resistance. 

How Can Type 1 Diabetes Be Managed?

According to the ICMR guidelines, type 1 diabetes can be managed by maintaining a proper lifestyle, consuming a balanced diet, exercising, and monitoring the insulin levels. People with the condition should also know about acute complications associated with type 1 diabetes, along with microvascular complications including retinopathy, diabetic kidney disease and nerve diseases. 

Lifestyle Management By People With Type 1 Diabetes

Lifestyle management plays an important role in managing type 1 diabetes mellitus, and understanding the effect of diet and physical activity on glycemia is essential for optimal management of the condition. 

According to the ICMR guidelines, people with type 1 diabetes should have a diet plan considering their socio-cultural environment, food habits, preferences, and work schedule to facilitate proper compliance. Obese and overweight individuals must reduce their caloric intake. 

For people with type 1 diabetes, the recommended carbohydrate intake is 50 to 55 per cent of total calories. Meanwhile, the recommended fat content is 25 to 35 per cent of total calories, and recommended protein content is 15 to 20 per cent of total calories. The sucrose intake must be less than 10 per cent. The overall consumption of saturated fat and trans fatty acids must be less than 10 per cent of the total calories. 

Meanwhile, the recommended intake levels for trans fatty acids, polyunsaturated fat, and monounsaturated fat are less than one per cent, less than 10 per cent, and between 10 to 20 per cent of total calories, respectively. 

Unsaturated fatty acids are mainly derived from plant and vegetable sources, and have beneficial effects on low density lipoprotein (LDL) cholesterol. Monounsaturated fatty acids have beneficial effects on high density lipoprotein (HDL) cholesterol, and glycemic control, helping reduce the risk of cardiovascular disease. In simple terms, LDL is bad cholesterol while HDL is cholesterol. 

Monounsaturated fatty acids are found in olive, canola, groundnut, peanut, sesame, rice bran, mustard oils, almonds and avocados. 

Exercise has multiple benefits in individuals with type 1 diabetes mellitus, as it increases the feeling of general well-being and helps prevent obesity and mitigate increased cardiovascular risk in patients with this condition. Regular physical activity can also improve glycaemic control and reduce microvascular complications. Individuals with type 1 diabetes must consume some carbohydrate snacks before physical activity.

A relatively lower blood glucose level at the initiation of physical activity and not adjusting the insulin doses before exercise increases the hypoglycemia risk. 

Adults with type 1 diabetes are recommended to engage in physical activity for 150 minutes or more every week. The activity should be spread over at least three days a week, but without more than two consecutive days of no activity. 

Children and adolescents with type 1 diabetes are recommended to exercise for at least 60 minutes every day. They should engage in muscle-strengthening and bone-strengthening activities at least three days a week. 

Type 1 Diabetes Management Through Insulin Therapy

Children and adults with type 1 diabetes require insulin as soon as they are diagnosed with the condition. After this, they should take insulin continuously throughout their life. 

The different types of insulin available include short-acting recombinant regular human insulin, which is the most commonly used bolus insulin to prevent post-meal glucose elevation. For a person with diabetes, a bolus is a dose of insulin taken to keep blood sugar levels under control after eating. Bolus insulin, also known as "rapid-acting" insulin, works in about 15 minutes, peaks in about one hour, and continues to work for two to four hours.

Over the last 100 years, insulin therapy has constantly evolved. Insulin analogues are also available, and are beneficial because they provide increased flexibility and probably a reduced risk of hypoglycemia. However, their use is associated with increased treatment costs. 

According to the ICMR guidelines, toddlers with fussy eating patterns, and school or college going children with limited recess time could be given insulin analogues. 

Continuous subcutaneous insulin infusion (CSII) provides the most physiological insulin delivery, but its use in Indian settings is limited by cost, technical expertise and healthcare provider awareness.

Type 1 Diabetes Management Through Blood Glucose Monitoring

Blood glucose monitoring is an important factor which predicts glycemic control in patients with type 1 diabetes mellitus. Glycemic control refers to the typical levels of blood sugar in a person with diabetes mellitus. According to the Diabetes Control and Complications Trial, achieving good glycemic control in the initial years of type 1 diabetes results in reduced incidence of macrovascular and microvascular complications. Macrovascular complications of type 1 diabetes include coronary heart disease, arrhythmias, cerebrovascular disease, and peripheral artery disease. Microvascular complications of diabetes are long-term complications which affect small blood vessels, and include diabetic retinopathy, nephropathy, and neuropathy. 

Neuropathy is the result of damage to the nerves located outside the brain and spinal cord, causing weakness, numbness and pain, usually in the hands and feet. Diabetes is one of the most common causes of neuropathy. 

Nephropathy is the deterioration of kidney function, the final stage of which is called kidney failure. Retinopathy means disease of the retina, and is a complication of diabetes. Diabetic retinopathy is caused by damage to the blood vessels of the retina, which is the light-sensitive tissue at the back of the eye. 

In order to prevent macrovascular and microvascular complications, it is important to achieve near-normal glycemic status during the early years of type 1 diabetes. 

Self-monitoring of blood glucose is important for glycemic control in patients with type 1 diabetes. The American Diabetes Association recommends that patients with type 1 diabetes should monitor capillary blood glucose before meals, at bedtime, prior to exercise, and before starting critical tasks such as driving. 

Also, blood glucose should be checked every one to two weeks for nocturnal hypoglycemia, a condition in which blood glucose levels fall below 70 milligrams per decilitre while sleeping at night.

A glucometer can be used for self-monitoring of blood glucose.

Type 1 Diabetes Management By Understanding Microvascular Complications

It is very important to understand the different microvascular complications associated with type 1 diabetes in order to manage the condition. These complications include diabetic retinopathy, neuropathy, and nephropathy.

Diabetic retinopathy is one of the most common microvascular complications of type 1 diabetes, and is a leading cause of blindness in adults. 

Poor glycemic control continues to be a problem in many patients with type 1 diabetes, despite better intensive management of diabetes. Patients with diabetic retinopathy are at higher risk of developing other eye diseases such as cataract and glaucoma. Cataract surgery may be associated with worse visual outcomes in such patients. 

In order to prevent diabetic retinopathy, patients with diabetes type 1 must undergo retinal screening. 

Optical coherence tomography (OCT), a non-invasive imaging method that uses reflected light to create pictures of the back of the eye, can provide an accurate diagnosis of diabetic retinopathy. 

Panretinal Photocoagulation Laser therapy is an innovative treatment that gets rid of and stops the growth of abnormal blood vessels in the eye, and is the gold standard treatment for diabetic neuropathy.

Diabetic Kidney Disease (DKD) is the most common cause of chronic kidney disease in India and worldwide, and is characterised by a combination of albuminuria (having too much albumin in the urine), reduction of glomerular filtration rate, and hypertension with increased risk for cardiovascular diseases. 

Nephropathy develops in around 25 to 40 per cent of patients with type 1 diabetes, according to ICMR. 

In the last couple of decades, early diagnosis, along with optimal glycemic control and blood pressure management has improved the prognosis (likely course of medical condition) of patients with neuropathy.

Since diabetic neuropathy is a serious complication of type 1 diabetes with significant morbidity and mortality, newer biomarkers have been developed to ensure earlier diagnosis and personalised management of the condition. 

At present, management of the condition includes adequate glucose control and optimal blood pressure management.

Diabetic neuropathy is a chronic microvascular complication of diabetes, and may significantly affect a patient's quality of life. Neuropathy is the most important contributing factor for the development of foot ulcers.  According to the ICMR, management of diabetic neuropathy includes achievement of good glycemic control, treatment of risk factors, pain management, and foot care education. 

Management Of Type 1 Diabetes By Understanding Macrovascular Complications

People with type 1 diabetes are at increased risk of morbidity and mortality from cardiovascular disease compared to the non-diabetic population. The complications include coronary artery disease, stroke and peripheral artery disease, with coronary artery disease being the most common. 

In patients with type 1 diabetes and disease duration more than 20 years, cardiovascular disease remains a major cause of mortality.

If risk factors are addressed in a timely and appropriate manner, macrovascular complications can be prevented. 

Optimal glycemic control using multiple subcutaneous insulin injections or insulin pump therapy should be attempted in patients with type 1 diabetes, especially those without other comorbidities, according to the ICMR. Insulin pumps are small, computerised devices that mimic the way the human pancreas works by delivering small doses of short- acting insulin continuously. A short-acting insulin is often used 30 to 60 minutes before a meal, and takes effect and wears off more quickly than long-acting insulin. The onset of action is 30 to 60 minutes, and peak levels are reached within two to three hours.

Diet and lifestyle management is very important to prevent macrovascular complications, as this will help treat abnormal lipid levels. Patients with type 1 diabetes should also avoid smoking. 

In order to prevent macrovascular complications, the patients should engage in regular physical activity, and consume a diet low in salt, saturated fat and simple sugars, and rich in fruits, green leafy vegetables, dairy products and dietary fibre. Each patient must follow a structured diet plan designed by a qualified dietician and should monitor body weight periodically. 

Diabetes education is very important for a person with type 1 diabetes to stay healthy, both physically and mentally.

How The ICMR Guidelines Can Ensure Improved Care Of Patients With Type 1 Diabetes

In India, adolescents and children are suffering from different types of diabetes, with type 1 diabetes being the most common. 

According to the ICMR, more and more children are being diagnosed with type 1 diabetes in our country at present. This may be because the actual prevalence of the condition is increasing in India, and may also reflect better awareness and improved diagnosis of type 1 diabetes. It could also suggest that children are surviving more due to early diagnosis and better treatment.

The ICMR guidelines on management of type 1 diabetes will be useful for patients with the condition, and also for students, physicians, diabetologists and endocrinologists. This is expected to ensure improved care of children and adolescents with type 1 diabetes, which would help them to live a long and healthy life despite the disorder. 

By ensuring improved diabetes control, the dreaded complications of diabetes including blindness, kidney failure, amputations, heart attacks, stroke, and neuropathy can be reduced, if not entirely eliminated.

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