All about type 1 diabetes. Diabetes mellitus - symptoms, first signs, causes, treatment, nutrition and complications of diabetes. Causes and pathogenesis

Type 1 diabetes is usually diagnosed in children and young adults. The disease occurs when the immune system begins to destroy the islets of Langerhans, the endocrine cells of the pancreas that secrete the hormone insulin. Insulin reduces the concentration of glucose in the blood, and its deficiency leads to the development of chronic hyperglycemia, ketoacidosis and other complications. We talk about the causes, symptoms, complications and treatment of type 1 diabetes.

What is type 1 diabetes

Diabetes mellitus (DM) type 1 is one of the most common endocrine diseases in children. According to statistics, more than 75% of all cases of type 1 diabetes are diagnosed in children under 18 years of age. The disease is characterized by elevated blood glucose levels (hyperglycemia) due to insulin deficiency. It is noteworthy that, unlike type 2 diabetes mellitus, type 1 diabetes is characterized by an absolute deficiency of insulin.

Type 1 diabetes has some geographic features. This disease is more common in Europeans and less common in Asian countries. Thus, the likelihood of developing type 1 diabetes in a child from Finland is almost 40 times greater than in a child in Japan and almost 100 times greater than in children from some provinces of China. Interesting data was obtained in one of the studies, which states that currently the incidence of type 1 diabetes is increasing fastest in non-white racial and ethnic groups. However, the reasons for this trend remain unclear.

Causes of type 1 diabetes mellitus

Currently, the causes of type 1 diabetes have not been established. However, the disease is considered to be autoimmune. That is, the pathology is based on the destruction of beta cells of the pancreas (which produce insulin) due to an autoimmune process.

It is not yet clear how the autoimmune reaction against beta cells is realized. What is the trigger for such a pathology? There are several theories on this matter, each of which is supported by a number of indirect evidence. The hereditary predisposition to autoimmune destruction of beta cells, as well as the effect of certain viral infections, is considered. In particular, the role of Coxsackie viruses and rubella virus is considered.

It has been established that the destruction of beta cells of the pancreas takes place over several months or years in the form of an inflammatory process. Hyperglycemia develops when more than 80-90% of beta cells are already destroyed.

Types of diabetes mellitus type 1

There are two types of type 1 diabetes mellitus:

• Autoimmune - characterized by absolute insulin deficiency, as well as the presence of specific antibodies to pancreatic beta cells.
• Idiopathic type 1 diabetes. Sometimes doctors diagnose type 1 diabetes, in which antibodies to pancreatic beta cells are not detected. In this case, we are dealing with type 1 diabetes of unknown etiology, which is why it is called idiopathic. This form of type 1 diabetes most often occurs in people of African or Asian descent.

Symptoms of type 1 diabetes

The main symptoms of type 1 diabetes include:

• Hyperglycemia is an increase in blood sugar levels above normal (7 mmol/l or more). Since insulin is necessary for the absorption of glucose by muscle cells, when there is a lack of insulin, glucose does not penetrate into the cells, but accumulates in the blood.
• Increased frequency of urination. This happens due to the fact that in this case the body tries to get rid of excess glucose by excreting it in the urine, which leads to increased diuresis.
• Intense thirst (polydipsia).
• Losing body weight while maintaining the same lifestyle and usual calorie intake.
• Feeling tired and unwell.
• The smell of acetone in the exhaled air. This is due to ketoacidosis - a noticeable increase in the concentration of ketone bodies. They are formed due to increased oxidation of fat tissue. Since cells cannot receive glucose, the body switches to breaking down fats with the formation of ketone bodies.

Hyperglycemia due to diabetes in children can also manifest as irritability. Persistent increases in blood sugar levels weaken the immune system, making the child more susceptible to certain infections, especially urinary tract, respiratory and skin infections. These children have an increased risk of developing candidiasis.

Diagnostic criteria

• Fasting blood glucose level is 7 mmol/l or more.
• The blood glucose level after 2 hours of a glucose tolerance test (taking a sugar solution and measuring glucose levels every 30 minutes for 2 hours) is more than 11 mmol/L.
• The level of glycosylated hemoglobin (HbA1c) is more than 6.5%.

ADA experts recommend repeat testing for asymptomatic diabetes, which will allow doctors to confirm the diagnosis. As for patients with severe symptoms of diabetes mellitus, in this case, studies of fasting glucose levels and a glucose tolerance test will be more informative, rather than a study of the level of glycosylated hemoglobin.

The above studies allow us to establish persistent hyperglycemia, but not to establish the type of diabetes (type 1 or 2). To diagnose type 1 diabetes, in addition to taking into account the clinical manifestations and age of the patient, you should also undergo the following types of studies:

• C-peptide analysis. C-peptide (or coupling peptide) is a protein that detaches from proinsulin, the precursor to insulin. Accordingly, the concentration of C-peptide indicates the level of insulin production by the body.
• Test for antibodies toGADA. Antibodies to glutamic acid decarboxylase (GADA) make it possible to establish the autoimmune nature of type 1 diabetes.

Of the two studies listed above, the test for antibodies to glutamic acid decarboxylase is of greater value. Even if the level of C-peptide is low, but the test for antibodies to GADA is positive, then such a patient is diagnosed with type 1 diabetes.

A blood or urine test for the presence of ketone bodies can also help to suspect type 1 diabetes. It should be noted that sometimes the level of ketone bodies is also high in type 2 diabetes.

Treatment of type 1 diabetes

To treat type 1 diabetes, non-drug methods are used, as well as insulin replacement therapy, which maximally imitates the physiological secretion of the hormone.

To monitor the effectiveness of treatment, ADA experts recommend measuring glycosylated hemoglobin 2-4 months after the start of treatment. For children and adolescents, the target HbA1c level is 7.5% or lower, and for adults it is up to 7%. It has been reliably established that controlling the level of glycosylated hemoglobin within the given limits allows one to avoid or minimize complications associated with diabetes mellitus.

For patients with type 1 diabetes, it is extremely important to maintain constant self-monitoring. It is best to measure glucose levels using glucometers before meals, before bed, as well as before exercise and any other activities that could potentially lead to hypoglycemia (a decrease in sugar levels below 3.5 mmol/L).

Nutrition and exercise

As for nutrition, there are currently no standardized approaches in this regard. The diet is selected individually. This is done by a dietitian who has experience in preparing a diet for patients with type 1 diabetes. Such a doctor must also teach the patient such a concept as a bread unit (XE). This is a conventional unit that was developed to estimate the approximate amount of carbohydrates consumed. One bread unit corresponds to 12 grams of carbohydrates or 1 piece of white bread (20 g). Correct counting of bread units allows patients with type 1 diabetes to more competently carry out insulin therapy, thereby minimizing the likelihood of developing hypoglycemic and hyperglycemic conditions.

Regarding physical activity, adults with type 1 diabetes are recommended to get at least 150 minutes of moderate-intensity aerobic exercise (eg, race walking) per week. But this does not mean that you can work out for 150 minutes for 1 day and then rest for a week. Physical exercises should be done at least 3 days a week so that the break is no more than 2 days.

Insulin therapy for type 1 diabetes mellitus

Since type 1 diabetes is characterized by an absolute deficiency of insulin, the patient needs to receive it from the outside. The main goal of insulin therapy is maximum imitation of physiological secretion. It should be noted that there is basal and bolus secretion of insulin. Basal secretion is the background secretion of a hormone that is not associated with food intake. The body constantly produces glucose (gluconeogenesis) and breaks down glycogen (glycogenolysis) into glucose, which enters the blood. And to utilize this glucose, a certain amount of insulin is also needed (the so-called background insulin). Bolus secretion is the production of insulin immediately after a meal, when the level of glucose in the blood rises sharply, and relatively high doses of insulin are required for its disposal.

The insulin therapy strategy is to provide both basal and bolus insulin. For these purposes, different types of insulin are used - ultra-short, short, medium and long-acting. The total daily dose of insulin for adults is about 0.2-0.4 U/kg per day; for children - 0.5-1 IU/kg per day.

Short-acting and ultra-short-acting insulin are administered before meals. For example, if the onset of action of insulin is 5-15 minutes, then it should be administered approximately 15 minutes before a meal to ensure effective correction of hyperglycemia. The duration of action of such insulins is 4-6 hours.

The effect of intermediate-acting insulin is up to 16 hours, and long-acting insulin is up to 36 hours. The main task of such insulins is to provide the body with background insulin for the utilization of glucose, which is formed regardless of food intake. As a rule, intermediate-acting insulin is administered 1-2 times a day, and long-acting insulin is administered once before bedtime.

The main way to administer insulin is with a pen or insulin syringe. There is also a more modern method - the use of an insulin pump, which provides a more accurate simulation of the physiological secretion of insulin. It should be noted that in Western Europe and the USA, only 5% of patients use a pump, since its use is associated with a number of objective difficulties that neutralize its advantages.

Medicine of the future: new strategies for treating type 1 diabetes

Unfortunately, type 1 diabetes has not yet been overcome. Modern medicine can eliminate the consequences of this disease, but not the causes. However, scientists are not at all ready to put up with this state of affairs. Currently, research is being conducted in many developed countries of the world, the goal of which is to relieve patients with type 1 diabetes mellitus from insulin injections. Scientists have set a task - to restore the destroyed pancreatic cells responsible for the production of insulin. Let's consider several main strategies in this direction and the results that have been obtained to date.

Diabetes vaccine

It sounds somewhat utopian, but if the viral theory of the development of an autoimmune process that destroys the beta cells of the pancreas is confirmed, then this will become the same reality as a vaccine against cervical cancer. In this case, scientists are of particular interest to the Coxsackie virus. In particular, it has been found that more than 5% of people infected with the Coxsackie virus strain CVB1 suffer from type 1 diabetes. It is possible that the virus is one of the causes of the autoimmune reaction.

In 2017, a Finnish group of researchers developed a vaccine against the CVB1 virus and successfully tested it on mice. The next stage is clinical trials on volunteers.

Transplantation of insulin-producing cells

For 1.5 years now, scientists and doctors at the University of Miami have been monitoring the condition of a patient (name not disclosed), who had insulin-producing cells implanted into her abdominal fat. The transplantation was successful and the patient no longer required insulin injections.

It is noteworthy that previously implantation was carried out in the liver, but this led to complications. After monitoring the patient for many months, scientists have tentatively concluded that the abdominal fat fold appears to be an ideal site for transplantation of insulin-producing cells.

Reprogramming pancreatic cells

A group of Swiss scientists led by Pedro Herera conducted an interesting experiment. The researchers took alpha cells from the pancreas and reprogrammed them to produce insulin. The reprogrammed cells were then implanted into the pancreas of mice. As scientists expected, alpha cells, unlike beta cells, do not attract attention from the immune system in type 1 diabetes. Moreover, the transplanted cells successfully began to produce insulin in response to increased glucose levels. The work was published in February 2019 in one of the most respected scientific journals, Nature.

Type 1 diabetes mellitus in children develops due to dysfunction of the pancreas. This can happen against the background of chronic pancreatitis or a stressful situation for the baby’s body. The pancreas is located on the posterior abdominal wall in the retroperitoneal space and is a mixed gland that performs endocrine and exocrine functions.

It produces pancreatic juice, which contains digestive enzymes and is involved in the digestion process in the small intestine, and insulin. The hormone insulin is an endogenous substance that is involved in many metabolic reactions and mainly controls the flow of glucose into the cell.

Type 1 diabetes mellitus in children is caused by a lack of insulin release due to damage to the insulin-producing apparatus of the pancreas.

Type 1 diabetes mellitus was formerly called “insulin-dependent diabetes mellitus.” Since this type of diabetes always requires insulin therapy.

It is known that some patients also require insulin, but in the treatment of type 1 disease it is more necessary.

Causes of type 1 diabetes in children

The underlying causes of type 1 diabetes in children are damage to the islets of Langerfeld in the tail of the pancreas. Damage to the pancreas can occur due to many reasons, for example, the action of. But most often the disease develops against the background of aggression of one’s own immune system. In this case, the insulin-producing cells of the pancreas are destroyed by cells of lymphoid tissue, which normally attack only foreign agents. This process is called “autoimmune”, and refers to the mechanism of producing antibodies against the cells of one’s body.

Autoimmune diseases as causes of type 1 diabetes mellitus

There are various autoimmune diseases, such as those of the thyroid and adrenal glands, which are more common in patients with type 1 diabetes. This indicates a hereditary predisposition to autoimmune diseases and the systemic nature of immune damage, which can be triggered by other environmental factors.

The exact trigger for the disease is not known, but scientists suggest that contracting a viral infection or drinking cow's milk can trigger an autoimmune process. And it, in turn, will cause the development of type 1 diabetes in children.

What are the symptoms of type 1 diabetes in children?

Symptoms of type 1 diabetes in children are usually acute. This can be expressed in sudden attacks of weakness and dizziness during a hungry state or after eating. Glucose is one of the main types of fuel used by the body's cells for their energy needs. The brain and nervous system use only glucose, while most other cells can also convert fats and other nutrients into energy. Glucose coming from the carbohydrate component of food stimulates the production of insulin, which acts on cell membrane receptors and causes glucose to enter the cell. If this does not happen, the metabolic processes and energy of the cell are disrupted.

Blood sugar levels rise and glucose begins to be found in large quantities in the blood and urine. Because the use of glucose becomes very inefficient, a person with decompensated type 1 diabetes develops the following symptoms:

• increased thirst;
• fatigue;
• frequent urination during the day and at night (nocturia);
• weight loss (although appetite often increases);
• itching, especially in the genital area, caused by the development of a fungal infection;
• other skin infections (and furunculosis).

If you regularly experience any of these symptoms of type 1 diabetes, you should visit your GP and get tested.

A family history of the disease increases the likelihood of the disease, but type 1 diabetes is much less common than.

Treatment of type 1 diabetes in children

Treatment of type 1 diabetes in children almost always involves compensatory injections of human insulin. Also, therapeutic measures should be aimed at normalizing metabolism and strengthening the child’s immunity.

In general terms, treatment of type 1 diabetes in children can be expressed in the following points:

• Regular insulin injections. They are performed daily or several times a day, depending on the type of insulin used.
• Maintaining an active lifestyle (eliminating physical inactivity).
• Maintaining normal body weight.
• Following a special diet containing a reduced, regulated amount of carbohydrates.
• The goal of insulin therapy is to maintain a normal amount of glucose in the blood and normalize the energy processes of the cell.

Treatment of type 1 diabetes mellitus in children is selected individually by a qualified endocrinologist and depends on the stage of the severity of symptoms and the stage of the disease.

Prevention of type 1 diabetes in children

Prevention of type 1 diabetes in children includes a set of measures to prevent the occurrence of negative factors that can trigger the development of this disease.

1. Watch for any signs that indicate high or low blood glucose levels.

2. If you have a medical condition, regularly measure your blood glucose levels using modern glucose meters and correct your glucose levels with insulin injections.

3. Follow the prescribed diet as carefully as possible.

4. Always carry glucose or sugar (low blood glucose) with you. Glucagon injections (GlucaGen) may be necessary for severe hypoglycemia.

5. See your doctor regularly to evaluate your blood glucose levels, examine your eyes, kidneys, legs, and monitor symptoms of late-stage diabetes.

6. Contact your doctor at an early stage of the disease to prevent decompensation of the pathological process.

7. Keep a “diabetes diary” and record your self-measured glycemic levels.

Etiology and pathogenesis of type 1 diabetes mellitus in children

The etiology and pathogenesis of type 1 diabetes mellitus suggests that violations of the principles of a healthy lifestyle play a huge role in the development of disease symptoms. A sedentary lifestyle plays an important role in the pathogenesis of type 1 diabetes. Eating high-carbon and fatty foods contributes to the development of the disease. Therefore, to prevent type 1 diabetes, it is important to follow the principles of a healthy lifestyle.

Physical activity will help reduce the risk of developing and progressing diabetes, atherosclerosis, and also improve overall well-being.

During physical activity, your insulin dose may need to be adjusted depending on the intensity of your physical activity. Excess insulin and exercise can lower blood sugar levels and lead to hypoglycemia.

Eat healthy foods rich in plant fiber, well balanced in carbohydrates, fats and proteins. Eliminate the consumption of low molecular weight carbohydrates (sugar) and reduce carbohydrate intake in general.

Try to eat the same amount of carbohydrates every day. You should have three main meals and two to three snacks daily.

To create a personalized diet, consult a qualified nutritionist or endocrinologist.

Currently, it is impossible to completely prevent the occurrence of the disease. But scientists are constantly studying this disease and making effective additions to the treatment and diagnostic regimen.

Possible complications of type 1 diabetes in children

In most cases, type 1 diabetes mellitus produces complications in the short term only in the absence of adequate treatment. If you do not follow the doctor's instructions, the following complications may occur:

1. Low blood sugar, which occurs with an overdose of insulin, a long break between meals, physical activity, hyperthermia, leads to loss of consciousness.

2. Insufficient replacement of insulin with pharmacological substitutes leads to high blood sugar levels and can cause ketoacidosis.

3. Atherosclerosis is aggravated by diabetes and can lead to poor circulation in the legs (diabetic foot), the development of strokes and heart disease (angina pectoris and myocardial infarction).

4. Diabetic kidney damage (diabetic nephropathy).

5. Diabetic retinopathy (diabetic eye disease).

6. Diabetic neuropathy (nerve degeneration) and angiopathy, which lead to ulcers and.

7. Increased predisposition.

8. Ketoacidotic, hyperosmolar, lacticacidemic and hypoglycemic coma in advanced severe cases of the disease.

Diet for type 1 diabetes - the basis of treatment

There is no complete cure for type 1 diabetes. Diet for type 1 diabetes is the basis for all subsequent treatment. Only with strict correction of the diet can stable remission and normal well-being of the patient be achieved.

But with properly selected therapy, the risk of developing late stages of diabetic complications is significantly reduced. This determines the need to constantly monitor and maintain normal blood sugar levels.

Patients with diabetes who suffer from hypertension can reduce the likelihood of complications by regularly taking antihypertensive medications to normalize blood pressure.

Diabetes causes hardening of the arteries, and this risk increases if the patient smokes. In order to reduce the risk of complications, you should break the bad habit.

According to statistics, doctors can diagnose every 3 people in the world with diabetes. This disease is on a par with such pathologies threatening humanity as oncology and AIDS. Despite the fact that diabetes mellitus is a well-studied disease, in order to carry out an accurate diagnosis it is necessary to undergo a complete examination of the body - in medicine there are several types and degrees of pathology.

Diabetes mellitus - the essence of the disease

Disorders of metabolic processes involving carbohydrates and water are classified in medicine as diabetes mellitus. For this reason, there are disturbances in the functioning of the pancreas, which produces the hormone insulin - it is actively involved in the processing of sugar in the body. It is insulin that promotes the processing of sugar into glucose, otherwise sugar accumulates in the blood and is excreted through the urinary tract (with urine); in this condition, the body’s tissues are unable to retain water in their cells - it also begins to be excreted from the body.

Diabetes mellitus is an increased level of sugar and glucose in the blood, but a catastrophic lack of these elements in the cells of organ tissues.

The disease can be congenital (we are talking about burdened heredity) or acquired. The severity of the development of diabetes mellitus does not depend on this; patients still suffer from a lack of insulin, against which pustular skin diseases, atherosclerosis, hypertension, kidney and nervous system diseases develop, and vision deteriorates.

Pathogenesis of the disease

The pathogenesis of diabetes mellitus is a very conditional thing, because doctors only partially recognize it. Considering that there are two main types of the disease in question, which are radically different from each other, it is impossible to talk about an unconditional mechanism for the development of pathology. Nevertheless, the basis of pathogenesis is taken hyperglycemic index. What it is?

Hyperglycemia– a condition in which sugar entering the body is not processed into glucose due to an insufficient amount of insulin produced by the pancreas. In turn, this leads to a lack of glucose in the cells of the organs - insulin simply stops interacting with the cells.

Why do doctors accept this explanation of the mechanism of development of diabetes mellitus as the only correct one? Because other diseases can lead to a hyperglycemic state. These include:

• hyperthyroidism;
• adrenal tumor - it produces hormones that have the opposite effect in relation to insulin;
• hyperfunction of the adrenal glands;
• cirrhosis of the liver;
• glucagonoma;
• somatostatinoma;
• transient hyperglycemia is a short-term accumulation of sugar in the blood.

Important:Not every hyperglycemia can be considered unconditional diabetes mellitus - only that which develops against the background of a primary violation of the action of insulin.

When diagnosing hyperglycemia in a patient, doctors must differentiate the above diseases - if they are diagnosed, then diabetes mellitus in this case will be conditional, temporary. After the underlying disease is cured, the function of the pancreas and the action of insulin are restored.

Types of diabetes

Dividing the disease in question into two main types is an important task. Each of them has not only distinctive characteristics, but even treatment in the initial stages of diabetes mellitus will follow completely different schemes. But the longer a patient lives with diagnosed diabetes, the less noticeable the signs of its types become, and treatment usually comes down to the same regimen.

Diabetes mellitus type 1

He is called insulin-dependent diabetes, it is considered a fairly serious disease and patients are forced to adhere to a strict diet all their lives. Type 1 diabetes is the destruction of pancreatic cells by the body itself. Patients with this diagnosis are forced to constantly inject themselves with insulin, and since it is destroyed in the gastrointestinal tract, the effect will only be from injections.
Important:It is impossible to completely get rid of the pathology, but in medicine there have been cases where recovery occurred - the patients adhered to special conditions and natural raw food.

Diabetes mellitus type 2

This type of disease is considered insulin-independent, develops in people of the older age category (after 40 years) with obesity. What happens is that the body's cells become overloaded with nutrients and become less sensitive to insulin.
Prescribing insulin injections to such patients is not mandatory and only a specialist can determine the advisability of such treatment. Most often, patients with type 2 diabetes are prescribed a strict diet, as a result of which the weight will decrease gradually (no more than 3 kg per month). As a last resort.

If the diet does not give positive dynamics, sugar-lowering tablets may be prescribed. Insulin is prescribed as a last resort, when the pathology begins to pose a danger to the patient’s life.

Degrees of diabetes

This differentiation helps to quickly understand what is happening to the patient at different stages of the disease. This classification is needed by doctors who can make the right decision regarding treatment in an emergency situation.

1st degree. This is the most favorable course of the disease in question - the glucose level is not higher than 7 mmol/l, glucose is not excreted in the urine, blood counts remain within normal limits. The patient is completely free of any complications of diabetes mellitus; it is compensated by diet and special medications.

2nd degree. Diabetes mellitus becomes partially compensated, and the patient shows signs of complications. There is damage to some organs - for example, vision, kidneys, and blood vessels are affected.

3rd degree. This degree of diabetes mellitus cannot be treated with medications and diet; glucose is actively excreted in the urine, and its level is 14 mmol/l. Stage 3 diabetes mellitus is characterized by clear signs of complications - vision rapidly decreases, numbness of the upper/lower extremities actively develops, and persistent high blood pressure (hypertension) is diagnosed.

4th degree. The most severe course of diabetes mellitus is characterized by high glucose levels - up to 25 mmol/l, both glucose and protein are excreted in the urine, the condition is not corrected by any medications. With this degree of the disease in question, gangrene of the lower extremities and diabetic ulcers are often diagnosed.

Symptoms of diabetes

Diabetes mellitus never “starts” with lightning speed - it is characterized by a gradual increase in symptoms and long-term development. The first signs of the disease in question include:

1. Intense thirst that is almost impossible to quench. Diabetic patients consume up to 5-7 liters of fluid per day.
2. Dry skin and periodic itching, which is often attributed to nervous manifestations.
3. Constant dry mouth, no matter how much liquid the patient drinks per day.
4. Hyperhidrosis is excessive sweating, especially pronounced on the palms.
5. Weight variability - a person either quickly loses weight without any diets, or quickly gains weight.
6. Muscle weakness – patients at the earliest stages of diabetes mellitus report fatigue and the inability to perform any physical work.
7. Long-term healing of skin wounds - even an ordinary scratch can develop into a purulent wound.
8. Pustular processes are often observed on the skin for no apparent reason.

Note:even if any of the above signs are present, you need to seek help from specialists as soon as possible - most likely the patient will be diagnosed with diabetes.
But even if the disease in question has been diagnosed and is treatable, complicated diabetes may also develop. Its symptoms include:

1. Regular and dizziness.
2. Increased blood pressure - at certain moments the indicators can reach.
3. Walking is impaired, pain is constantly present in the lower extremities.
4. Liver enlargement - this syndrome is considered a complication only if it was absent before the diagnosis of diabetes mellitus.
5. Severe swelling of the face and...
6. Significant reduction in foot sensitivity.
7. Progressive decline in visual acuity.
8. A clearly noticeable odor of acetone begins to emanate from the patient.

Causes of diabetes mellitus

Doctors have identified several factors that can lead to the development of the disease in question. These include:

1. Heredity. This factor does not at all mean the birth of a child with existing diabetes mellitus, there is simply such a predisposition. Other risk factors must be kept to a minimum.
2. Viral infections. Influenza, rubella, epidemic hepatitis and chicken pox - these infections can become a “push” for the development of diabetes mellitus, especially if the patient is at risk for the disease in question.
3. Obesity. In order to avoid the appearance of the first signs of diabetes, it is enough to reduce weight.
4. Some diseases. Inflammation of the pancreas (pancreatitis), pancreatic cancer, and pathological processes in other glandular organs can lead to damage to the cells that produce insulin.

In addition, you should protect the body from nervous stress, depression and nervous conditions - this can serve as a kind of trigger for the development of diabetes.

Important:The older a person gets, the higher the likelihood of developing the disease in question. According to statistics, every 10 years the chances of developing diabetes double.

Diagnosis of diabetes mellitus

If you suspect diabetes mellitus, you need to undergo a full examination - for this you will need to take several tests and use instrumental examination methods. The list of diagnostic measures for diabetes mellitus includes:

1. Laboratory testing of blood to determine the presence of glucose in it - fasting glycemia is determined.
2. Test determination of glucose tolerance - examination is done after taking glucose.
3. The dynamics of the development of the disease are monitored - glycemia is measured several times a day.
4. A general urine test to check for the presence of protein, glucose and leukocytes (normally these components are absent).
5. Laboratory testing of urine for the presence of acetone.
6. Blood testing for the presence of glycosylated hemoglobin - this indicator is used to determine the level of development of complications of diabetes mellitus.
7. Biochemical blood test - the doctor can determine the degree of functioning of the liver and kidneys against the background of progressive diabetes.
8. A Rehberg test is performed to determine the degree of damage to the kidneys and urinary tract in cases of diagnosed diabetes mellitus.
9. Blood test to determine the level of endogenous insulin.
10. Consultation with an ophthalmologist and examination of the fundus.
11. Ultrasound examination of the abdominal organs.
12. Electrocardiogram – monitors heart function against the background of diabetes mellitus.
13. Studies aimed at determining the level of vascular damage in the lower extremities - this helps prevent the development of diabetic foot.

Patients diagnosed with diabetes mellitus or suspected of having this disease should undergo examination by specialized specialists as part of diagnostic measures. Mandatory visits include doctors:

• endocrinologist;
• ophthalmologist;
• cardiologist;
• vascular surgeon;
• neurologist.

Blood sugar levels

One of the most important indicators of health in diabetes mellitus, which can serve as a diagnostic of the functioning of organs and systems, is blood sugar level. It is from this indicator that doctors “start” to conduct more specialized diagnostics and prescribe treatment. There is a clear value that will indicate to the patient and doctor the state of carbohydrate metabolism.

Note:To exclude false positive results, you need to not only measure your blood sugar level, but also conduct a glucose tolerance test (a blood test with a sugar load).

To take a blood sample with a sugar load, you must first take a regular blood test for sugar, then take 75 grams of soluble glucose (sold in pharmacies) and take the test again after 1 or 2 hours. The norms are given in the table (measurement value – mmol/l):
After passing two tests, it is necessary to determine the following values:

• Hyperglycemic coefficient is the ratio of the glucose level one hour after a glucose load to the fasting blood glucose level. Normally, the indicator should not exceed 1.7.
• Hypoglycemic coefficient is the ratio of the blood glucose level 2 hours after a sugar load to the fasting blood glucose level. Normally, the indicator should not exceed 1.3.

Possible complications of diabetes

In fact, diabetes mellitus does not pose a threat to the health and life of the patient, but if complications develop, the most tragic consequences are possible, leading to disruption of normal life activities.

Diabetic coma

The symptoms of a diabetic coma increase rapidly, with lightning speed - you cannot hesitate for a minute, and leaving the patient in this state directly threatens his life. The most dangerous sign is a violation of a person’s consciousness, which is characterized by depression and lethargy of the patient.
The most commonly diagnosed is ketoacidotic coma, a condition caused by the accumulation of toxic substances. At the same time, nerve cells come under the harmful effects of toxic substances, and the main, and sometimes the only, symptom of ketoacidotic coma is a persistent, intense odor of acetone from the patient.

The second most common type of coma is hypoglycemic, which can be triggered by an overdose of insulin. In this case, the patient has the following symptoms:

• clouding of consciousness - fainting state;
• the face and palms become covered with cold sweat - the amount is quite large and noticeable to the naked eye;
• a rapid/critical decrease in blood glucose levels is recorded.

There are other types of diabetic comas, but they develop extremely rarely.

Unstable blood pressure

Blood pressure indicators can determine the severity of the development of the disease in question. For example, if when regularly measuring blood pressure, a constant increase is noted, this may indicate the occurrence of one of the most dangerous complications - diabetic nephropathy (kidneys do not work). Doctors often recommend that patients diagnosed with diabetes mellitus regularly measure blood pressure in the lower extremities - its decrease indicates damage to the blood vessels of the legs.

Edema in diabetes mellitus

They indicate the development of heart failure and nephropathy. If there is constant swelling, accompanied by instability of blood sugar levels, it is necessary to urgently seek help from doctors - the situation is very serious and at any moment the kidneys can completely fail or a myocardial infarction can occur.

Trophic ulcers

They occur only in those patients who have been struggling with diabetes for a long time and develop, first of all, on the feet (there is the concept of “diabetic foot”). The problem is that people do not pay attention to the first signs of the diabetes complication in question - corns, accompanied by pain in the legs and swelling. Patients see a doctor when the foot becomes noticeably red and the swelling reaches its maximum (the patient cannot stand on his foot or put on shoes).

Gangrene

A very serious complication that develops against the background of damage to large and small blood vessels. Most often, gangrene is diagnosed on the lower extremities, cannot be treated and almost always leads to amputation of the legs (but there are exceptions).

Prevention of diabetes complications

If the diagnosis of diabetes has already been confirmed by a doctor, then every effort must be made to prevent the development of its complications. It is quite possible to live with the disease in question, and to live fully, but only if there are no serious complications. Preventive measures include:

• weight control– if the patient feels that he is gaining extra pounds, then he needs to contact a nutritionist and get advice on creating a rational menu;
• constant physical activity– the attending physician will tell you how intense they should be;
• constant monitoring of blood pressure levels.

Diabetes mellitus is recognized as an incurable disease, but if type 2 diabetes is diagnosed, then there are chances for a complete recovery - you just need to choose a diet aimed at normalizing carbohydrate metabolism. The main task of a patient with the disease in question is to prevent the development of complications, which pose a real danger to human health and life. You will receive more detailed information about diagnostic methods, types, stages and treatment of diabetes mellitus by watching this video review:

Tsygankova Yana Aleksandrovna, medical observer, therapist of the highest qualification category

Diabetes mellitus is a major medical and social problem throughout the world. This is explained by its wide distribution, the severity of late complications, and the high cost of diagnostic and treatment tools that patients need throughout their lives.

According to experts from the World Health Organization, the total number of patients with all forms of diabetes mellitus today is over 160 million people. Every year, the number of newly diagnosed cases is 6-10% of the total number of patients, thus the number of people suffering from this disease doubles every 10-15 years. Type 1 diabetes is the most severe form of diabetes, accounting for no more than 10% of all cases of the disease. The highest incidence is observed in children aged 10 to 15 years - 40.0 cases per 100 thousand people.

An international expert committee, founded in 1995 with the support of the American Diabetes Association, proposed a new classification, which is accepted in most countries of the world as a recommendation document. The main idea underlying the modern classification of diabetes is a clear identification of the etiological factor in the development of diabetes.

Type 1 diabetes mellitus is a metabolic (metabolic) disease characterized by hyperglycemia, which is based on the destruction of β-cells, leading to an absolute deficiency of insulin. This form of diabetes was previously referred to as insulin-dependent diabetes mellitus or juvenile diabetes mellitus. The destruction of β-cells in most cases among the European population is of an autoimmune nature (with the participation of the cellular and humoral components of the immune system) and is caused by the congenital absence or loss of tolerance to β-cell autoantigens.

Multiple genetic predisposing factors lead to autoimmune destruction of β-cells. The disease has a clear association with the HLA system, with the DQ A1 and DQ B1 genes, as well as DR B1. HLA DR/DQ alleles can be both predisposing and protective.

Type 1 diabetes is often combined with other autoimmune diseases, such as Graves' disease (diffuse toxic goiter), autoimmune thyroiditis, Addison's disease, vitiligo and pernicytic anemia. Type 1 diabetes may be a component of an autoimmune syndrome complex (autoimmune polyglandular syndrome type 1 or 2, “rigid person” syndrome).

Summarizing the clinical and experimental data obtained to date, we can present the following concept of the pathogenesis of type 1 diabetes. Despite the appearance of an acute onset, type 1 diabetes develops gradually. The latent period can last for several years. Clinical symptoms appear only after 80% of β-cells have been destroyed. An autopsy study of pancreatic tissue from patients with type 1 diabetes reveals the phenomena of insulitis, a specific inflammation characterized by infiltration of islets with lymphocytes and monocytes.

The earliest stages of the preclinical period of type 1 diabetes are characterized by the appearance of clones of autoreactive T lymphocytes that produce cytokines, which leads to the destruction of β-cells. Insulin, glutamate decarboxylase, heat-shock protein 60, and fogrin are currently considered as putative primary autoantigens that, under certain conditions, cause proliferation of cytotoxic T-lymphocytes.

In response to the destruction of β-cells, plasma cells secrete autoantibodies to various β-cell antigens, which are not directly involved in the autoimmune reaction, but indicate the presence of an autoimmune process. These autoantibodies belong to the immunoglobulin G class and are considered as immunological markers of autoimmune damage to β-cells. There are islet cell autoantibodies (ICA - a set of autoantibodies to various cytoplasmic antigens of the β-cell), β-cell-specific autoantibodies to insulin, antibodies to glutamate decarboxylase (GAD), to phosphotyrosine phosphatase (IA-2), and fogrin. Autoantibodies to β-cell antigens are the most important markers of autoimmune destruction of β-cells and they appear in typical type 1 diabetes much earlier than the clinical picture of diabetes develops. Autoantibodies to islet cells appear in the serum 5-12 years before the first clinical manifestations of diabetes mellitus, their titer increases at the late stage of the preclinical period.

There are 6 stages in the development of type 1 diabetes, starting with genetic predisposition and ending with complete destruction of β-cells.

Stage 1 - genetic predisposition - is characterized by the presence or absence of genes associated with type 1 diabetes. The first stage occurs in less than half of genetically identical twins and in 2-5% of siblings. The presence of HLA antigens, especially class II - DR 3, DR 4 and DQ, is of great importance.

Stage 2 - the beginning of the autoimmune process. External factors that can play the role of a trigger in the development of autoimmune damage to β-cells can be: viruses (Coxsackie B virus, rubella, mumps, cytomegalovirus, Epstein-Barr virus), medications, stress factors, nutritional factors (use of infant formula containing animal proteins; products containing nitrosamines). The fact of exposure to various environmental factors can be established in 60% of patients with newly diagnosed type 1 diabetes.

Stage 3 - development of immunological disorders. Specific autoantibodies to various β-cell structures can be detected in the blood: insulin autoantibodies (IAA), ICA, GAD, IA2 and IA2b. In stage 3, there is impaired β-cell function and, as a result of a decrease in β-cell mass, loss of the first phase of insulin secretion, which can be diagnosed by performing an intravenous glucose tolerance test.

Stage 4 - severe immunological disorders - is characterized by impaired glucose tolerance, but there are no clinical signs of diabetes mellitus. When performing an oral glucose tolerance test (OGTT), an increase in glucose levels on an empty stomach and/or 2 hours after the OGTT is detected.

At stage 5, clinical manifestation of the disease is noted, since by this moment the bulk of β-cells (more than 80%) die. Residual low secretion of C-peptide persists for many years and is the most important factor in maintaining metabolic homeostasis. Clinical manifestations of the disease reflect the degree of insulin deficiency.

Stage 6 is characterized by a complete loss of functional activity of β-cells and a decrease in their number. This stage is diagnosed when there is a high level of glycemia, a low level of C-peptide and no response during the exercise test. This stage is called “total” diabetes. Due to the final destruction of β-cells at this stage, a decrease in the titer of antibodies to islet cells or their complete disappearance is sometimes observed.

There is also idiopathic type 1 diabetes mellitus, in which there is a decrease in β-cell function with the development of symptoms of insulinopenia, including ketosis and ketoacidosis, but there are no immunological markers of autoimmune destruction of β-cells. This subtype of diabetes mellitus occurs mainly among patients of African or Asian race. This form of diabetes mellitus has a clear inheritance. The absolute need for replacement therapy in such patients may appear and disappear over time.

As population studies have shown, type 1 diabetes among the adult population is much more common than previously thought. In 60% of cases, type 1 diabetes develops after age 20. The onset of diabetes in adults can have a different clinical picture. The literature describes the asymptomatic development of type 1 diabetes in first- and second-degree relatives of patients with type 1 diabetes with a positive titer of autoantibodies to β-cell antigens, when the diagnosis of diabetes mellitus was made only based on the results of an oral glucose tolerance test.

The classic course of type 1 diabetes with the development of a state of ketoacidosis at the onset of the disease also occurs in adults. The development of type 1 diabetes has been described in all age groups, up to the ninth decade of life.

In typical cases, the onset of type 1 diabetes has pronounced clinical symptoms, reflecting a deficiency of insulin in the body. The main clinical symptoms are: dry mouth, thirst, frequent urination, weight loss. Quite often the onset of the disease is so acute that patients can pinpoint the month, and sometimes even the day, when they first experienced the above symptoms. Rapid, sometimes up to 10-15 kg per month, loss of body weight for no apparent reason is also one of the main symptoms of type 1 diabetes. In some cases, the onset of the disease is preceded by a severe viral infection (influenza, mumps, etc.) or stress. Patients complain of severe weakness and fatigue. Autoimmune diabetes mellitus usually begins in children and adolescents, but can develop at any age.

If symptoms of diabetes mellitus are present, laboratory tests are necessary to confirm the clinical diagnosis. The main biochemical signs of type 1 diabetes are: hyperglycemia (as a rule, a high percentage of sugar in the blood is determined), glucosuria, ketonuria (the presence of acetone in the urine). In severe cases, decompensation of carbohydrate metabolism leads to the development of diabetic ketoacidotic coma.

Diagnostic criteria for diabetes mellitus:

• fasting plasma glucose more than 7.0 mmol/l (126 mg%);
• fasting capillary blood glucose more than 6.1 mmol/l (110 mg%);
• plasma glucose (capillary blood) 2 hours after a meal (or a load of 75 g of glucose) more than 11.1 mmol/l (200 mg%).

Determining the level of C-peptide in serum allows one to assess the functional state of β-cells and, in doubtful cases, to distinguish type 1 diabetes from type 2 diabetes. Measuring C-peptide levels is more informative than insulin levels. In some patients at the onset of type 1 diabetes, a normal basal level of C-peptide may be observed, but there is no increase in it during stimulation tests, which confirms the insufficient secretory ability of β-cells. The main markers confirming the autoimmune destruction of β-cells are autoantibodies to β-cell antigens: autoantibodies to GAD, ICA, insulin. Autoantibodies to islet cells are present in the serum of 80-95% of patients with newly diagnosed type 1 diabetes and in 60-87% of individuals in the preclinical period of the disease.

The progression of β-cell destruction in autoimmune diabetes mellitus (type 1 diabetes) may vary.

In childhood, the loss of β-cells occurs rapidly and by the end of the first year of the disease the residual function fades away. In children and adolescents, the clinical manifestation of the disease usually occurs with symptoms of ketoacidosis. However, in adults there is also a slowly progressive form of type 1 diabetes mellitus, described in the literature as slowly progressive autoimmune diabetes of adults - Latent Autoimmune Diabetes in Adults (LADA).

Slowly progressive autoimmune diabetes of adults (LADA)

This is a special variant of the development of type 1 diabetes mellitus observed in adults. The clinical picture of type 2 diabetes and LADA at the onset of the disease is similar: compensation of carbohydrate metabolism is achieved through diet and/or the use of oral hypoglycemic drugs, but then, during a period that can last from 6 months to 6 years, decompensation of carbohydrate metabolism is observed and insulin need develops. A comprehensive examination of such patients reveals genetic and immunological markers characteristic of type 1 diabetes.

LADA is characterized by the following features:

• age of debut, usually exceeding 25 years;
• clinical picture of type 2 diabetes without obesity;
• initially, satisfactory metabolic control achieved through the use of diet and oral hypoglycemic drugs;
• development of insulin requirements in the period from 6 months to 10 years (on average from 6 months to 6 years);
• presence of markers of type 1 diabetes: low level of C-peptide; the presence of autoantibodies to β-cell antigens (ICA and/or GAD); presence of HLA alleles at high risk of developing type 1 diabetes.

As a rule, patients with LADA do not have a clear clinical picture of the onset of type I diabetes, which is typical for children and adolescents. At onset, LADA is “masked” and initially classified as type 2 diabetes because the process of autoimmune β-cell destruction in adults may be slower than in children. Symptoms of the disease are erased, there is no pronounced polydipsia, polyuria, weight loss and ketoacidosis. Excess body weight also does not exclude the possibility of developing LADA. The function of β-cells fades slowly, sometimes over several years, which prevents the development of ketoacidosis and explains the satisfactory compensation of carbohydrate metabolism when taking PSSP in the first years of the disease. In such cases, type 2 diabetes is mistakenly diagnosed. The gradual nature of the development of the disease leads to the fact that patients seek medical help too late, having time to adapt to the developing decompensation of carbohydrate metabolism. In some cases, patients come to the doctor 1-1.5 years after the manifestation of the disease. In this case, all the signs of a sharp insulin deficiency are revealed: low body weight, high glycemia, lack of effect from PSSP. P. Z. Zimmet (1999) gave the following definition to this subtype of type 1 diabetes: “Autoimmune diabetes that develops in adults may not be clinically different from type 2 diabetes, and is manifested by a slow deterioration of metabolic control with the subsequent development of insulin dependence.” At the same time, the presence in patients of the main immunological markers of type 1 diabetes - autoantibodies to β-cell antigens, along with low basal and stimulated levels of C-peptide, allows a diagnosis of slowly progressing autoimmune diabetes of adults.

Main diagnostic criteria for LADA:

• presence of autoantibodies to GAD and/or ICA;
• low basal and stimulated C-peptide levels;
• presence of HLA alleles at high risk for type 1 diabetes.

The presence of autoantibodies to β-cell antigens in patients with clinical symptoms of type II diabetes at the onset of the disease has a high prognostic value regarding the development of insulin requirement. The results of the UK Prospective Diabetes Study (UKPDS), which examined 3672 patients with an initial diagnosis of type 2 diabetes, showed that antibodies to ICA and GAD have the greatest prognostic value in young patients ( ).

According to P. Zimmet, the prevalence of LADA is about 10-15% among all patients with diabetes mellitus and about 50% of cases occur in type 2 diabetes without obesity.

The results of our study showed that patients aged 30 to 64 years, who at the onset of the disease had a clinical picture of type 2 diabetes without obesity, a significant decrease in body weight (15.5 ± 9.1 kg) and concomitant autoimmune thyroid diseases (TDD) or AIT) represent a group at increased risk of developing LADA. Determination of autoantibodies to GAD, ICA and insulin in this category of patients is necessary for timely diagnosis of LADA. Most often in LADA, antibodies to GAD are detected (according to our data, in 65.1% of patients with LADA), compared with antibodies to ICA (in 23.3% of LADA) and to insulin (in 4.6% of patients). The presence of a combination of antibodies is not typical. The titer of antibodies to GAD in patients with LADA is lower than in patients with type 1 diabetes with the same duration of the disease.

LADA patients represent a high-risk group for developing insulin requirements and require timely administration of insulin therapy. The OGTT results indicate the absence of stimulated insulin secretion in 46% of LADA patients and its decrease in 30.7% of patients already in the first 5 years of the disease. As a result of our study, 41.9% of patients with LADA, whose disease duration was no more than 5 years, were switched to insulin on average 25.2±20.1 months from the onset of the disease. This figure was significantly higher than in the group of patients with type 2 diabetes with the same duration of the disease (14% after 24±21.07 months from the onset of the disease, p< 0,05).

However, patients with LADA represent a heterogeneous group of patients. 53.7% of LADA patients have peripheral insulin resistance, while 30.7% of patients have a combination of insulin resistance and insulin deficiency due to autoimmune damage to β-cells.

When choosing treatment tactics in patients with LADA, insulin secretion and peripheral tissue sensitivity to insulin should be assessed. A basal C-peptide level of less than 1 ng/ml (as determined by radioimmunoassay) indicates insulin deficiency. However, for patients with LADA, the absence of stimulated insulin secretion is more typical, while fasting insulin and C-peptide values ​​are within normal limits (close to the lower limit of normal). The ratio of the maximum insulin concentration (at the 90th minute of the OGTT test) to the initial one is less than 2.8 with low initial values ​​(4.6±0.6 µU/ml), which indicates insufficient stimulated insulin secretion and indicates the need for early administration insulin.

The absence of obesity, decompensation of carbohydrate metabolism when taking PSSP, low basal levels of insulin and C-peptide in LADA patients indicate a high probability of absence of stimulated insulin secretion and the need for insulin administration.

If patients with LADA have a high degree of insulin resistance and insulin hypersecretion in the first years of the disease, it is recommended to prescribe drugs that do not deplete the function of β-cells, but improve the peripheral sensitivity of tissues to insulin, for example biguanides or glitazones (actos, avandia). Such patients are usually overweight and have satisfactory compensation of carbohydrate metabolism, but require further observation. To assess peripheral insulin resistance, the insulin resistance index can be used - Homa-IR = ins0/22.5 eLnglu0 (where ins0 is the fasting insulin level and glu0 is fasting plasma glucose) and/or the index of overall tissue sensitivity to insulin (ISI - insulin sensitivity index, or Matsuda index ), obtained based on the results of the OGTT. With normal glucose tolerance, Homa-IR is 1.21-1.45 points; in patients with type 2 diabetes, the Homa-IR value increases to 6 and even 12 points. The Matsuda index in the group with normal glucose tolerance is 7.3±0.1 UL -1 x ml x mg -1 x ml, and in the presence of insulin resistance its values ​​decrease.

Preserving one's own residual insulin secretion in patients with type 1 diabetes mellitus is very important, since it is noted that in these cases the disease is more stable, and chronic complications develop more slowly and later. The importance of C-peptide in the development of late complications of diabetes mellitus is discussed. It was found that in the experiment, C-peptide improves kidney function and glucose utilization. It was found that infusion of small doses of biosynthetic C-peptide can affect microcirculation in human muscle tissue and renal function.

To determine LADA, more widespread immunological studies are indicated among patients with type 1 diabetes, especially in the absence of obesity and early ineffectiveness of PSSP. The main diagnostic method is the determination of autoantibodies to GAD and to ICA.

A special group of patients who also require close attention and where there is a need to determine autoantibodies to GAD and ICA are women with gestational diabetes mellitus (GDM). It has been established that 2% of women with gestational diabetes mellitus develop type 1 diabetes within 15 years. The etiopathogenetic mechanisms of the development of GDM are very heterogeneous, and for the doctor there is always a dilemma: is GDM the initial manifestation of type 1 or type 2 diabetes. McEvoy et al. published data on the high incidence of autoantibodies to ICA among Native and African-American women in America. According to other data, the prevalence of autoantibodies to ICA and GAD was 2.9 and 5%, respectively, among Finnish women with a history of GDM. Thus, patients with GDM may experience a slow development of insulin-dependent diabetes mellitus, as with LADA diabetes. Screening patients with GDM to determine autoantibodies to GAD and ICA makes it possible to identify patients who require insulin administration, which will make it possible to achieve optimal compensation of carbohydrate metabolism.

Considering the etiopathogenetic mechanisms of LADA development, it becomes obvious the need for insulin therapy in these patients, while early insulin therapy is aimed not only at compensating carbohydrate metabolism, but also allows maintaining basal insulin secretion at a satisfactory level for a long period. The use of sulfonylurea derivatives in LADA patients entails an increased load on β-cells and their faster depletion, while treatment should be aimed at maintaining residual insulin secretion and attenuating the autoimmune destruction of β-cells. In this regard, the use of secretogens in patients with LADA is pathogenetically unjustified.

After clinical manifestation, most patients with a typical clinical picture of type 1 diabetes in a period of 1 to 6 months experience a transient decrease in insulin requirements associated with an improvement in the function of the remaining β-cells. This is the period of clinical remission of the disease, or “honeymoon”. The need for exogenous insulin is significantly reduced (less than 0.4 units/kg body weight); in rare cases, even complete withdrawal of insulin is possible. The development of remission is a distinctive feature of the onset of type 1 diabetes and occurs in 18-62% of cases of newly diagnosed type 1 diabetes. The duration of remission ranges from several months to 3-4 years.

As the disease progresses, the need for exogenously administered insulin increases and averages 0.7-0.8 U/kg body weight. During puberty, the need for insulin can increase significantly - up to 1.0-2.0 U/kg body weight. With increasing duration of the disease due to chronic hyperglycemia, micro- (retinopathy, nephropathy, polyneuropathy) and macrovascular complications of diabetes mellitus (damage to coronary, cerebral and peripheral vessels) develop. The main cause of death is renal failure and complications of atherosclerosis.

Treatment of type 1 diabetes

The goal of treatment for type 1 diabetes is to achieve target levels of glycemia, blood pressure and blood lipids ( ), which can significantly reduce the risk of developing micro- and marcovascular complications and improve the quality of life of patients.

The results of the multicenter randomized Diabetes Control and Complication Trail (DCCT) trial have convincingly shown that good glycemic control reduces the incidence of diabetes complications. Thus, a decrease in glycohemoglobin (HbA1c) from 9 to 7% led to a reduction in the risk of developing diabetic retinopathy by 76%, neuropathy by 60%, and microalbuminuria by 54%.

Treatment of type 1 diabetes includes three main components:

• diet therapy;
• physical exercise;
• insulin therapy;
• training and self-control.

Diet therapy and physical activity

When treating type 1 diabetes, foods containing easily digestible carbohydrates (sugar, honey, sweet confectionery, sweet drinks, jam) should be excluded from the daily diet. It is necessary to control the consumption (count bread units) of the following products: grains, potatoes, corn, liquid dairy products, fruits. The daily caloric intake should be covered by 55-60% from carbohydrates, 15-20% from proteins and 20-25% from fats, while the proportion of saturated fatty acids should be no more than 10%.

The physical activity regime should be purely individual. It should be remembered that physical exercise increases tissue sensitivity to insulin, reduces glycemic levels and can lead to the development of hypoglycemia. The risk of hypoglycemia increases during physical activity and for 12-40 hours after prolonged heavy physical activity. Light to moderate exercise lasting no more than 1 hour requires additional intake of easily digestible carbohydrates before and after exercise. With moderate long-term (more than 1 hour) and intense physical activity, adjustment of insulin doses is necessary. It is necessary to measure blood glucose levels before, during and after exercise.

Lifelong insulin replacement therapy is essential for the survival of patients with type 1 diabetes and plays a crucial role in the routine management of this disease. When prescribing insulin, different regimens can be used. Currently, it is customary to distinguish between traditional and intensified insulin therapy regimens.

The main feature of the traditional insulin therapy regimen is the lack of flexible adjustment of the dose of administered insulin to the glycemic level. In this case, self-monitoring of blood glucose is usually absent.

The results of multicenter DCCT convincingly proved the advantage of intensified insulin therapy in compensating carbohydrate metabolism in type 1 diabetes. Intensive insulin therapy includes the following:

• basal-bolus principle of insulin therapy (multiple injections);
• planned number of bread units for each meal (diet liberalization);
• self-monitoring (monitoring blood glucose throughout the day).

For the treatment of type 1 diabetes and the prevention of vascular complications, genetically engineered human insulins are the drugs of choice. Porcine and human semi-synthetic insulins obtained from pork are of lower quality compared to human genetically engineered ones.

Insulin therapy at this stage involves the use of insulins with different durations of action. To create a basic insulin level, intermediate-acting or long-acting insulins are used (approximately 1 unit per hour, which is an average of 24-26 units per day). In order to regulate the level of glycemia after meals, short-acting or ultra-short-acting insulins are used in a dose of 1-2 units per 1 bread unit ( ).

Ultra-short-acting insulins (humalog, novorapid), as well as long-acting insulins (lantus) are insulin analogues. Insulin analogues are specially synthesized polypeptides that have the biological activity of insulin and have a number of specified properties. These are the most promising insulin preparations in terms of intensified insulin therapy. Insulin analogues Humalog (lispro, Lilly), as well as novorapid (aspart, Novo Nordisk) are highly effective in regulating postprandial glycemia. Their use also reduces the risk of hypoglycemia between meals. Lantus (insulin glargine, Aventis) is produced using recombinant DNA technology using a non-pathogenic laboratory strain of Escherichia coli (K12) as a producing organism and differs from human insulin in that the amino acid asparagine from position A21 is replaced by glycine and 2 molecules of arginine are added at C -end of the B-chain. These changes made it possible to obtain a peak-free, constant concentration profile of insulin action over 24 hours/day.

Ready-made mixtures of human insulins of various actions have been created, such as Mixtard (30/70), Insuman Comb (25/75, 30/70), etc., which are stable mixtures of short- and long-acting insulin in specified proportions.

To administer insulin, disposable insulin syringes are used (U-100 for administering insulin with a concentration of 100 U/ml and U-40 for insulin with a concentration of 40 U/ml), syringe pens (Novopen, Humapen, Optipen, Bd-pen, Plivapen) and insulin pumps. All children and adolescents with type 1 diabetes, as well as pregnant women with diabetes, patients with impaired vision and lower limb amputations due to diabetes should be provided with syringe pens.

Achieving target glycemic values ​​is impossible without regular self-monitoring and adjustment of insulin doses. Patients with type 1 diabetes need to independently monitor glycemia daily, several times a day, for which not only glucometers can be used, but also test strips for visual determination of blood sugar (Glucochrome D, Betachek, Suprima Plus).

To reduce the incidence of micro- and macrovascular complications of diabetes, it is important to achieve and maintain normal levels of lipid metabolism and blood pressure.

The target blood pressure level for type 1 diabetes in the absence of proteinuria is BP< 135/85 мм рт. ст., а при наличии протеинурии — более 1 г/сут и при хронической почечной недостаточности — АД < 125/75 мм рт. ст.

The development and progression of cardiovascular diseases largely depends on the level of blood lipids. So, with cholesterol levels above 6.0 mol/l, LDL > 4.0 mmol/l, HDL< 1,0 ммоль/ и триглицеридах выше 2,2 ммоль/л у больных СД 1 типа наблюдается высокий риск развития сердечно-сосудистых осложнений. Терапевтическими целями лечения, определяющими низкий риск развития сердечно-сосудистых осложнений у больных СД 1 типа, являются: общий холестерин < 4,8 ммоль/л, ЛПНП < 3,0 ммоль/л, ЛПВП >1.2 mmol/l, triglycerides< 1,7 ммоль/л.

In the coming decades, research will continue to create new pharmaceutical forms of insulin and means of their administration, which will make replacement therapy as close as possible to the physiological nature of insulin secretion. Research on islet cell transplantation is ongoing. However, a real alternative to allo- or xenotransplantation of cultures or “fresh” islet cells is the development of biotechnological methods: gene therapy, generation of β-cells from stem cells, differentiation of insulin-secreting cells from pancreatic duct cells or pancreatic cells. However, today insulin still remains the main treatment for diabetes.

For questions regarding literature, please contact the editor.

I. V. Kononenko, Candidate of Medical Sciences
O. M. Smirnova,Doctor of Medical Sciences, Professor
Endocrinological Research Center of the Russian Academy of Medical Sciences, Moscow

Type 1 diabetes mellitus is a disease that has been known since ancient times. However, if in the times of Ancient Greece and Rome doctors did not really know what it was, and there were no methods for treating the disease, now the situation has changed for the better. However, type 1 diabetes remains to this day a disease that claims many lives every year.

Description

What is diabetes? Diabetes mellitus (DM) is a disease associated with the pancreas. Many people do not know anything about this organ or why it is needed. Meanwhile, one of the functions of the pancreas is the production of the insulin peptide, which is necessary for processing glucose entering the body through the gastrointestinal tract, which belongs to the class of simple sugars. More precisely, insulin is produced only by part of the pancreas - the islets of Langerhans. Such islets contain several types of cells. Some cells produce insulin, the other part produces an insulin antagonist, the hormone glucagon. The cells that produce insulin are called beta cells. The word “insulin” itself comes from the Latin insula, which means “island”.

If there is no insulin in the body, then glucose entering the blood cannot penetrate various tissues, primarily muscle tissue. And the body will lack the energy that glucose gives it.

But this is far from the main danger. “Restless” glucose, not processed by insulin, will accumulate in the blood and, as a result, be deposited both on the walls of the blood vessels themselves and in various tissues, causing their damage.

This type of diabetes is called insulin-dependent. The disease mainly affects young adults (under 30 years of age). However, it is not uncommon for children, adolescents and the elderly to become ill.

Causes of the disease

What can cause insulin production to stop? Although people have been studying diabetes for more than 2000 years, the etiology, that is, the root cause of the disease, has not been reliably determined. True, there are various theories on this matter.

First of all, it has long been established that many cases of type 1 diabetes are caused by autoimmune processes. This means that the pancreatic cells are attacked by their own immune cells and are destroyed as a result. There are two main versions of why this happens. According to the first, due to a violation of the blood-brain barrier, lymphocytes, which are called T-helpers, interact with proteins of nerve cells. Due to a malfunction of the foreign protein recognition system, T-helper cells begin to perceive these proteins as proteins of a foreign agent. By an unfortunate coincidence, pancreatic beta cells also have similar proteins. The immune system turns its “wrath” on the pancreatic cells and destroys them in a relatively short time.

The viral theory tends to give a simpler explanation of the reasons for the attack of lymphocytes on beta cells - the effect of viruses. Many viruses can infect the pancreas, for example, rubella viruses and some enteroviruses (Coxsackie viruses). Once the virus takes up residence in a beta cell of the pancreas, the cell itself becomes a target for lymphocytes and is destroyed.

It is possible that in some cases of type 1 diabetes there is one mechanism for the development of the disease, and in some cases another, or perhaps they both contribute. But often the root cause of the disease cannot be determined.

In addition, scientists have found that diabetes mellitus is often caused by genetic factors, which also contribute to the onset of the disease. Although the hereditary factor in the case of type 1 diabetes is not as clearly visible as in the case of type 2 diabetes. However, genes have been discovered whose damage can trigger the development of type 1 diabetes.

There are other factors favoring the development of the disease:

• decreased immunity,
• stress,
• unhealthy diet
• other diseases of the endocrine system,
• thin physique,
• alcoholism,
• smoking.

Sometimes type 1 diabetes can be caused by pancreatic cancer or poisoning.

Stages and development of the disease

Unlike type 2 diabetes, which develops slowly over several years, type 1 diabetes becomes severe within a month or even 2-3 weeks. And the first symptoms indicating a disease usually manifest themselves violently, in such a way that they are difficult to miss.

In the very first stages of the disease, when immune cells are just beginning to attack the pancreas, patients usually have no obvious symptoms. Even when 50% of the beta cells are destroyed, the patient may not feel anything other than mild discomfort. And the real manifestation of the disease with all its characteristic symptoms occurs only when approximately 90% of the cells are destroyed. At this stage of the disease, the remaining cells cannot be saved, even if treatment is started on time.

The last stage of the disease is the complete destruction of insulin-producing cells. At this stage, the patient can no longer do without insulin injections.

Symptoms

Diabetes of the first type is in many ways similar in its symptoms to type 2 of the disease. The only difference is the intensity of their manifestation and the severity of the onset of the disease.

The main symptom of diabetes is frequent urination associated with acute thirst. The patient drinks a lot of water, but it seems as if the water is not retained in him.

Another characteristic symptom is sudden weight loss. Type 1 diabetes usually affects thin people, but once the disease begins, a person may lose several more pounds.

At first, the patient's appetite increases because the cells lack energy. Then appetite may decrease as the body becomes intoxicated.

If a patient experiences such symptoms, he should immediately consult a doctor.

Complications

An increase in blood glucose is called hyperglycemia. Hyperglycemia entails such serious consequences as disruption of the kidneys, brain, nerves, peripheral and great vessels. Blood cholesterol levels may increase. Damage to small vessels often leads to ulcers and dermatitis. Retinopathy may develop, eventually leading to blindness.

Severe, life-threatening complications of type 1 diabetes include:

• ketoacidosis,
• coma,
• gangrene of the limbs,

Ketoacidosis is a condition caused by poisoning with ketone bodies, primarily acetone. Ketone bodies occur when the body begins to burn fat reserves to extract energy from fat.

Even if complications do not kill a person, they can make him disabled. However, the prognosis of type 1 diabetes without proper treatment is poor. The mortality rate reaches 100%, and the patient can only live for a year or two.

Hypoglycemia

This is a dangerous complication that occurs in type 1 diabetes. It is typical for patients undergoing insulin therapy. Hypoglycemia occurs when glucose levels are below 3.3 mmol/L. It can occur when eating habits are violated, excessive or unplanned physical activity, or insulin dosage is exceeded. Hypoglycemia is dangerous due to loss of consciousness, coma and death.

Diagnostics

Typically, the symptoms of the disease are difficult to confuse with something else, so in most cases a doctor can easily diagnose diabetes. However, it is sometimes possible to confuse type 1 diabetes with its counterpart, type 2 diabetes, which requires a slightly different approach to treatment. There are also rare borderline types of diabetes, which have a set of features of both type 1 diabetes and type 2 diabetes.

The main diagnostic method is a blood sugar test. Blood for analysis is usually taken on an empty stomach - from a finger or from a vein. A urine test for sugar content, a glucose load test, and an analysis for glycated hemoglobin may be prescribed. To determine the condition of the pancreas, a C-peptide test is done.

Treatment of type 1 diabetes

Therapy is carried out only under the supervision of an endocrinologist. Currently, the only way to treat type 1 diabetes is with insulin injections. All other methods are auxiliary.

Insulin therapy for diabetes mellitus

There are several types of insulin depending on the speed of action - short, ultra-short, medium and long-acting. Insulins also differ in origin. Previously, they were mainly obtained from animals - cows, pigs. Nowadays, insulins produced by genetic engineering are mostly common. Long-acting insulin must be injected either twice a day or once a day. Short-acting insulins are administered immediately before meals. The dosage should be advised by the doctor, as it is calculated depending on the patient’s weight and physical activity.

Insulin is injected into the blood by the patient himself or the person serving him using syringes or syringe pens. Now a promising technology has emerged - insulin pumps. This is a structure that is attached to the patient’s body and helps eliminate the need for manual insulin injection.

Complications of the disease (angiopathy, nephropathy, hypertension, etc.) are treated with medications that are effective against these diseases.

Diet for diabetes

Another treatment method is diet. Due to the constant supply of insulin, insulin-dependent diabetes does not require such strict restrictions as type 2 diabetes. But this does not mean that the patient can eat whatever he wants. The goal of the diet is to avoid sharp fluctuations in blood sugar levels (both up and down). It must be remembered that the amount of carbohydrates entering the body must correspond to the amount of insulin in the blood and take into account changes in insulin activity depending on the time of day.

As with type 2 diabetes, the patient must avoid foods containing fast carbohydrates - refined sugar, confectionery. The total amount of carbohydrates consumed should be strictly dosed. On the other hand, with compensated insulin-dependent diabetes combined with insulin therapy, you don’t have to go on debilitating low-carbohydrate diets, especially since excessive carbohydrate restriction increases the risk of hypoglycemia, a condition in which blood glucose levels drop below life-threatening levels.

Physical exercise

Exercise can also be beneficial for diabetes. They should not be too long and exhausting. In case of hypoglycemia and hyperglycemia (blood glucose level more than 15 mmol/l), physical exercise is prohibited.

Self-control

The patient should monitor his blood sugar level every day. This is where portable glucose meters with test strips can be helpful. It is important to use high-quality devices and use strips that have not expired. Otherwise, the results may differ significantly from real ones.