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

Type 1 diabetes mellitus (DM) 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 levels of glucose in the blood (hyperglycemia) against the background of insulin deficiency. It is noteworthy that, unlike type 2 diabetes, type 1 diabetes is characterized by absolute insulin deficiency.

Type 1 diabetes has some geographical features. This disease is more common in Europeans and less common in Asian countries. Thus, a child from Finland is almost 40 times more likely to develop type 1 diabetes than a child in Japan and almost 100 times more than children from some provinces of China. Interesting data was obtained in one of the studies, which states that at present the incidence of type 1 diabetes is increasing most rapidly in non-white racial and ethnic groups. The reasons for this trend, however, remain unclear.

Causes of Type 1 Diabetes

At present, 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 pancreatic beta cells (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? On this account, there are several theories, each of which is supported by a number of circumstantial evidence. The hereditary predisposition to autoimmune destruction of beta cells, as well as the effect of some viral infections, is considered. In particular, the role of Coxsackieviruses and rubella virus is considered.

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

Types of type 1 diabetes

There are two types of type 1 diabetes:

• Autoimmune - characterized by absolute insufficiency of insulin, 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, so it is called idiopathic. This form of type 1 diabetes is most common in people of African or Asian descent.

Type 1 diabetes symptoms

The main symptoms of type 1 diabetes include:

• Hyperglycemia - an increase in blood sugar above normal (7 mmol / l or more). Since insulin is necessary for the absorption of glucose by muscle cells, when it is lacking, glucose does not enter the cells, but accumulates in the blood.
• Increased frequency of urination. This happens due to the fact that in this case the body is trying to get rid of excess glucose by excreting it in the urine, which leads to increased diuresis.
• Intense thirst (polydipsia).
• Weight loss with a preserved lifestyle and the usual caloric content of the diet.
• Feeling tired and unwell.
• The smell of acetone in the exhaled air. This is due to ketoacidosis - a marked increase in the concentration of ketone bodies. They are formed due to increased oxidation of fatty tissues. Since the cells cannot receive glucose, the body switches to the breakdown of fats with the formation of ketone bodies.

Hyperglycemia associated with diabetes in children can also be manifested by irritability. Persistently high blood sugar lowers 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

• The level of glucose in the blood on an empty stomach is 7 mmol / l or more.
• The blood glucose level after 2 hours of 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 glycated hemoglobin (HbA1c) is more than 6.5%.

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

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

• C-peptide analysis. C-peptide (or connecting peptide) - a protein that is detached from proinsulin, the precursor of insulin. Accordingly, the concentration of C-peptide shows the level of insulin production by the body.
• Analysis for antibodies toGADA. Antibodies to glutamic acid decarboxylase (GADA) allows you to establish the autoimmune nature of type 1 diabetes.

Of the two studies listed above, the analysis for antibodies to glutamic acid decarboxylase is of greater value. Even if the C-peptide level 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 in them also helps to suspect type 1 diabetes. It should be noted that sometimes the level of ketone bodies is high in type 2 diabetes.

Treatment of type 1 diabetes

For the treatment of 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 less, and for adults up to 7%. It has been reliably established that the control of the level of glycated hemoglobin within the given limits allows avoiding or minimizing the complications associated with diabetes mellitus.

It is extremely important for patients with type 1 diabetes to adhere to constant self-monitoring. Glucose measurements with glucometers are best done before meals, at bedtime, as well as before training and any other activity that can 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 to this. The diet is selected on an individual basis. This is done by a dietitian who has experience in formulating diets 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). The correct calculation of bread units allows patients with type 1 diabetes to conduct insulin therapy more competently, thereby minimizing the likelihood of developing hypoglycemic and hyperglycemic conditions.

Regarding physical activity, adults with type 1 diabetes are recommended to have 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

Since type 1 diabetes is characterized by an absolute deficiency of insulin, the patient must receive it from outside. The main goal of insulin therapy is the 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 bloodstream. And for the utilization of this glucose, a certain amount of insulin (the so-called background insulin) is also needed. 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 utilization.

The strategy for insulin therapy is to provide both basal and bolus insulin. For these purposes, different types of insulin are used - ultrashort, 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 U / 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 action 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 - 1 time 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 the countries of Western Europe and the USA only 5% of patients use a pump, since its use is associated with a number of objective difficulties that level its advantages.

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

Unfortunately, type 1 diabetes has not yet been defeated. Modern medicine allows you to 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, in many developed countries of the world, studies are underway, the purpose of which is to save patients with type 1 diabetes from insulin injections. Scientists set the task - to restore the destroyed cells of the pancreas responsible for the production of insulin. Let's consider several main strategies in this direction and the results that have been obtained to date.

Vaccine for diabetes

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

In 2017, a vaccine against the CVB1 virus was developed by a Finnish research team and successfully tested in mice. The next stage is clinical trials on volunteers.

Transplantation of insulin-producing cells

For 1.5 years, scientists and doctors at the University of Miami have been monitoring the condition of a patient (name not disclosed), who was implanted with insulin-producing cells in a fat fold on her stomach. The transplant was successful and the patient no longer needs insulin injections.

It is noteworthy that earlier implantation was carried out in the liver, but this led to complications. Months of observation of the patient allow scientists to draw a preliminary conclusion that the fat fold on the abdomen seems to be an ideal place for transplantation of insulin-producing cells.

Reprogramming of pancreatic cells

A group of Swiss scientists led by Pedro Herer conducted an interesting experiment. The researchers selected pancreatic alpha cells and reprogrammed them to produce insulin. The reprogrammed cells were then implanted into the pancreas of mice. As 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 an increase in glucose levels. The work was published in February 2019 in one of the most respected scientific journals, Nature.

Type 1 diabetes 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 process of digestion 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 the lack of insulin release due to damage to the insulin-producing apparatus of the pancreas.

Type 1 diabetes used to be 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, action. 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 the cells of the lymphoid tissue, which normally attack only foreign agents. This process is called "autoimmune", and refers to the mechanism for the production of antibodies against the cells of your body.

Autoimmune diseases as causes of type 1 diabetes

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 suggests a hereditary predisposition to autoimmune diseases and the systemic nature of immune damage, which can be triggered by other environmental factors.

The trigger mechanism of the disease is not exactly known, but scientists suggest that contracting a viral infection or drinking cow's milk can trigger an autoimmune process. And he, 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 against the background of a hungry state or after eating. Glucose is one of the main fuels used by body cells for their energy needs. The brain and nervous system only use glucose, while most other cells can also convert fats and other nutrients into energy. The glucose coming from the carbohydrate component of the food stimulates the production of insulin, which acts on the receptors of cell membranes and causes the penetration of glucose into the cell. If this does not happen, the processes of metabolism and cell energy are disrupted.

Blood sugar levels rise and glucose begins to show up in large quantities in the blood and urine. As 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 local doctor and get tested.

Family cases of the disease increase 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 mellitus in children almost always involves compensatory injections of human insulin. Also, therapeutic measures should be aimed at normalizing the metabolism and strengthening the immunity of the child.

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

• Regular injections of insulin. They are performed daily or several times a day, depending on the type of insulin used.
• Maintaining an active lifestyle (eliminating physical inactivity).
• Maintain normal body weight.
• Compliance with 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 degree of symptoms and the stage of the disease.

Prevention of type 1 diabetes in children

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

1. Watch for any signs of high or low blood glucose.

2. If you have a medical condition, check your blood glucose levels regularly with modern glucometers and adjust 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 needed for severe hypoglycemia.

5. See your doctor regularly to check your blood glucose levels, have your eyes, kidneys, and legs examined, and monitor symptoms of advanced diabetic disease.

6. Consult a doctor at an early stage of the disease to prevent decompensation of the pathological process.

7. Keep a "diabetes diary" and record self-measured glycemia.

Etiology and pathogenesis of type 1 diabetes mellitus in children

The etiology and pathogenesis of type 1 diabetes mellitus suggests that a violation of the principles of a healthy lifestyle plays a huge role in the development of the symptoms of the disease. An important role in the pathogenesis of type 1 diabetes is played by a sedentary lifestyle and. Eating high-carbohydrate 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 development and progression of diabetes, atherosclerosis and, as well as improve overall well-being.

It may be necessary to adjust the insulin dose during physical activity, depending on the intensity of 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 use of low molecular weight carbohydrates (sugar) and reduce the intake of carbohydrates in general.

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

Consult a qualified dietitian or endocrinologist for a personalized diet plan.

At present, it is impossible to completely prevent the onset of the disease. But scientists are constantly studying this disease and making effective additions to the treatment and diagnosis regimen.

Possible Complications of Type 1 Diabetes in Children

In most cases, type 1 diabetes mellitus gives 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 that 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 exacerbated by diabetes and can lead to circulatory disorders in the legs (diabetic foot), the development of strokes and heart disease (angina pectoris and myocardial infarction).

4. Diabetic kidney disease (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, lactacidemic 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. The type 1 diabetes diet is the basis for all subsequent treatment. Only with a strict correction of the diet can a 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 for constant monitoring and maintaining normal blood sugar levels.

Patients with diabetes mellitus who suffer from arterial hypertension can reduce the likelihood of complications with regular use of antihypertensive drugs to normalize blood pressure.

Diabetes leads to hardening of the arteries, and this risk is increased if the patient smokes. In order to reduce the risk of complications, you should give up bad habits.

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

Diabetes mellitus - the essence of the disease

Violation of metabolic processes relating to carbohydrates and water is classified in medicine as diabetes mellitus. For this reason, there are violations in the work 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, is excreted through the urinary tract (with urine), in this state the body tissues are not able to retain water in their cells - it also begins to be excreted from the body.

Diabetes mellitus is an increased content 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 aggravated 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, diseases of the kidneys and nervous system develop, and vision deteriorates.

Disease pathogenesis

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 under consideration, which are radically different from each other, it is impossible to speak of 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 the 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 as the only true one? Because other diseases can lead to a hyperglycemic state. These include:

• hyperthyroidism;
• adrenal tumor - it produces hormones that have the opposite effect on 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 insulin action.

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 curing the underlying disease, the work of the pancreas and the action of insulin are restored.

Types of Diabetes

The division of the disease under consideration into two main types is an important task. Each of them has not only distinctive characteristics, even treatment in the initial stage of diabetes will occur according to completely different schemes. But the longer the patient lives with diagnosed diabetes, the less noticeable the signs of its types become, and the treatment usually comes down to the same scheme.

Type 1 diabetes

He's called insulin dependent diabetes, it is considered a rather 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 be only from injections.
Important:it is impossible to completely get rid of the pathology, but in medicine there have been cases when recovery happened - patients adhered to special conditions and natural raw food.

Type 2 diabetes

This type of disease is considered non-insulin dependent, develops in people of the older age category (after 40 years) with obesity. What happens is that the body's cells are overwhelmed with nutrients and lose sensitivity to insulin.
The appointment of insulin injections in such patients is not mandatory, and only a specialist can determine the appropriateness 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 pills may be prescribed. Insulin is prescribed in the most extreme case, when the pathology begins to pose a danger to the life of the patient.

Degrees of diabetes

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

1 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 the normal range. The patient does not have any complications of diabetes mellitus, it is compensated with the help of diet and special medications.

2 degree. Diabetes mellitus becomes partially compensated, the patient has signs of complications. There is damage to some organs - for example, vision, kidneys, blood vessels suffer.

3 degree. This degree of diabetes mellitus is not treatable with medications and diet, glucose is actively excreted in the urine, and its level is 14 mmol / l. The 3rd degree of diabetes mellitus is characterized by clear signs of complications - vision is rapidly decreasing, numbness of the upper / lower extremities is actively developing, stable high blood pressure (hypertension) is diagnosed.

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

Symptoms of Diabetes

Diabetes mellitus never "starts" at lightning speed - it is characterized by a gradual increase in symptoms, a long development. The first signs of the disease in question include:

1. Intense thirst that is almost impossible to quench. Patients with diabetes consume up to 5-7 liters of fluid per day.
2. Dryness of the skin and recurrent itching, which is often referred to as nervous manifestations.
3. Constant dry mouth, no matter how much liquid the patient drinks per day.
4. Hyperhidrosis is excessive sweating, especially on the palms.
5. Weight variability - a person either rapidly loses weight without any diets, or quickly gains weight.
6. Muscle weakness - patients at the earliest stage of development of diabetes note fatigue, the inability to perform any physical work.
7. Prolonged healing of skin wounds - even an ordinary scratch can develop into a purulent wound.
8. Pustular processes are often noted on the skin for no apparent reason.

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

1. Regular and dizzy.
2. Increased blood pressure - at certain points, the indicators can reach.
3. Walking is disturbed, 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 decrease in the sensitivity of the feet.
7. Progressive loss of visual acuity.
8. A clearly perceptible smell of acetone begins to emanate from the patient.

Causes of diabetes

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 should be kept to a minimum.
2. Viral infections. Influenza, rubella, epidemic hepatitis and chicken pox - these infections can become a "push" to the development of diabetes, especially if the patient is at risk for the disease in question.
3. Obesity. In order to avoid the first signs of diabetes, it is enough to reduce weight.
4. Some diseases. Inflammation of the pancreas (pancreatitis), pancreatic cancer, pathological processes in other glandular organs can lead to damage to the cells that produce insulin.

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

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

Diagnosis of diabetes

If there are suspicions of diabetes mellitus, then it is necessary to undergo a full examination - for this you will need to pass several tests, use instrumental methods of examination. The list of diagnostic measures for diabetes mellitus includes:

1. A laboratory study of blood for the presence of glucose in it - fasting glycemia is determined.
2. Test determination of glucose tolerance - the examination is done after taking glucose.
3. The dynamics of the development of the disease is monitored - glycemia is measured several times a day.
4. General analysis of urine for the presence of protein, glucose and leukocytes in it (normally, these components are absent).
5. Laboratory study of urine analysis for the presence of acetone in it.
6. A blood test for the presence of glycosylated hemoglobin in it - this indicator determines the level of development of complications of diabetes mellitus.
7. A biochemical blood test - a doctor can determine the degree of functioning of the liver and kidneys against the background of progressive diabetes.
8. Reberg's test is carried out - the degree of damage to the kidneys and urinary tract is determined in case of diagnosed diabetes mellitus.
9. Blood test to determine the level of endogenous insulin.
10. Ophthalmologist consultation and eye examination.
11. Ultrasound examination of the abdominal organs.
12. Electrocardiogram - monitors the work of the heart against the background of diabetes mellitus.
13. Studies aimed at determining the level of damage to the vessels of the lower extremities - this allows you to prevent the development of diabetic foot.

Patients diagnosed with diabetes mellitus or suspected of having this disease should also be examined by narrow specialists as part of diagnostic measures. Physicians required to attend:

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

Blood sugar levels

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

Note:in order to exclude false positive results, it is necessary not only to measure the level of sugar in the blood, but also to conduct a glucose tolerance test (a blood sample 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 retake the test 1 or 2 hours later. The norms are given in the table (measurement value - mmol / l):
After passing two analyzes, it is necessary to determine the following values:

• The 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.
• The 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 danger to the health and life of the patient, but with the development of complications, the most unfortunate consequences are possible, leading to disruption of normal life.

diabetic coma

The symptoms of a diabetic coma grow rapidly, at lightning speed - you can not 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 his depression, lethargy of the patient.
The most commonly diagnosed ketoacidotic coma is a condition triggered by the accumulation of toxic substances. At the same time, nerve cells fall under the destructive effect of toxic substances, and the main, and sometimes the only, symptom of ketoacidotic coma is a stable, intense smell of acetone from the patient.

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

• clouding of consciousness - a semi-conscious state;
• the face and palms are covered with cold sweat - its 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 coma, but they are extremely rare.

Unstable blood pressure

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

Edema in diabetes

They indicate the development of heart failure and nephropathy. With constant edema, accompanied by instability in blood sugar levels, it is urgent to seek help from doctors - the situation is very serious and at any time the kidneys can completely fail or 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 considered complication of diabetes - corns, accompanied by pain in the legs and their swelling. Patients go to the doctor when the foot becomes pronounced red, swelling reaches a maximum (the patient cannot stand on his foot and 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, is not treatable and almost always leads to amputation of the legs (but there are exceptions).

Prevention of complications of diabetes

If the diagnosis of diabetes mellitus has already been approved by a doctor, then every effort must be made to prevent the development of its complications. Living with the disease in question is quite realistic, and living 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 you need to contact a nutritionist and get advice on compiling a rational menu;
• constant physical activity- about how intense they should be, the attending physician will tell;
• constant monitoring of blood pressure.

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 Alexandrovna, medical observer, therapist of the highest qualification category

Diabetes mellitus is a major medical and social problem worldwide. This is due to its wide distribution, the severity of late complications, the high cost of diagnostics and treatment, which are necessary for patients throughout their lives.

According to experts from the World Health Organization, the total number of patients with all forms of diabetes today is over 160 million people. Annually, the number of newly diagnosed cases is 6-10% in relation to 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 DM is a clear identification of the etiological factor in the development of DM.

Type 1 diabetes mellitus is a metabolic (exchange) 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 formerly 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 parts of the immune system) and is due to 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 either predisposing or protective.

Type 1 diabetes is often associated with other autoimmune diseases such as Graves' disease (diffuse toxic goiter), autoimmune thyroiditis, Addison's disease, vitiligo, and pernicious 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 the destruction of 80% of β-cells. An autopsy study of the pancreatic tissue of patients with type 1 diabetes reveals the phenomena of insulitis, a specific inflammation characterized by infiltration of islets by 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 producing cytokines, which leads to the destruction of β-cells. To date, insulin, glutamate decarboxylase, heat-shock protein 60, and fogrin are considered as putative primary autoantigens that cause proliferation of cytotoxic T-lymphocytes under certain conditions.

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 class of immunoglobulins G and are considered as immunological markers of autoimmune damage to β-cells. Islet cell autoantibodies are isolated (ICA - a set of autoantibodies to various cytoplasmic antigens of the β-cell), specific only for β-cells, autoantibodies to insulin, antibodies to glutamate decarboxylase (GAD), to phosphotyrosine phosphatase (IA-2), fogrin. Autoantibodies to β-cell antigens are the most important markers of autoimmune destruction of β-cells and appear in typical type 1 DM much earlier than the clinical picture of DM develops. Autoantibodies to islet cells appear in serum 5-12 years before the first clinical manifestations of diabetes mellitus, their titer increases at the late stage of the preclinical period.

In the development of DM 1, 6 stages are distinguished, starting with a genetic predisposition and ending with the 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 is realized in less than half of genetically identical twins and in 2-5% of siblings. Of great importance is the presence of HLA antigens, especially class II - DR 3, DR 4 and DQ.

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), drugs, stress factors, nutritional factors (use of milk formulas 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.

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

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

At the 5th stage, a clinical manifestation of the disease is noted, since by this time 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. The clinical manifestations of the disease reflect the degree of insulin deficiency.

The 6th stage is characterized by a complete loss of the functional activity of β-cells and a decrease in their number. This stage is diagnosed in the presence of a high glycemic level, a low C-peptide level, 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 noted.

Type 1 idiopathic diabetes mellitus is also distinguished, 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 has a clear inheritance. The absolute need for replacement therapy in such patients may come and go over time.

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

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

In typical cases, the onset of type 1 diabetes has severe clinical symptoms, reflecting insulin deficiency 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 accurately indicate the month, and sometimes the day, when they first developed the above symptoms. Rapid, sometimes up to 10-15 kg per month, for no apparent reason, weight loss 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 (flu, mumps, etc.) or stress. Patients complain of severe weakness, fatigue. Autoimmune diabetes usually begins in children and adolescents, but can develop at any age.

In the presence of symptoms of diabetes mellitus, 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), glycosuria, 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%);
• capillary blood glucose on an empty stomach 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%).

Determination of the level of C-peptide in serum allows assessing the functional state of β-cells and, in doubtful cases, distinguishing type 1 diabetes from type 2 diabetes. Measurement of the level of C-peptide is more informative than the level of insulin. 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 in 80-95% of patients with newly diagnosed type 1 DM 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) can 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. In children and adolescents, the clinical manifestation of the disease occurs, as a rule, with the phenomena of ketoacidosis. However, adults also have a slowly progressive form of type 1 diabetes mellitus, described in the literature as slowly progressive autoimmune diabetes in adults - Latent Autoimmune Diabetes in Adults (LADA).

Slowly progressive autoimmune diabetes in adults (LADA)

This is a special variant of the development of type 1 diabetes observed in adults. The clinical picture of type 2 DM 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, in a period that can last from 6 months to 6 years, decompensation of carbohydrate metabolism is observed and insulin demand develops. A comprehensive examination in such patients reveals genetic and immunological markers characteristic of type 1 diabetes mellitus.

LADA is characterized by the following features:

• the age of debut, as a rule, 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 demand in the period from 6 months to 10 years (average from 6 months to 6 years);
• presence of type 1 diabetes markers: low level of C-peptide; the presence of autoantibodies to β-cell antigens (ICA and/or GAD); the presence of HLA alleles of a high risk of developing type 1 diabetes.

As a rule, patients with LADA do not have a vivid clinical picture of the onset of type 1 diabetes, which is typical for children and adolescents. At its debut, LADA "masks" and is initially classified as type 2 diabetes, because the process of autoimmune destruction of β-cells in adults may be slower than in children. Symptoms of the disease are erased, there is no severe polydipsia, polyuria, weight loss and ketoacidosis. Excess body weight also does not exclude the possibility of developing LADA. The function of β-cells fades away 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, the diagnosis of type 2 diabetes is erroneously made. 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 onset of the disease. At the same time, 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 clinically differ from type 2 diabetes, and manifest itself as a slow deterioration in metabolic control, followed by the 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, makes it possible to diagnose slowly progressive autoimmune diabetes in adults.

Main diagnostic criteria for LADA:

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

The presence of autoantibodies to β-cell antigens in patients with a clinical picture of type II diabetes at the onset of the disease has a high prognostic value in relation to the development of insulin demand. 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 predictive 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 had a clinical picture of type 2 diabetes without obesity at the onset of the disease, a significant decrease in body weight (15.5 ± 9.1 kg) and concomitant autoimmune thyroid diseases (DTG) or AIT) represent an increased risk group for developing LADA. Determination of autoantibodies to GAD, ICA, and insulin in this category of patients is necessary for the timely diagnosis of LADA. Antibodies to GAD are detected most frequently in LADA (according to our data, in 65.1% of LADA patients), compared with antibodies to ICA (in 23.3% of LADA) and 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.

Patients with LADA represent a high-risk group for developing insulin demand and need timely insulin therapy. The results of OGTT 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, in whom the duration of the disease was not more than 5 years, were switched to insulin after an average of 25.2±20.1 months from the onset of the disease. This indicator 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 LADA patients, insulin secretion and peripheral tissue sensitivity to insulin should be assessed. The value of the basal level of C-peptide less than 1 ng / ml (as determined by radioimmunoassay) indicates insulin deficiency. However, for LADA patients, the absence of stimulated insulin secretion is more typical, while fasting insulin and C-peptide values ​​are within the normal range (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 was less than 2.8 at low initial values ​​(4.6±0.6 μU/ml), which indicates insufficient stimulated insulin secretion and indicates the need for early prescription 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 the absence of stimulated insulin secretion and the need to prescribe insulin.

If patients with LADA have a high degree of insulin resistance and hypersecretion of insulin in the first years of the disease, the administration of drugs that do not deplete the function of β-cells, but improve the peripheral sensitivity of tissues to insulin, such as biguanides or glitazones (actos, avandia), is indicated. Such patients are, as a rule, overweight and have satisfactory compensation for 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 fasting insulin level and glu0 is fasting plasma glucose) and / or the index of general tissue insulin sensitivity (ISI - insulin sensitivity index, or Matsuda index ) obtained on the basis of the OGTT results. 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 up to 12 points. 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.

Preservation of own residual secretion of insulin in patients with type 1 diabetes mellitus is very important, since it has been noted that in these cases the disease is more stable, and chronic complications develop more slowly and later. The issue of the significance 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 the infusion of small doses of biosynthetic C-peptide can affect microcirculation in human muscle tissue and renal function.

To determine LADA, more extensive immunological studies are shown among patients with type 1 diabetes, especially in the absence of obesity, 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 GDM development are very heterogeneous, and there is always a dilemma for the doctor: 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 American and African American women. 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, in patients with GDM, a slow development of insulin-dependent diabetes mellitus can be observed, as in LADA-diabetes. Screening patients with GDM for GAD and ICA autoantibodies makes it possible to identify patients who require insulin administration, which will make it possible to achieve optimal carbohydrate metabolism compensation.

Considering the etiopathogenetic mechanisms of LADA development, it becomes obvious the need for insulin therapy in these patients, while early insulin therapy aims not only to compensate for carbohydrate metabolism, but allows you to maintain 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 autoimmune destruction of β-cells. In this regard, the use of secretogens in LADA patients is pathogenetically unjustified.

After clinical manifestation, in most patients with a typical clinical picture of type 1 diabetes, a transient decrease in insulin requirements is noted within 1 to 6 months, 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 U / kg of body weight), in rare cases, even complete abolition of insulin is possible. The development of remission is a distinctive feature of the debut 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 of body weight. During puberty, the need for insulin can increase significantly - up to 1.0-2.0 U / kg of body weight. With an increase in the duration of the disease due to chronic hyperglycemia, the development of micro- (retinopathy, nephropathy, polyneuropathy) and macrovascular complications of diabetes mellitus (damage to the coronary, cerebral and peripheral vessels) occurs. The main cause of death is renal failure and complications of atherosclerosis.

Treatment of type 1 diabetes

The goal of type 1 diabetes therapy is to achieve the target values ​​of glycemia, blood pressure and blood lipid levels ( ), which can significantly reduce the risk of developing micro- and marco-vascular complications and improve the quality of life of patients.

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

Treatment for type 1 diabetes includes three main components:

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

Diet therapy and exercise

In the treatment of 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: cereals, potatoes, corn, liquid dairy products, fruits. Daily calorie content 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 mode of physical activity should be purely individual. It should be remembered that physical exercise increases the sensitivity of tissues to insulin, reduces the level of glycemia and can lead to the development of hypoglycemia. The risk of developing hypoglycemia increases during exercise and within 12-40 hours after prolonged heavy exercise. With light and moderate physical exercises lasting no more than 1 hour, an additional intake of easily digestible carbohydrates is required before and after sports. With moderate prolonged (more than 1 hour) and intense physical exertion, insulin doses need to be adjusted. Blood glucose levels should be measured before, during and after exercise.

Lifelong insulin replacement therapy is the main condition for the survival of patients with type 1 diabetes and plays a crucial role in the daily 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 regimen of insulin therapy is the lack of flexible adjustment of the dose of insulin administered to the level of glycemia. In this case, self-monitoring of blood glucose is usually absent.

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

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

Genetically engineered human insulins are the drugs of choice for the treatment of type 1 diabetes and the prevention of vascular complications. Porcine and human semi-synthetic insulins derived from pigs 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, insulins of medium duration or prolonged action are used (approximately 1 unit per hour, which is 24-26 units per day on average). In order to regulate the level of glycemia after meals, short-acting or ultra-short-acting insulins are used at a dose of 1-2 IU per 1 bread unit ( ).

Ultrashort-acting insulins (Humalog, Novorapid), as well as long-acting insulins (Lantus) are analogues of insulin. Insulin analogs are specially synthesized polypeptides that have the biological activity of insulin and have a number of desired properties. These are the most promising insulin preparations in terms of intensified insulin therapy. Insulin analogs humalog (lispro, Lilly) as well as novorapid (aspart, Novo Nordisk) are highly effective in regulating postprandial glycemia. They also reduce the risk of developing hypoglycemia between meals. Lantus (insulin glargine, Aventis) is produced by 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 asparagine amino acid from position A21 is replaced by glycine and 2 molecules of arginine are added to C - end of the B chain. These changes made it possible to obtain a peak-free, constant-concentration insulin action profile over 24 h/day.

Ready-made mixtures of human insulins of different action have been created, such as mixtard (30/70), insuman comb (25/75, 30/70), etc., which are stable mixtures of short-acting and extended-acting insulin in given proportions.

For the administration of 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 amputation of the lower extremities due to diabetes should be provided with syringe pens.

Achieving the target values ​​of glycemia is impossible without regular self-monitoring and correction of insulin doses. Patients with type 1 diabetes need to carry out self-monitoring of 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 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, at 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 on the creation of new pharmaceutical forms of insulin and means of their administration, which will make it possible to bring 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 cells of the pancreatic ducts or pancreatic cells. However, insulin is still the main treatment for diabetes today.

For literature inquiries, 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 is a disease that has been known since ancient times. However, if in the days 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 a disease that claims many human lives every year.

Description

What is it - diabetes? Diabetes mellitus (DM) is a disease associated with the pancreas. Many do not know anything about this body, about why it is needed. Meanwhile, one of the functions of the pancreas is the production of 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, while others produce the 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 the glucose entering the blood cannot penetrate into various tissues, primarily into the muscle. 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, it will 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 affects mainly young adults (up to 30 years). However, it is not uncommon for children, adolescents and the elderly to become ill.

Causes of the disease

What can stop insulin production? Although people have been researching 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.

First of all, it has long been established that many cases of type 1 diabetes are caused by autoimmune processes. This means that the cells of the pancreas 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 the proteins of nerve cells. Due to a malfunction in the foreign protein recognition system, T-helpers 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 "anger" on the cells of the pancreas, and in a relatively short time destroys them.

The virus 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, such as rubella viruses and some enteroviruses (Coxsackieviruses). After the virus settles in the 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 there is another, or perhaps they both contribute. But often the root cause of the disease cannot be established.

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

There are other factors that favor the development of the disease:

• decreased immunity,
• stress,
• malnutrition,
• other diseases of the endocrine system,
• skinny body,
• alcoholism,
• smoking.

Sometimes type 1 diabetes can be caused by oncological diseases of the pancreas, poisoning.

Stages and development of the disease

Unlike type 2 diabetes, which develops slowly over several years, type 1 diabetes progresses to a severe degree within a month, or even 2-3 weeks. And the first symptoms that indicate the disease usually appear violently, in such a way that it is difficult not to notice them.

In the very first stages of the disease, when immune cells are just beginning to attack the pancreas, there are usually no clearly visible symptoms in patients. Even when 50% of the beta cells are destroyed, the patient may not feel anything, except for a slight malaise. And the real manifestation of the disease with all its characteristic symptoms occurs only when about 90% of the cells are destroyed. With this degree of disease, the remaining cells can no longer 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

Type 1 diabetes is similar in its symptoms to type 2 diabetes. 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 that the water does not linger in him.

Another characteristic symptom is sudden weight loss. Type 1 diabetes usually affects thin people, but after the onset of the disease, a person can lose a few more pounds.

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

If the patient encounters such symptoms, then he should immediately consult a doctor.

Complications

An increase in blood glucose is called hyperglycemia. Hyperglycemia entails such severe consequences as impaired functioning of the kidneys, brain, nerves, peripheral and main vessels. The level of cholesterol in the blood may rise. The defeat of small vessels often leads to ulcers, dermatitis. Retinopathy may develop, eventually leading to blindness.

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

• ketoacidosis,
• coma,
• gangrene of the extremities,

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

If complications do not kill a person, they can make him disabled. However, the prognosis of type 1 diabetes without proper treatment is poor. Mortality reaches 100%, and the patient can live a year or two at the most.

hypoglycemia

This is a dangerous complication that occurs with type 1 diabetes. It is typical for patients undergoing insulin therapy. Hypoglycemia is observed at glucose levels below 3.3 mmol / l. It can occur when there is a violation of the meal schedule, excessive or unplanned physical activity, exceeding the dosage of insulin. Hypoglycemia is dangerous with loss of consciousness, coma and death.

Diagnostics

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

The main diagnostic method is a blood test for sugar content. 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 a glycated hemoglobin test may be prescribed. To determine the state of the pancreas, an analysis is made for C-peptide.

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

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. Now, genetically engineered insulins are mostly common. Long-acting insulins need to 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 weight of the patient and his physical activity.

Insulin is injected into the blood by the patient himself or by the person serving him with the help of syringes or syringe pens. Now there is a promising technology - insulin pumps. This is a design that is attached to the patient's body and helps to get rid of the manual injection of insulin.

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

Diet for diabetes

Another treatment is diet. Due to the constant supply of insulin, insulin-dependent diabetes does not require such severe restrictions as type 2 diabetes. But this does not mean that the patient can eat whatever he wants. The purpose of the diet is to avoid sudden fluctuations in blood sugar levels (both upward and downward). 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 mellitus combined with insulin therapy, it is possible not to sit on debilitating low-carbohydrate diets, especially since excessive carbohydrate restriction increases the risk of hypoglycemia, a condition in which blood glucose levels fall below life-threatening levels.

Physical exercise

Exercise can also be helpful for diabetics. They should not be too long and exhausting. With hypoglycemia and hyperglycemia (blood glucose more than 15 mmol / l), exercise is prohibited.

self control

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