The Type I diabetes curve

KOCHI: With diabetes, the tables are turning but not in a good way, with the country being dubbed as the diabetic capital of the world. So often we hear how diabetes (Type 2) prevalent in older generation is increasingly becoming common in younger generation. But with Type 1 diabetes, which is commonly known as juvenile diabetes, another trend is developing, posing another serious health concern. Experts say incidence of Type 1 diabetes developing in adults is increasing these days and there is misdiagnosis of this as Type 2 diabetes. One of the possible signs of Type 1 diabetes being misdiagnosed as Type 2 in adults is the decreasing effectiveness of Type 2 diabetes medication in controlling blood glucose. This in many cases leads to death in sleep.

Type 1 diabetes is an autoimmune disease in which the immunity of body turns against itself and destroys pancreatic cells that produce insulin. Unfortunately, the factors causing the disease are unknown and the disease is non-curable. As a result, patients are left managing the disease with insulin injections or pump alone. “Due to high incidence of the disease in children, there is a predominant belief that Type 1 diabetes happens to children alone. But increasingly, it is evident that incidence of the disease is similarly high in adults, even who are aged around 40 years or older. Moreover, diagnosis of the disease becomes difficult in adults as more people develop Type 2 diabetes in later stages of life,” says Dr Tom Babu, endocrinologist and medical director Silverline Hospital, Girinagar, Kochi.

According to Dr Jothydev Kesavadev, chairman, Jothydev's Diabetes Research Centres, Kerala, Type 1 constitutes 6-10% of diabetes in India.   “It is totally different from commonly seen Type 2 diabetes. There is even a global movement to change the terminology to easily identify the gravity of this disease. Whatever be the age of onset - 5 years or 75 years - insulin secretion comes to a complete standstill in a couple of weeks to months' time in Type 1 diabetes. It is a fact that many cases treated as Type 2 diabetes may be Type 1 and vice-versa. Fasting c-peptide levels, which is an indirect measurement of insulin production, will be low in Type 1 diabetes and will drop to zero when the disease becomes full-fledged. Estimation of c-peptide, serum insulin levels and many other investigations in diabetes are the only way by which the type of the disease can be identified, and specific therapies tailored accordingly,” said Dr Jothydev.

According to Dr. Vipin V.P., endocrinologist with Aster Medcity, Kochi,  the incidence of Type 1 diabetes throughout the world is increasing at 3-5 % per year. “The cause of the disease is mainly autoimmune, wherein our own body attacks our pancreas. The white blood cells cause inflammation in the pancreatic beta cells followed by its direct destruction. Other diseases and infections may also cause destruction of pancreatic beta cells, such as Hepatitis C, mumps and so on,” Dr Vipin said.“Type 1 diabetes patients need to be really wary of dying in their beds. It is estimated that around 6% of deaths in Type 1 diabetes patients worldwide are caused by the syndrome.  In the past, Type 1 diabetes patients were at times found dead with no signs of foul play,” said Dr Vipin.

“The sudden death of patients with no time for preventive action with Type 1 diabetes was first suggested by Tunbridge as early as 1981.  However, only in 1991, Tattersall and Gill   conducted a study under British Diabetes Association (now Diabetes UK), in which they looked at a total of 22 unexplained deaths. The study concluded that hypoglycemic (drop in blood sugar levels) episode at night contributed to the deaths of the patients. Those younger than 40 years seem to be at a higher risk. Preventive measures like checking insulin and sugar levels in the body or using insulin pump therapy can reduce the chances of such accidental deaths,” said Dr Tom Babu.

“India is host to over 97,000 Type 1 diabetic children. In my practice, the prevalence of Type 1 diabetes would be from 3 to 5% in the state of Kerala. Around 4 to 5 patients visit us weekly. Past viral infections triggering an autoimmune process could be one the most common reasons for the disease,” said Dr Tom Babu. “Sometimes, Type 2 diabetes also behaves erratic with unexpected rise and fall in blood glucose values, gradually damaging the kidneys, eyes and heart. The cause of Type 1 diabetes and other types of diabetes is totally different and hence choice of drugs is also totally different. Patient should be willing to perform expensive laboratory investigations at diagnosis and at periodic intervals to ensure that they are in the right track. Four or more injections per day or insulin pump therapy if feasible along with glucose monitoring are the most accepted methodologies for treating this condition. There will be thousands of patients getting treated for Type 2 diabetes missing the diagnosis of Type 1. This is a worldwide phenomenon since investigations must be repeated at periodic intervals.

The very poor longevity of Type 1 diabetes over the last 60-75 years in Kerala, with patients diagnosed in childhood rarely surviving only till their third decade in life, calls for urgent measures to implement team-based diabetes care beyond providing free medications since treating Type 1 diabetes is a very difficult process and the medication dosages need to be adjusted several times a day,” said Dr Jothydev. “The newer ways of managing diabetes with the use of insulin pumps is gaining popularity, which are also equipped with continuous glucose monitoring device, keeping track of fluctuating glucose levels and alarms whenever the body requires insulin. The insulin can be delivered with the press of a button. Being portable in nature, these can be worn on the clothing being connected to the body with a small infusion set while performing daily and many sporting activities, especially in the case of children,” said Dr Tom Babu.