Type 1 Diabetes
Type 1 diabetes usually occurs in children or young adults, people who normally were very healthy before they developed diabetes. It results from deficiency of the hormone, insulin. Insulin works by taking glucose out of the blood and into the body’s cells where it is used for energy. Without it, the cells are starved of energy and the level of glucose in the blood rises to high levels. Type 1 diabetes is very different from type 2 diabetes in two important ways: it is not associated with unhealthy lifestyles and also not associated with excess insulin levels and insulin resistance.
My approach is to try and help people with type 1 diabetes replace the missing hormone (insulin) so that they can lead as normal a life as possible. That means injecting the right amount of insulin each day to keep glucose levels as near normal as possible, avoiding levels that are either too high (hyperglycaemia) or too low (hypoglycaemia). It also means it is essential to check the glucose level frequently every day. Thankfully, in the UK and many other countries, continuous glucose monitoring (CGM) systems are now available. These are sensors that are stuck to the skin with a small cannula that is inserted into the fat below the skin. They provide a continuous reading of the glucose level day and night so that finger prick blood testing is unnecessary. The Freestyle Libre™ is the first so-called Flash glucose monitoring device. It is cheaper than most CGM systems and requires the user to scan the sensor with their mobile phone to get a glucose reading. It is available on the NHS to everyone with type 1 diabetes.
Crucial to maintaining near normal glucose levels is the ability to match the food eaten with the correct amount of insulin, and this does require a lot of learning, both to be able to assess the amount of carbohydrate in each meal and to know how to calculate the correct amount of insulin to inject. Many diabetes centres run education programmes to teach these skills – in 1999, with colleagues from the Bournemouth diabetes team, I developed the BERTIE structured education programme and in 2004 we launched the world’s first online education programme for type 1 diabetes (BertieOnline). In 2018 I published my book 'Take Control of Type 1 Diabetes' that aims to provide all the information required to manage the condition successfully.
In the past 20 years, with new rapid-acting insulins becoming available, many believed that a person with type 1 diabetes could eat whatever they like, as long as they injected the correct amount of insulin. Over time, it has become apparent that it is not as simple as that, and eating large amounts of carbohydrates can make it difficult to achieve stable glucose levels. I therefore encourage people with type 1 diabetes to enjoy a variety of foods, while understanding the effect of different foods on their glucose levels. Where necessary, I encourage restriction of sugars and refined carbohydrates, as these can cause too fast and high a spike in glucose levels, even when using the most modern insulins. It is possible to have meals with no carbohydrate – with the bonus of often not needing to inject insulin for them.
The key to effective management of type 1 diabetes is to ensure appropriate self-management education, whether attained through a structured education programme, a book or a website and to use an insulin regimen appropriate to one’s lifestyle, together with a glucose monitoring system. This usually involves one or two injections daily of a long-acting insulin to keep glucose levels stable overnight and when not eating; and a ‘bolus’ dose of rapid-acting insulin before each meal. Increasingly, insulin pumps are used as an alternative to injections.
However, despite the best self-management education, the most modern insulins and advanced technology, many people find that their glucose levels seem to have a life of their own. That is because just about everything can affect glucose levels, not just the food eaten or exercise done, but also factors like stress, illness and even menstrual cycle can affect the amount of insulin required. Understandably, that can cause a lot of additional stress and anxiety and recognising and helping with that is an important part of my role as a diabetes doctor.