Diabetes refers to a metabolic disorder of several etiology. The disorder is typified by chronic hyperglycemia and metabolic disturbances of fat, carbohydrate and protein due to insulin deficiency, defect in its action or a combination of both (Alberti & Zimmet, 2004). The chronic hyperglycemia leads to damage, dysfunction of several organs including the eyes, heart, blood vessels, kidneys and nerves (American Diabetes Association, 2011). Diabetic patients present primarily with excessive thirst, loss of weight, blurring of vision and weight loss. Long standing diabetes is associated with complications such as retinopathy, cardiovascular diseases, neuropathy, hypertension and metabolic abnormalities. There are two types of diabetes based on clinical stages and type of etiology (Alberti & Zimmet, 2004). Clinical stages imply that the disease progresses through a number of clinical stages regardless of the cause, and the stage is based upon the extent of underlying disease as illustrated in figure 1. Type 1 is caused by destruction of beta cells while type 2 results from insulin resistance and lack of compensatory insulin secretory response. This essay will discuss type 1 diabetes.
Type 1 diabetes results from the damage of beta-cells resulting in total deficiency of insulin (Alberti & Zimmet, 2004). It accounts for 5-10% of the total diabetes cases and is mainly diagnosed in children and young adults (American Diabetes Association, 2011). Ketoacidosis develops in advanced cases and progress to coma and ultimately death. Therefore, insulin is required for survival (Alberti & Zimmet, 2004). Highly specific indicators of type 1 disease have been revealed. These indicators include; insulin antibodies and anti-GAD. While type 1 diabetes patient may exhibit normal metabolic processes, the destruction of beta cells can still be detected. According to Zimmet and Albert, the beta-cell autoantibodies in a normoglycemic individual are an indication that the individual has type 1 autoimmune process. It has two categories based on the pathogenic processes involved in the development (Alberti & Zimmet, 2004). The first group is caused by autoimmune processes while the second group is known as idiopathic since it has no known cause.
Etiology of Diseases
Immune-mediated diabetes is caused by cellular-mediated autoimmune destruction of the pancreatic beta cells (American Diabetes Association, 2011). The beta cells are genetically predisposed to immune destruction. According to the American Diabetes Association, the HLA-DR/DQ genes can either predispose or protect an individual from the disease. Other factors suspected to cause this form of type 1 disease are environmental factors. However, the specific mechanism by which they cause the destruction of beta cells is not well understood (Alberti & Zimmet, 2004). While obesity is not a significant factor in this form of diabetes, its presence is not incompatible with the condition. The factors used to detect the destruction of the cells are beta-cell autoantibodies, insulin autoantibodies, tyrosine phosphatase IA-2 and IA-2β autoantibodies and glutamic acid decarboxylase autoantibodies. Up to 90% individuals exhibit one or more of the autoantibodies when the fasting hyperglycemia is detected. Individuals with immune-mediated diabetes also present with other autoimmune disorders such as Addison's disease and Grave's disease.
Type 1 diabetes results from the damage of beta-cells resulting in total deficiency of insulin (Alberti & Zimmet, 2004). Insulin is a biological chemical that controls the sugar content in blood hence lack of it leads to hyperglycemia. The chronic hyperglycemia leads to damage, dysfunction of several organs including the eyes, heart, blood vessels, kidneys and nerves (American Diabetes Association, 2011). Diabetic patients present primarily with excessive thirst, loss of weight, blurring of vision and weight loss. Long standing diabetes is associated with complications such as retinopathy, cardiovascular diseases, neuropathy, hypertension and metabolic abnormalities. It accounts for 5-10% of the total diabetes cases and is mainly diagnosed in children and young adults (American Diabetes Association, 2011). Therefore, insulin is required for survival (Alberti & Zimmet, 2004).
The risk of developing Insulin dependent diabetes has been linked to certain variations of the human leukocyte antigen (HLA) complex (GHR, 2014). Individuals with HLA-DQA1, HLADQB1 and HLA-DRB1 variations of the HLA complex are at the highest risk. HLA genes enable the immune system to differentiate between self-proteins and proteins from foreign sources. However, HLA-DQA1, HLADQB1 and HLA-DRB1 variants cause an abnormal immune response to beta cells. Other variations confer protection against the condition. Other contributing factors are environmental and to a minimal extent, obesity (Alberti & Zimmet, 2004).
Type 1 diabetes has a tendency to be passed through family generations (GHR, 2014). This condition is likely to develop in individuals whose immediate relative have the disorder. For a child with type 1 diabetes, their sibling has a 1-10 chance of developing the condition before the age of 50. However, the inheritance patterns are not predictable (GHR, 2014).
Body System Affected By the Diabetes
Different body systems are affected differently by diabetes. Some of these systems include eyes where the condition may affect blood vessels taking blood to the eyes resulting in cataracts, glaucoma, and changes in the retina. The condition may also affect the nervous system where too much glucose in the blood may result in damaging the nerve cells and consequently result in complications such as tingling, numbness, and pain especially in the legs American Diabetes Association, 2014). Neuropathy arises due to decreased blood flow to nerves due to damaged small blood vessels. It may lead to sensory loss, erectile dysfunction and foot ulcers that could lead to amputations. Neuropathy is one of the major complication of diabetes. The symptoms are based on the damaged nerves and range from numbness, pain to impotence (World Health Organization, 2014).
The other major system that is affected is the heart. Diabetes increases the chances of developing heart diseases by almost twice as a result of damaged blood vessels. Increased levels of sugar in the blood may also make it hard for the kidney to function optimally. The kidney is usually overworked when sugar levels are high in the blood, and this may result in the development of kidney diseases. Diabetes also has a great effect on the liver system mainly by damaging liver tissues. The damage may result in a number of conditions such as cirrhosis and nonalcoholic fatty liver disease (American Diabetes Association, 2014).
Lifestyle Factors Related To Diabetes
The components of a successful lifestyle intervention program are physical activities, dietary modifications, and behavioral change. Regular physical activities coupled with cardiovascular fitness reduce the rates of mortality and morbidity in diabetic patients (Canadian Diabetes Association, 2013). A study involving type 1 diabetic patients indicated a 50% reduction in a 7-year mortality for the patients who recorded >2000 kcal of weekly exercise (Canadian Diabetes Association, 2013). Aerobic exercises increase cardiovascular fitness while delaying progression of diabetic neuropathy. One study found that patients with peripheral neuropathy of the feet experienced delayed development of foot ulcers as compared to those who led a sedentary lifestyle. Exercise stress testing has been shown to detect unsuspected coronary disease and higher risks of cardiovascular diseases.
Physical programs should be supervised as some individuals have conditions such as severe peripheral neuropathy that could lead to adverse events. Type 1 diabetes patients risk developing hypoglycemia during exercise hence they are advised to ingest about 30g of carbohydrates prior to the exercise. In type one diabetes, patient exercise could also increase hyperglycemia, and vigorous exercises should be discouraged in those whose levels of ketones are elevated. The exercises should be modified to suit individual needs e.g. elderly people should be encouraged to walk while patients who experience pain when walking can cycle.
Nutrition therapy helps to improve the quality of life and to treat acute and chronic complications associated with concomitant disorders. According to (Canadian Diabetes Association, 2013), nutrition therapy improves glycemic control through reduction of glycated hemoglobin (AIC). When integrated with other features of diabetes care, it improves metabolic outcomes and minimizes the need for hospitalization. The appropriate diet is one that is low in energy density, but high in volume in order to prevent overconsumption (Canadian Diabetes Association, 2013). This type of diet enables an individual to attain a healthy body weight. Like exercises, nutrition therapy should be tailored to accommodate the patient’s treatment goals, age, culture, and economic status. The daily recommended constitutes carbohydrate intake of 130g/day, sucrose intake not exceeding 10% total daily energy, about 7-10 vegetable servings and a fat intake of about 20-30% of energy. Proteins should be modified at 1-1.5/kg body weight per day (Canadian Diabetes Association, 2013).
The Action for Health in Diabetes carried out a program targeting to reduce 7% of weight, 30% reduction of total fat and 10& of saturated fat, 15% increase in protein intake and increase in physical activity (175 min/week). The results were progressive weight loss, improved fitness, better glycemic control and reduced cardiovascular risk factors (Canadian Diabetes Association, 2013).
Complications Associated With Type 1 Diabetes
Diabetes associated complications are either microvascular or macrovascular (World Health Organization, 2014). Microvascular complications are the major cause of mortality in type 1 diabetes and include retinopathy, nephropathy, and neuropathy. They are caused by chronic hyperglycemia and factors that occur secondary to hyperglycemia such as hypertension.
Diabetic retinopathy is a primary cause of visual disability and blindness causing an estimate of 10,000 cases annually in the Unites States (Fowler, 2008). It results from the damaged small blood vessels resulting in loss of vision and ultimately blindness. Patients present with blurred vision and delayed onset is achieved by proper metabolic control. Nephropathy leads to renal failure and eventually death. It is the leading cause of dialysis and kidney transplants in developed countries (World Health Organization, 2014). The early stages are asymptomatic but as the disease progresses, the patients present with electrolyte imbalances, fatigue and loss of cognition. The main indicator is microalbuminuria of 30-299 mg every 24 hours that progresses to proteinuria. Delayed progression is possible if detected early through control of high blood sugar levels, high blood pressure, low protein diet and medication.
Macrovascular diseases are majorly due to atherosclerosis that causes narrowing of arterial walls throughout the body. This process increases the risk of developing cardiovascular diseases. Though the mechanisms through which diabetes increases the chances of atherosclerotic plaque formation are poorly understood, there is a major association in the two. According to Fowler (2008), Cardiovascular diseases are the major causes of death in individuals with type 1 or 2 diabetes. They account for the largest component of healthcare expenditure in diabetic patients.
Prognosis of Diabetes
Though the prognosis for diabetes type 1 has been poor, it has greatly improved over the years with the discovery of new and improved insulin regimens. It is still limited due to end-stage organ diseases such as kidney and cardiac diseases. Approximately one-thirds of children in specialized centers are at high risk of developing kidney disease. However, it can be prevented through angiotensin converting enzyme inhibitors. Anti-hypertensive and skilled laser therapies are used to prevent progression of retinopathy. The diabetes control and complications analysis indicated that complications arising from small vessels damage can be controlled by near-normal glucose control which minimizes coronary risk.
Treatment of Diabetes
Treatment seeks to control blood glucose levels and prevent complications associated with diabetes. Type 1 diabetes patients rely on insulin for survival (Canadian Diabetes Association, 2013). Insulin is prepared through recombinant DNA technology into forms identical to human insulin or modifications of human insulin. These preparations differ in terms of onset of action, peak time and duration of action.
Insulin therapy is initiated once diagnosis is confirmed (Canadian Diabetes Association, 2013). Insulin may be administered using a pen, pump or syringe (American Diabetes Association, 2014). The pens allow multiple insulin injections. Therapy entails selection of insulin regimen and initiation of education. Patients receive ongoing education in order to learn on how to use insulin. To learn management strategies such as regulated food intake and physical activity, and to know how to carry out self-monitoring of glucose. Insulin regimens should be modified to suit the individual’s goals, general health, age, diet, and lifestyle and socio-economic aspects.
There are fixed-dose regimens that have been replaced with basal-bolus regimens. Basal-bolus are used in intensive treatment. Basal insulin is provided by either long-acting insulin or intermediate-acting insulin administered once or two times daily. Bolus insulin is provided by either rapid-acting or short-acting insulin given at each meal. The objective of the basal-bolus preparations is to try and achieve a duplicate of the normal pancreatic insulin secretions
Adjunctive therapy helps in maintaining optimal glycemic targets. It improves insulin sensitivity in obese patients. Metformin has been used to decrease insulin requirements and reduce cholesterol levels. It may aid in the reduction of weight. However, according to Canadian Diabetes Association (2013), use of metformin is off-label and poses a danger in renal and heart failure.
The major challenge in diabetes management is insulin-induced hypoglycemia (Canadian Diabetes Association, 2013). When very severe, hypoglycemia causes confusion and seizures and may lead to coma. These effects may cause some patients not to comply with intensive therapy. Effective self-management, professional support, glycemic targets coupled with self-monitoring of blood glucose lead to low incidents of hypoglycemia.
Quality of Life for Patient with Diabetes
Research studies have shown that pediatric diseases negatively impact adulthood demographic factors such as education, socioeconomic level, and marital life (Imayama, Plontnikoff, et, al 2011). This corresponds with type 1 diabetes which in most cases is diagnosed during childhood. According to Imayama & Plontnikoff (2011), type 1 diabetes patients are likely to have lower incomes and on employment opportunities. These factors affect life satisfaction in patients. Conditions such as hypertension and cardiovascular disease affect the health-related quality of life. Individuals with these comorbidities exhibited a reduced health-related quality of life. Occurrence of type 1 diabetes among the younger adults has been shown to affect the health-related quality of life. According to Imayama (2011), this observation is attributed to lower incidences of social support in young adults as compared to an older group.
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