Type 1 Diabetes

Diagnosis

Diagnostic tests for type 1 diabetes often begin with a glycated hemoglobin (A1C) test. This blood test measures average blood sugar levels over the past two to three months. It works by showing how much sugar is attached to hemoglobin, the protein in red blood cells. Higher blood sugar results in higher A1C levels. An A1C level of 6.5% or higher on two separate tests indicates diabetes.

If the A1C test is not available or may be inaccurate due to conditions such as pregnancy or uncommon hemoglobin variants, other testing methods may be used. These include a random blood sugar test, which collects a blood sample at any time. A random blood sugar reading of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes. A fasting blood sugar test may also be performed after an overnight fast. A fasting reading under 100 mg/dL (5.6 mmol/L) is healthy, while a reading between 100 and 125 mg/dL (5.6 to 6.9 mmol/L) suggests prediabetes. A value of 126 mg/dL (7 mmol/L) or higher on two separate tests confirms diabetes.

If the diagnosis of diabetes is confirmed, your provider may order blood tests to look for autoantibodies that are typically present in type 1 diabetes. Testing for ketones in the urine may also help differentiate between type 1 and type 2 diabetes.

After the diagnosis

Regular visits with your provider will help guide the management of type 1 diabetes. These appointments include checking A1C levels, which show how well your treatment plan is working. The American Diabetes Association generally recommends keeping A1C levels below 7%, or an average glucose level around 154 mg/dL (8.5 mmol/L). A higher A1C level may mean adjustments are needed in insulin, diet or both.

Your provider may take blood and urine samples to evaluate cholesterol levels and thyroid, liver and kidney function. Blood pressure will also be checked regularly. During visits, your provider may examine the areas where insulin is injected or where blood sugar is tested.

Treatment

Treatment for type 1 diabetes includes several essential components: taking insulin, counting carbohydrates, fats and protein, monitoring blood sugar, eating healthy foods, and staying physically active. The goal is to keep blood sugar levels close to normal to delay or prevent complications. Generally, the recommended daytime blood sugar range before meals is 80 to 130 mg/dL (4.44 to 7.2 mmol/L). Two hours after eating, levels should stay below 180 mg/dL (10 mmol/L).

Insulin and other medications

People with type 1 diabetes need lifelong insulin therapy. Different types of insulin may be used.

• Short-acting insulin begins to work about 30 minutes after injection, peaks at 90 to 120 minutes and lasts roughly 4 to 6 hours.
• Rapid-acting insulin starts working within 15 minutes, peaks at about 60 minutes and lasts around 4 hours.
• Intermediate-acting insulin begins working in 1 to 3 hours, peaks at 6 to 8 hours and lasts 12 to 24 hours.
• Long- and ultra-long-acting insulin may last from 14 to 40 hours.

Most people use a combination of long-acting and rapid-acting insulin to better mimic natural insulin patterns. Insulin can be given by injection or by insulin pump. Injections may be done using a needle and syringe or an insulin pen. A pump is a small device worn outside the body that delivers insulin through a catheter under the skin. Tubeless pump options are also available.

Blood sugar monitoring

Depending on your insulin regimen, you may need to check your blood sugar at least four times a day. The American Diabetes Association recommends checking before meals and snacks, before bed, before exercise or driving, and whenever low blood sugar is suspected. Monitoring helps ensure levels stay within a safe range and can help lower A1C over time.

Blood sugar levels can vary due to food, illness, physical activity, stress, hormones, medication or alcohol. Understanding patterns can help with better management.

Continuous glucose monitoring

Continuous glucose monitoring checks blood sugar every few minutes using a sensor placed under the skin. These devices may help prevent low blood sugar and can reduce A1C levels.

Closed loop system

A closed loop system links a continuous glucose monitor to an insulin pump. The device adjusts insulin delivery automatically when blood sugar levels change. Several hybrid systems are approved, meaning the user still needs to provide some input, such as carbohydrate counts. Fully automated systems are still in development and are being studied in clinical trials.

Other medications

Additional medications may be recommended depending on your health needs. These may include blood pressure medications such as ACE inhibitors or ARBs to protect kidney health. Aspirin may be recommended for heart protection if cardiovascular risk is high. Cholesterol-lowering drugs are often prescribed because people with diabetes have a higher risk of heart disease.

Guidelines recommend:
• LDL cholesterol below 100 mg/dL (2.6 mmol/L)
• HDL cholesterol above 50 mg/dL (1.3 mmol/L) for women and above 40 mg/dL (1 mmol/L) for men
• Triglycerides below 150 mg/dL (1.7 mmol/L)

Healthy eating and monitoring carbohydrates

There is no specific diabetes diet, but a healthy eating pattern focuses on fruits, vegetables and whole grains. Limiting refined carbohydrates and animal products is typically recommended. Learning to count carbohydrates helps match insulin doses to food intake. A registered dietitian can create a personalized meal plan.

Physical activity

Regular aerobic exercise is important for everyone, including people with type 1 diabetes. Aim for at least 150 minutes of moderate exercise each week, with no more than two days without activity. Because exercise lowers blood sugar, monitoring levels more often when starting new activities is important. You may need to adjust insulin or meals based on activity.

Activities of concern

Certain activities may require extra planning.

• Driving: Check blood sugar before driving. If it is below 70 mg/dL (3.9 mmol/L), have a 15-gram carbohydrate snack and retest in 15 minutes.
• Working: Jobs involving driving or operating heavy machinery may require accommodations to prevent low blood sugar risks.
• Being pregnant: Pregnancy is high risk for people with type 1 diabetes. A1C should generally be below 6.5% before trying to conceive. Careful blood sugar control helps reduce the risk of birth defects and complications.
• Being older or having additional conditions: Tight blood sugar control may increase the risk of low blood sugar. A less strict A1C goal, such as under 8%, may be safer.

Potential future treatments

Pancreas transplant may eliminate the need for insulin, but carries serious risks and is usually reserved for complex cases, especially when kidney transplant is also needed.

Islet cell transplantation is being studied as a way to provide new insulin-producing cells. Improvements in procedures and medications are increasing its potential success.

Signs of trouble

Short-term complications such as low blood sugar require immediate care.

Low blood sugar may occur if meals are skipped, carbohydrates are reduced, exercise increases or too much insulin is taken. Early symptoms can include shakiness, sweating, hunger, dizziness, fast heartbeat, irritability and headache. Nighttime signs include waking with sweat-soaked clothing or a morning headache.

If untreated, symptoms worsen and may include confusion, slurred speech, blurry vision, muscle weakness, drowsiness or even seizures and unconsciousness. Low blood sugar should be treated with a fast-acting sugar source such as glucose tablets or juice.

Tell trusted people about your symptoms and where you keep glucagon. They should know to give glucagon by injection or nasal spray and call emergency services if you cannot respond or swallow.

Hypoglycemia unawareness

Some people stop noticing symptoms of low blood sugar. Avoiding low blood sugar episodes for several weeks may restore awareness. Temporarily increasing target blood sugar levels may also help.

High blood sugar

Blood sugar can rise from eating too much, eating certain foods, not taking enough insulin or illness. Symptoms include frequent urination, increased thirst, fatigue, headache and irritability. A correction dose of insulin may be needed. If blood sugar is above 240 mg/dL (13.3 mmol/L), test for ketones and avoid exercise. Seek medical care if high levels persist.

Increased ketones in the urine

If the body breaks down fat for energy, ketones can build up and cause diabetic ketoacidosis, a medical emergency. Symptoms include nausea, vomiting, abdominal pain, fruity breath, shortness of breath, dry mouth, weakness, confusion or coma. If ketones are high, contact your provider or seek emergency care immediately.