Diabetes , type 1

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DEFINITION

Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn't make enough insulin.

Various factors may contribute to type 1 diabetes, including genetics and exposure to certain viruses. Although type 1 diabetes usually appears during childhood or adolescence, it also can begin in adults.

Despite active research, type 1 diabetes has no cure. But it can be managed. With proper treatment, people with type 1 diabetes can expect to live longer, healthier lives than did people with type 1 diabetes in the past.

SYMPTOMS

Type 1 diabetes signs and symptoms can come on quickly and may include:

• Increased thirst
• Frequent urination
• Bedwetting in children who previously didn't wet the bed during the night
• Extreme hunger
• Unintended weight loss
• Irritability and other mood changes
• Fatigue and weakness
• Blurred vision
• In females, a vaginal yeast infection

When to see a doctor

Consult your doctor if you notice any of the above signs and symptoms in you or your child.

CAUSES

The exact cause of type 1 diabetes is unknown. In most people with type 1 diabetes, the body's own immune system — which normally fights harmful bacteria and viruses — mistakenly destroys the insulin-producing (islet) cells in the pancreas. Genetics may play a role in this process, and exposure to certain environmental factors, such as viruses, may trigger the disease.

The role of insulin

Once a significant number of islet cells are destroyed, you'll produce little or no insulin. Insulin is a hormone that comes from the pancreas, a gland situated behind and below the stomach.

• The pancreas secretes insulin into the bloodstream.
• Insulin circulates, enabling sugar to enter your cells.
• Insulin lowers the amount of sugar in your bloodstream.
• As your blood sugar level drops, so does the secretion of insulin from your pancreas.

The role of glucose

Glucose — a sugar — is a main source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources: food and your liver.
• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
• Your liver stores glucose as glycogen.
• When your glucose levels are low, such as when you haven't eaten in a while, the liver converts stored glycogen into glucose to keep your glucose level within a normal range.

In type 1 diabetes, there's no insulin to let glucose into the cells, so sugar builds up in your bloodstream, where it can cause life-threatening complications.

The cause of type 1 diabetes is different from the cause of the more familiar type 2 diabetes. In type 2 diabetes, the islet cells are still functioning, but the body becomes resistant to insulin or the pancreas doesn't produce enough insulin or both.

RISK FACTORS

Some known risk factors for type 1 diabetesinclude:

• Family history. Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition.
• Genetics. The presence of certain genes indicates an increased risk of developing type 1 diabetes.
• Geography. The incidence of type 1 diabetes tends to increase as you travel away from the equator. People living in Finland and Sardinia have the highest incidence of type 1 diabetes — about two to three times higher than rates in the United States and 400 times the incidence among people living in Venezuela.
• Age. Although type 1 diabetes can appear at any age, it appears at two noticeable peaks. The first peak occurs in children between 4 and 7 years old, and the second is in children between 10 and 14 years old.

Many other possible risk factors for type 1 diabetes have been investigated, though none have been proved. Some other possible risk factors include:

• Exposure to certain viruses, such as the Epstein-Barr virus, Coxsackie virus, mumps virus and cytomegalovirus
• Early exposure to cow's milk
• Low vitamin D levels
• Drinking water that contains nitrates
• Early (before 4 months) or late (after 7 months) introduction of cereal and gluten into a baby's diet
• Having a mother who had preeclampsiaduring pregnancy
• Being born with jaundice

COMPLICATIONS

Type 1 diabetes can affect major organs in your body, including heart, blood vessels, nerves, eyes and kidneys. Keeping your blood sugar level close to normal most of the time can dramatically reduce the risk of many complications.

Long-term complications of type 1 diabetesdevelop gradually, over decades. Good blood sugar management can help lower the risk of complications. Eventually, diabetescomplications may be disabling or even life-threatening.

• Heart and blood vessel disease. Diabetes dramatically increases your risk of various cardiovascular problems, including coronary artery disease with chest pain(angina), heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
• Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in the legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Poorly controlled blood sugar could cause you to eventually lose all sense of feeling in the affected limbs.
  Damage to the nerves that affect the gastrointestinal tract can cause problems with nausea, vomiting, diarrhea or constipation. For men, erectile dysfunctionmay be an issue.
• Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which requires dialysis or a kidney transplant.
• Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
• Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can become serious infections, which often heal poorly and may ultimately require toe, foot or leg amputation.
• Skin and mouth conditions. Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
• Pregnancy complications. High blood sugar levels can be dangerous for both the mother and the baby. The risk of miscarriage, stillbirth and birth defects are increased when diabetes isn't well-controlled. For the mother, diabetesincreases the risk of diabetic ketoacidosis, diabetic eye problems (retinopathy), pregnancy-induced high blood pressure and preeclampsia.

PREPARING FOR YOUR APPOINTMENT

If you suspect that you or your child might have type 1 diabetes, get evaluated immediately. A simple blood test can let your doctor know if you need further evaluation and treatment.

After you've received a diagnosis of type 1 diabetes, you'll need close medical follow-up until your blood sugar level stabilizes and your doctor determines the most effective type and doses of insulin for you. A doctor who specializes in hormonal disorders (endocrinologist) generally coordinates diabetescare. Your health care team will also likely include:

• Certified diabetes educator
• Dietitian
• Social worker
• Doctor who specializes in eye care (ophthalmologist)
• Doctor who specializes in foot health (podiatrist)

Once you've learned the basics of managing type 1 diabetes, your endocrinologist likely will recommend checkups every few months. A thorough yearly exam and regular foot and eye exams also are important — especially if you're having a hard time managing your diabetes, if you have high blood pressure or kidney disease, or if you're pregnant.

It's good to prepare for your appointments, which may include visits with several members of your health care team as well as your primary doctor. Here's some information to help you get ready for your appointment and to know what to expect from your doctor.

What you can do

• Write down any questions you have as they occur. Once you begin insulin treatment, the initial symptoms of diabetes should go away. However, you may have new issues that you need to address, such as recurring low blood sugar episodes or how to address high blood sugar after eating certain foods.
• Write down key personal information,including any major stresses or recent life changes. Many factors can affect your diabetes control, including stress.
• Make a list of all medications, vitamins and supplements you're taking.
• For your regular checkups, bring a book with your recorded glucose values or your meter to your appointments.
• Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your time with your doctor and the rest of your health care team. For type 1 diabetes, topics you want to clarify with your doctor, dietitian or diabetes educator include:

• The frequency and timing of blood glucose monitoring
• Insulin therapy — types of insulin used, timing of dosing, amount of dose
• Insulin administration — shots versus a pump
• Low blood sugar — how to recognize and treat
• High blood sugar — how to recognize and treat
• Ketones — testing and treatment
• Nutrition — types of food and their effect on blood sugar
• Carbohydrate counting
• Exercise — adjusting insulin and food intake for activity
• Medical management — how often to visit the doctor and other diabetes care specialists
• Sick day management

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

• How comfortable are you managing your diabetes?
• How frequent are your low blood sugar episodes?
• Are you aware of when your blood sugar is getting low?
• What's a typical day's diet like?
• Are you exercising? If so, how often?
• On average, how much insulin are you using daily?

What you can do in the meantime

If you're having trouble managing your blood sugar, or if you're not sure about what to do in a certain situation, don't hesitate to contact your doctor or diabetes educator in between appointments for advice and guidance.

TESTS AND DIAGNOSIS

To diagnose type 1 diabetes, your doctor will ask for a:

• Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes.

If the A1C test isn't available, or if you have certain conditions that can make the A1C test inaccurate — such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:

• Random blood sugar test. A blood sample will be taken at a random time. Blood sugar values are expressed in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). Regardless of when you last ate, a random blood sugar level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes, especially when coupled with any of the signs and symptoms of diabetes, such as frequent urination and extreme thirst.
• Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.

If you receive a diagnosis of diabetes, your doctor will also run blood tests to check for autoantibodies that are common in type 1 diabetes. These tests help your doctor distinguish between type 1 and type 2 diabetes. The presence of ketones — byproducts from the breakdown of fat — in your urine also suggests type 1 diabetes, rather than type 2.

After the diagnosis

Once you've been diagnosed with type 1 diabetes, you'll regularly visit your doctor to help you with your diabetes management. During these visits, the doctor will check your A1C levels. Your target A1C goal may vary depending on your age and various other factors, but the American Diabetes Association generally recommends that A1C levels be below 7 percent, which translates to an estimated average glucose of 154 mg/dL (8.5 mmol/L).

Compared with repeated daily blood sugar tests, A1C testing better indicates how well your diabetes treatment plan is working. An elevated A1C level may signal the need for a change in your insulin regimen, meal plan or both.

People who are meeting their A1C goals and who are confident in their diabetes management are generally seen twice a year by their endocrinologists. People who are having trouble reaching their A1C goals are usually seen every three months.

In addition to the A1C test, the doctor will also take blood and urine samples periodically to check your cholesterol levels, thyroid function, liver function and kidney function. The doctor will also examine you to assess your blood pressure, and he or she will check the sites where you test your blood sugar and deliver insulin.

TREATMENTS AND DRUGS

Treatment for type 1 diabetes includes:

• Taking insulin
• Carbohydrate counting
• Frequent blood sugar monitoring
• Eating healthy foods
• Exercising regularly and maintaining a healthy weight

The goal is to keep your blood sugar level as close to normal as possible to delay or prevent complications. Although there are exceptions, generally, the goal is to keep your daytime blood sugar levels before meals between 70 and 130 mg/dL (3.9 to 7.2 mmol/L) and your after meal numbers no higher than 180 mg/dL (10 mmol/L) two hours after eating.

Good diabetes management can be overwhelming, especially when you're first diagnosed. Take it one day at a time. And remember that you're not alone. You'll work closely with your diabetes treatment team to keep your blood sugar level as close to normal as possible.

Insulin and other medications

Anyone who has type 1 diabetes needs lifelong insulin therapy. After the diagnosis, there may be a "honeymoon" period, during which blood sugar is controlled with little or no insulin. However, this phase doesn't last.

Types of insulin are many and include:

• Rapid-acting insulin
• Long-acting insulin
• Intermediate options

Examples are regular insulin (Humulin 70/30, Novolin 70/30, others), insulin isophane (Humulin N, Novolin N), insulin glulisine (Apidra), insulin lispro (Humalog) and insulin aspart (Novolog). Long-acting insulins include glargine (Lantus) and detemir (Levemir).

Insulin administration

Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action. Therefore, it must be given either through injections or an insulin pump.

• Injections. You can use a fine needle and syringe or an insulin pen to inject insulin under your skin. Insulin pens look similar to ink pens, and are available in disposable or refillable varieties. Needles are available in a variety of sizes, so you can find one that's most comfortable for you.
  If you choose injections, you'll likely need a mixture of insulin types to use throughout the day and night. Multiple daily injections that include a combination of a long-acting insulin, such as Lantus or Levemir combined with a rapid-acting insulin, such as Apidra, Humolog or Novolog, more closely mimic the body's normal use of insulin than older insulin regimens that only required one or two shots a day. Three or more insulin injections a day has been shown to improve blood sugar levels.
• An insulin pump — a device about the size of a cellphone worn on the outside of your body. A tube connects a reservoir of insulin to a catheter that's inserted under the skin of your abdomen. This type of pump can be worn in a variety of ways, such as on your waistband, in your pocket, or with specially designed pump belts.
  There's also a wireless pump option. You wear a pod that houses the insulin reservoir on your body that has a tiny catheter that's inserted under your skin. The insulin pod can be worn on your abdomen, lower back, or on a leg or an arm. The programming is done with a wireless device that communicates with the pod.
  Pumps are programmed to dispense specific amounts of rapid-acting insulin automatically. This steady dose of insulin is known as your basal rate, and it replaces whatever long-acting insulin you were using.
  When you eat, you program the pump with the amount of carbohydrates you're eating and your current blood sugar, and it will give you what's called a "bolus" dose of insulin to cover your meal and to correct your blood sugar if it's elevated. Some research has found that in some people an insulin pump can be more effective at controlling blood sugar levels than injections. But many people achieve good blood sugar levels with injections, too.

Artificial pancreas

An emerging treatment approach, not yet available, is closed-loop insulin delivery, also known as the artificial pancreas. It links a continuous glucose monitor to an insulin pump. The device automatically delivers the correct amount of insulin when the monitor indicates the need for it. There are a number of different versions of the artificial pancreas, and clinical trials have had encouraging results. More research needs to be done before a fully functional artificial pancreas can receive regulatory approval.

The first step toward an artificial pancreas was approved in 2013. Combining a continuous glucose monitor with an insulin pump, this system stops insulin delivery when blood sugar levels drop too low. Studies on the device found that it could prevent low blood sugar levels overnight without significantly increasing morning blood sugar levels.

Other medications

Additional medications also may be prescribed for people with type 1 diabetes, such as:

• Pramlintide (Symlin). An injection of this medication before you eat can slow the movement of food through your stomach to curb the sharp increase in blood sugar that occurs after meals.
• High blood pressure medications. Your doctor may prescribe medications known as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), because these medications also can help keep your kidneys healthy. These medications are recommended for people with diabetesthat have blood pressures above 140/80 millimeters of mercury (mm Hg).
• Aspirin. Your doctor may recommend you take baby or regular aspirin daily to protect your heart.
• Cholesterol-lowering drugs. Your doctor may not wait until your cholesterol is elevated before he or she prescribes cholesterol-lowering agents known as statins. Cholesterol guidelines tend to be more aggressive for people with diabetesbecause of the elevated risk of heart disease. The American Diabetes Association recommends that low-density lipoprotein (LDL, or "bad") cholesterol be below 100 mg/dL (2.6 mmol/L), and if you already have heart disease, your LDL goal is below 70 mg/dL (1.8 mmol/L). Your high-density lipoprotein (HDL, or "good") cholesterol is recommended to be over 50 mg/dL (1.3 mmol/L) in women and over 40 mg/dL (1 mmol/L) in men. Triglycerides, another type of blood fat, are ideal when they're less than 150 mg/dL (1.7 mmol/L).

Blood sugar monitoring

Depending on what type of insulin therapy you select or require — twice daily injections, multiple daily injections or insulin pump — you may need to check and record your blood sugar level at least four times a day, and generally more often. The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and if you suspect you have low blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. Be sure to wash your hands before checking your blood sugar levels.

Even if you take insulin and eat on a rigid schedule, the amount of sugar in your blood can change unpredictably. With help from your diabetes treatment team, you'll learn how your blood sugar level changes in response to food, activity, illness, medications, stress, hormonal changes and alcohol.

Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels, and may be especially helpful for preventing hypoglycemia. Plus, when used by people older than 25, the devices have been shown to lower A1C.

Continuous glucose monitors attach to the body using a fine needle just under the skin that checks blood glucose level every few minutes. CGM isn't yet considered as accurate as standard blood sugar monitoring, so it's not considered a replacement method for keeping track of blood sugar, but an additional tool for some people.

Healthy eating and monitoring carbohydrates

Contrary to popular perception, there's no such thing as a diabetes diet. However, it's important to center your diet on nutritious, low-fat, high-fiber foods such as:

• Fruits
• Vegetables
• Whole grains

Your dietitian will recommend that you eat fewer animal products and refined carbohydrates, such as white bread and sweets. This healthy eating plan is recommended for everyone, even people without diabetes.

You'll need to learn how to count the amount of carbohydrates in the foods you eat so that you can give yourself enough insulin to properly metabolize those carbohydrates. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle.

Physical activity

Everyone needs regular aerobic exercise, and people who have type 1 diabetes are no exception. But get your doctor's OK to exercise first. Then choose activities you enjoy, such as walking, swimming and biking. Make physical activity part of your daily routine. Aim for at least 30 minutes of aerobic exercise most days of the week. The goal for children is at least an hour of activity a day. Flexibility and strength training exercises are important, too. If you haven't been active for a while, start slowly and build up gradually.

Remember that physical activity lowers blood sugar, often for long after you're done working out. If you begin a new activity, check your blood sugar level more often than usual until you know how that activity affects your blood sugar levels. You might need to adjust your meal plan or insulin doses to compensate for the increased activity. If you use an insulin pump, you can set a temporary basal rate to keep your blood sugar from dropping. Ask your doctor or diabeteseducator to show you how.

Situational concerns

Certain life circumstances call for different considerations.

• Driving. Hypoglycemia can occur at any time, even when you're driving. It's a good idea to check your blood sugar anytime you're getting behind the wheel. If it's below 70 mg/dL (3.9 mmol/L), have a snack and then retest again in 15 minutes to make sure it has risen to a safe level. Low blood sugar makes it hard to concentrate or to react as rapidly as you might need to when you're driving.
• Working. In the past, people with type 1 diabetes were often refused certain jobs because they had diabetes. Fortunately, advances in diabetes management and anti-discrimination laws have made such blanket bans largely a thing of the past.
  However, type 1 diabetes can pose some challenges in the workplace. For example, if you work in a job that involves driving or operating heavy machinery, hypoglycemiacould pose a serious risk to you and those around you. You may need to work with your doctor and your employer to ensure that certain accommodations are made, such as your having a quick break for blood sugar testing and fast access to food and drink anytime, so you can properly manage your diabetes and prevent low blood sugar levels. There are federal and state laws in place that require employers to make reasonable accommodations for people with diabetes.
• Being pregnant. Because the risk of pregnancy complications is higher for women with type 1 diabetes, experts recommend that women have a preconception evaluation and that A1C readings should be less than 7 percent before you attempt to get pregnant. Some drugs, such as high blood pressure medications and cholesterol-lowering medications, may need to be stopped before pregnancy.
  The risk of birth defects is increased for women with type 1 diabetes, particularly when diabetes is poorly controlled during the first six to eight weeks of pregnancy, so planning your pregnancy is key. Careful management of your diabetes during pregnancy can decrease your risk of complications.
• Being older. As long as you're still active and have normal cognitive abilities, your diabetes management goals will likely be the same as they were when you were younger. But for those who are frail, sick or have cognitive deficits, tight control of blood sugar may not be practical. If you're caring for a loved one with type 1 diabetes, ask his or her doctor what the new diabetes goals should be.

Investigational treatments

• Pancreas transplant. With a successful pancreas transplant, you would no longer need insulin. But pancreas transplants aren't always successful — and the procedure poses serious risks. You would need a lifetime of potent immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection and organ injury. Because the side effects can be more dangerous than the diabetes itself, pancreas transplants are generally reserved for those with very difficult-to-manage diabetes, or for people who also need a kidney transplant.
• Islet cell transplantation. Researchers are experimenting with islet cell transplantation, which provides new insulin-producing cells from a donor pancreas. Although this experimental procedure has met with problems in the past, new techniques and better drugs to prevent islet cell rejection may improve its future chance for success.
  Islet cell transplantation still requires the use of immune-suppressing medications. And just as it did with its own natural islet cells, the body often destroys transplanted islet cells, making the time off injected insulin short-lived. Additionally, a sufficient supply of islet cells isn't available for this treatment to become more widespread.
  Researchers are working on ways to expand the number of available islets, as well as find ways to protect islets from the immune system. Some ideas that may soon be in clinical trials include encapsulating the individual islet cells, or housing the islet cells in a device that would shield them from the immune cells, but still allow in oxygen and a blood supply.
• Stem cell transplant. In a 2007 study, a small number of people newly diagnosed with type 1 diabetes were able to stop using insulin for up to five years after being treated with stem cells made from their own blood. Although stem cell transplants — which involve shutting down the immune system and then building it up again — can be risky, the technique may one day provide an additional treatment option for type 1 diabetes.

Signs of trouble

Despite your best efforts, sometimes problems will arise. Certain short-term complications of type 1 diabetes, such as hypoglycemia, require immediate care.

Low blood sugar (hypoglycemia). This occurs when your blood sugar level drops below your target range. Ask your doctor what's considered a low blood sugar level for you. Blood sugar levels can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin.

Learn the symptoms of low blood sugar, and test your blood sugar if you think your blood sugar levels are dropping. When in doubt, always do a blood sugar test. Early signs and symptoms of low blood sugar include:

• Sweating
• Shakiness
• Hunger
• Dizziness or lightheadedness
• Rapid or irregular heart rate
• Fatigue
• Headaches
• Blurred vision
• Irritability

Later signs and symptoms of low blood sugar, which can sometimes be mistaken for alcohol intoxication in teens and adults include:

• Lethargy
• Confusion
• Behavior changes, sometimes dramatic
• Poor coordination
• Convulsions

If you develop hypoglycemia during the night, you might wake with sweat-soaked pajamas or a headache. Due to a natural rebound effect, nighttime hypoglycemia might cause an unusually high blood sugar reading first thing in the morning.

If you have a low blood sugar reading:

• Have 15 to 20 grams of a fast-acting carbohydrate, such as fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar. Foods with added fat, such as chocolate or ice cream, don't raise blood sugar as quickly because fat slows down the absorption of the sugar.
• Retest your blood sugar in about 15 minutes to make sure it's normal.
• If it's still low, have another 15 to 20 grams of carbohydrate from juice, candy, glucose tablets or other source of sugar, and retest in another 15 minutes.
• Repeat until you get a normal reading.
• Eat a mixed food source, such as peanut butter and crackers, to help stabilize your blood sugar.

If a blood glucose meter isn't readily available, treat for low blood sugar anyway if you have symptoms of hypoglycemia, and then test as soon as possible.

Always carry a source of fast-acting sugar with you. Left untreated, low blood sugar will cause you to lose consciousness. If this occurs, you may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. Be sure you always have a glucagon emergency kit available — at home, at work, when you're out — and make sure it hasn't expired.

Hypoglycemia unawareness. Some people may lose the ability to sense that their blood sugar levels are getting low, because they've developed a condition known as hypoglycemiaunawareness. With hypoglycemia unawareness, the body no longer reacts to a low blood sugar level with symptoms such as lightheadedness or headaches. The more you experience low blood sugars, the more likely you are to develop hypoglycemia unawareness. The good news is that if you can avoid having a hypoglycemic episode for several weeks, you may start to become more aware of impending lows.

High blood sugar (hyperglycemia). Your blood sugar can rise for many reasons, including eating too much, eating the wrong types of foods, not taking enough insulin or illness.

Watch for:

• Frequent urination
• Increased thirst
• Blurred vision
• Fatigue
• Irritability
• Hunger
• Difficulty concentrating

If you suspect hyperglycemia, check your blood sugar. You might need to adjust your meal plan or medications. If your blood sugar is higher than your target range, you'll likely need to administer a "correction" using an insulin shot or through an insulin pump. A correction is an additional dose of insulin that should bring your blood sugar back into the normal range. High blood sugar levels don't come down as quickly as they go up. Ask your doctor how long to wait until you recheck. If you use an insulin pump, random high blood sugar readings may mean you need to change the pump site.

If you have a blood sugar reading above 240 mg/dL (13.3 mmol/L), test for ketones using a urine test stick. Don't exercise if your blood sugar level is above 240 mg/dL or if ketones are present. If only a trace or small amounts of ketones are present, drink extra fluids to flush out the ketones.

If your blood sugar is persistently above 300 mg/dL (16.7 mmol/L), despite taking appropriate correction doses of insulin, call your doctor or seek emergency care.

Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat — producing toxic acids known as ketones. Diabetic ketoacidosis is a life-threatening emergency.

Signs and symptoms of this serious condition include:

• Nausea
• Vomiting
• Abdominal pain
• A sweet, fruity smell on your breath
• Weight loss

If you suspect ketoacidosis, check your urine for excess ketones with an over-the-counter ketones test kit. If you have large amounts of ketones in your urine, call your doctor right away or seek emergency care. Also, call your doctor if you have vomited more than once and you have ketones in your urine.

LIFESTYLE AND HOME REMEDIES

There's no known way to prevent type 1 diabetes. But researchers are working on preventing the disease or further destruction of the islet cells in people who are newly diagnosed. Ask your doctor if you might be eligible for one of these clinical trials, but carefully weigh the risks and benefits of any treatment available in a trial.

You can find more information on the types of research being done from TrialNet, a collaboration of diabetes researchers. TrialNet is also conducting a natural history study to check for diabetes genes in parents, children and siblings of people with type 1 diabetes.

COPING AND SUPPORT

Living with type 1 diabetes isn't easy. Diabetes management requires a lot of time and effort, especially in the beginning.

Diabetes can affect your emotions both directly and indirectly. Poorly controlled blood sugar can directly affect your emotions by causing behavior changes, such as irritability. Diabetes may also make you feel different from other people. And there may be times you feel resentful that you always have to incorporate diabetes planning in everything you do.

People with diabetes have an increased risk of depression and diabetes-related distress, which may be why many diabetes specialists regularly include a social worker or psychologist as part of their diabetes care team.

You may find that talking to other people with type 1 diabetes is helpful. Support groups are available both online and in person. Support groups aren't for everyone, but they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences or helpful information, such as where to find carbohydrate counts for your favorite takeout restaurant.

If you're interested in a support group, your doctor may be able to recommend one in your area. Or you can visit the websites of the American Diabetes Association (ADA) or the Juvenile Diabetes Research Foundation (JDRF) for support group information and to check out local activities for people with type 1 diabetes. You can also reach the ADA at 800-DIABETES (800-342-2383) or JDRF at 800-533-CURE (800-533-2873).

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