Whenever Type One Diabetics get in a room together we always end up discussing how little our families, friends, colleagues and even 80% of medical professionals actually understand our condition. That’s because it’s difficult to understand and even harder to explain… But I’ll have a go at the basics.
What causes it?
No matter what might have been implied in the Daily Mail to the contrary, I did not cause my own diabetes. My Type One Diabetes did not come about because I was overweight, failed to exercise, over-indulged in puddings, ate too many carbohydrates or even because I had funny eating habits as a teenager.
Anyone who is surprised by this may be confusing it with Type Two Diabetes. Similar name, similar symptoms, different disease. Sure enough, an ‘unhealthy’ lifestyle might increase the liklihood of Type Two but before you blame any T2s for causing their own condition, you might like to consider that there are plenty of perfectly slim, active T2s out there who follow perfectly reasonable diets.
So back to type one: what DOES cause it exactly? Nobody knows. It is carried in the genes but might be triggered by a virus. Anyway, it is an autoimmune condition like rheumatoid arthritis: for whatever reason the white blood cells attack the insulin-producing cells in the pancreas and this stops them from producing insulin.
Why do you need insulin?
Medics and physiologists, skip a few paragraphs. I am going to grossly simplify this. For the rest of you I’ll keep it simple.
All the cells in your body need energy to do what they do. They get this from ‘burning’ glucose. Where do we get glucose? Whenever we eat carbohydrates they end up as glucose in our blood stream. So how do our cells get glucose out of the bloodstream to use it as fuel? Suffice to say that they ‘just do,’ but they need insulin to do this.
For those who like analogies, water gets transported round the house in the pipes. But we can’t get the water (glucose) out of the pipe (the bloodstream) in any room (cell), without a tap. Insulin is like a chemical ‘tap.’
In Type Ones – who don’t make insulin – the cells can’t get fuel from the bloodstream. They ‘feel hungry’. The glucose in the blood has nowhere to go and so the blood glucose concentration goes up…. And up….
….So given that we can manufacture insulin, we can overcome this problem?
Yes, but the problem is more complex than that. Let me explain….
The level of glucose in your blood needs to stay within certain limits (between 3 and 7 mmol/l).
If the blood glucose level went too low (‘Hypoglycaemia’) the brain cells wouldn’t have enough fuel to work. Brain cells need glucose to make energy all the time, or else they just can’t think straight. Having low blood glucose (we say ‘having a hypo‘) is very like being drunk: symptoms range from talking nonsense to being unsteady on your feet, confused and even blacking out.
If blood sugars go higher than seven (‘Hyperglycaemia’), then symptoms include producing a lot of urine all the time, causing a full bladder and an almost unquenchable thirst. Even SLIGHTLY HIGH blood sugars can cause various side effects over a long time including kidney disease, blindness and nerve damage.
Luckily…. the body of a ‘normal’ person (lets call him ‘Fred’) is very clever at avoiding both extremes and keeping his blood glucose at 3.5-7 mmol/l. Fred produces insulin all of the time and can alter the amount that he produces.
So: if Fred drinks a pint of pineapple juice and his blood glucose level looks to be going too high, his body circulates extra insulin. This helps his cells to ‘tap’ more glucose from the blood and stops the level of glucose in the blood from going up very much. The cells can use the glucose as fuel or, if they don’t need to fuel, they store it.
If on the other hand Fred has worked through his lunch-break and his blood glucose levels are dwindling, the body circulates much less insulin and tells the cells with ‘stored’ glucose to release some back into the blood.
Of course, Fred doesn’t think about any of this: his body just produces the an appropriate amount of insulin to keep his blood glucose steady, which it regulates all the time.
Diabetics on the other hand, have to think. They have to think about how many carbohydrates (ie how much glucose) they’re eating, so how much insulin to take. The ‘correct’ insulin dose varies with every meal. If we get it right, our blood sugars stay on an even keel. If we take too much our body doesn’t rescue us: we end up having a ‘hypo’ which can be embarrassing or even dangerous. If we take too little and have high blood glucose, we risk making ourselves seriously ill. Blindness, kidney dialysis and leg amputation (due to infected ulcers resulting from neuropathy) are amongst the common outcomes of long-term high blood sugars. The more controlled our diabetes, the less likely the complications.
Sometimes when we are making too little insulin, our body cells are so ‘hungry’ that they burn other fuels instead of glucose: fat and protein for instance. This gives them energy but produces toxic bi-products (ketones) that change the acidity of our blood, can send us into a coma or even cause death.
So how do Type One Diabetics keep their blood sugars stable?
By trial and error, I have worked out my insulin: carbohydrate ratio I.e. the amount of insulin I need to inject for every 10g carbohydrate I eat. So if I can work out how much carbohydrate I am eating, I know how much insulin I need.
Of course, Fred also has some insulin circulating all the time, so the cells can access energy even when he hasn’t just eaten. Diabetics also have a ‘background’ insulin dose worked out which they take regardless of their carbohydrate intake.
Unfortunately the margin for error is enormous: if you go running one day and sit behind a desk the next, the amount of energy ‘burned’ will vary enormously and so will the required background dose…. Fred’s body handles this for him and his insulin levels change when he exercises. Mine don’t. I have to alter my insulin dose by an unspecified amount to account for the extra activity.
A lot of people take insulin by injection, ‘fast-acting’ injections to cover their food and ‘long-acting’ injections to cover the background dose. I have a ‘pump,’ a little tube attached to a cannula going under my skin attached to a pump the size of a match-box. It puts the insulin in a tiny amount at a time. This gives me finer control of my dosages and allows me to alter the ‘background’ to account for my varying activity levels (a long-acting injection dose, once injected is injected and if you then decide to climb a hill, it can’t then be changed…..)
As I run an active and varied life, I try to account for this in my insulin dose but inevitably make a lot of mistakes. I always carry sweets to increase my blood sugar if it sinks too low (I hate sweets now: I associate them with feeling horrible) and can increase my insulin dose if my sugars are too high. I also carry a ‘glucometer’ (I prick my finger to make it bleed, put the blood into a tiny machine and read my blood glucose levels) to check how I’m doing.
So how does this affect a Type One’s everyday life?
Carrying things: We take insulin injections or a pump with us everywhere we go. My pump is literally attached to me all the time. We carry sweets or fizzy dinks in case of a hypo, the little kit to test our blood sugar (six times a day or more) and ideally, a notebook to write our levels down, which helps us to look back and see where we make mistakes.
Diet: Type Ones don’t have to follow a diet because we can eat the same things as a normal person so long as we inject (or pump) the right amount of insulin. If the food contains carbohydrate that moves into the blood stream quickly (e.g. sweets), I should inject a short while before I eat, to give the insulin time to get working. Some carbohydrate is absorped so slowly that we don’t inject for it.
So: the number of carbohydrates and the speed it will be absorped has to be considered every meal time and if we get it wrong, we will be hypo or hyperglycaemic afterwards. Guessing or calculating the carbs in every meal or snack before we eat it is something we come to be very good at.
Sport: I can do any activities that Fred can do and indeed there are some very hardcore diabetic climbers, hillwalkers, marathon-runners and sailors. In fact, you name it and there are diabetics doing it. Frustratingly, we have to think about our blood glucose levels all the time. Different activities affect our blood glucose levels differently and this is different for every person, so trial and error is the only way to work it out.
We have to be prepared for hypos. I tell the people around me in case I have a hypo that gets out of control and they need to know what to do, but this tends to make them nervous.
Driving: I have to check my blood sugar, by law, every time I drive a car and restest every two hours. Driving while hypoglycaemic is as dangerous as drunk driving.
Pregnancy: I have carried two healthy babies, but high blood sugars while pregnant are extremely dangerous for the baby so pregnant women are scanned regularly to check for abnormalities and advised to run their glucose very low. We also loose ‘hypo awareness’when pregnant i.e. become unaware and show no symptoms when we are having a hypo, which is dangerous because if we don’t know it’s happening, we don’t eat and put it right.
Hormonal changes affect blood glucose levels in unpredictable ways so keeping them between 3.5 and 7 becomes an even bigger challenge : because of the hypo awareness, it is necessary to test blood glucose a ridiculous amount. I was lucky: my babies emerged complication-free and I only had the paramedics out once.
I think it’s safe to say that very few diabetic women enjoy pregnancy (post-natal depression is much more common). I might have had more babies, but as a diabetic I have decided not to.
Stress: Our levels get higher when we are stressed. The stress hormone, cortisol, affects out glucose levels… Sure we can cope with stress. It just adds to the stress, is all….
A Final Word
Type One Diabetes is getting increasingly common and the chances are that you know someone with it. There is no such thing as ‘bad’ or ‘mild’ Type One Diabetes (you either make insulin or you don’t), but our levels of blood glucose control vary from person to person.
Given the variety of food and activities in a normal life, not to mention the effects of stress, pregnancy, illness, temperature, altitude, hormones and dozens of things researchers don’t know about yet, we can never be as good at controlling our glucose levels as the normal human body is. Hyperglycaemia and Hypoglycaemia will happen to all of us sometimes. The people around us are often completely unaware of it: most of us get ‘warning symptoms’ and know we are going to hypo so do something about it before it becomes a problem. Similarly, if our sugars go too high, we can correct them (but not too much of course, or we end up with a hypo). It’s a good idea to talk to us about what to do if we have a bad hypo, just in case, but despite sounding scary, as long as a hypo is treated properly, problems are rare.
In fact there is nothing about being a Type One to stop us from living life to the full. It’s just complicated, that’s all…..