A new consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes highlights the major considerations for health care providers when providing care for people with type 1 diabetes.
Published simultaneously in the journals Diabetes Care and Diabetologia, the statement comes almost exactly three years after a similar report on the management of type 2 diabetes in adults, as noted in a Medscape article on the latest guidelines. The statement authors noted that in many discussions of adults with diabetes, the focus is often on type 2 — reflecting the much larger number of adults with type 2 diabetes. But adults with type 1 have unique care needs, and these needs may be forgotten in the larger discussion of the burden of diabetes in adults — such as in discussions about how to reduce the burden of long-term diabetes complications.
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Optimal approaches for type 1 diabetes care in adults
The new report outlines four strategies to help adults with type 1 live longer and healthier — keeping glucose levels within target range, managing cardiovascular risk factors, reducing the psychosocial burden of living with diabetes, and promoting psychological health and well-being. It also describes an optimal approach for diagnosing diabetes correctly in adults, noting that many people who develop type 1 diabetes in adulthood are incorrectly diagnosed with type 2 diabetes. That’s in part because a common blood measurement of insulin secretion by the pancreas — called C-peptide — can still be fairly high around the time of the onset of diabetes symptoms in a person with type 1. And tests that look at the immune system’s attack on the pancreas — autoantibody tests — don’t fully predict or reflect type 1 diabetes.
Recommended diagnostic approach
The recommended approach for diagnosing diabetes in an adult when type 1 is suspected — and diabetes is already confirmed, based on previous tests — is to first test for autoantibodies. If these tests come back positive, then type 1 diabetes can be diagnosed and a treatment plan can be developed. If tests come back negative for autoantibodies, and the person is under 35 years old and has no signs of type 2 diabetes such as insulin resistance, then testing for C-peptide is recommended. If C-peptide levels are below 200 pmol/l, then type 1 diabetes is diagnosed. If C-peptide is higher than this, then it’s recommended to test for monogenic diabetes — a fairly uncommon form of diabetes caused by a single gene mutation. If there are signs of type 2 diabetes or the person is over age 35, then type 2 diabetes is considered likely. But if there is any uncertainty about diabetes type after going through this process, the recommendation is to first try a therapy other than insulin and see how blood glucose levels respond. In tis case, C-peptide levels should also be tested again in three years, since at that point they will be below 200 pmol/l in someone with type 1.
Addressing emotional distress
The report also notes that addressing emotional distress is an often-overlooked aspect of care for adults with type 1. Between 20% and 40% of adults with type 1 report this distress, and the risk for emotional difficulty is higher around the time of diagnosis as well as whenever diabetes complications develop. And in the reported 15% of adults with type 1 who develop depression, there is an elevated risk for higher blood glucose, diabetes complications, and death. Anxiety linked to diabetes-related fears like hypoglycemia (low blood glucose) is also common in adults with type 1, and eating disorders are more common in adults with type 1 than in the general population. In light of these concerns, the report recommends periodic mental health evaluations and having a clear process in place for referring people to mental health professionals if the need arises.
The statement also notes that while low- and very-low-carbohydrate eating approaches have grown in popularity among adults with type 1, and that these approaches have been shown to reduce A1C levels (a measure of long-term blood glucose control), it’s important to take these approaches within the context of other healthy-eating guidelines like limiting your intake of saturated fat. It’s also important to be vigilant about glucose monitoring when taking a low-carb approach, since this way of eating may result in a more gradual rise in blood glucose after meals that requires making insulin dose adjustments for up to three hours after eating, or for even longer in some people. It remains to be seen whether the short-term A1C benefits of low-carb eating approaches translate into a lower risk for long-term diabetes complications, the report emphasizes.