Healthy food is important for any person.If the diagnosis is “type 2 diabetes”, then the diet will have to pay maximum attention.Now you need to keep an eye on what you eat and how much.The main goals are weight and sugar control.Now, prohibited foods in type 2 diabetes are not supposed to appear on your table.What does it concern?
- Features of type 2 diabetes and the importance of healthy nutrition
- Food recommended to diabetics
- What foods are prohibited for use in type 2 diabetes
- How to prepare meals
- How to manage food
Features of diabetes2 types and importance of healthy nutrition
Type 2 disease is also called insulin-independent.In this case, the body does not need insulin injections.According to statistics, the number of people suffering from this type of disease is 4 times higher than the number of patients with type 1 diabetes.
In patients with type 2 pancreas still produces insulin.However, it is either not enough for full-fledged work, or the body loses its ability
to recognize and use it correctly.As a result of such problems, glucose does not enter the tissue cells.Instead, it accumulates directly in the blood of a person.Normal functioning of the body is disturbed.
Why does it sometimes happen that a person develops this disease?This question is difficult to give an unambiguous answer.Often, type 2 diabetes is diagnosed in several members of the same family.That is, there is a hereditary aspect.
If there are any cases of illness in your family, it is better to take preventive measures in advance.It is worth talking about with an endocrinologist.Periodically hand over the necessary tests to timely identify the problem.Also, the likelihood of disease increases with age.The risk gradually increases to 45 years, reaching a maximum after 65.
The following factors repeatedly increase the likelihood of developing type 2 diabetes mellitus:
- overweight, obesity
- frequent consumption of fatty food
- systematic drinking of alcohol
- sedentary imageLife
- elevated blood levels of triglycerides( ie fats)
Problems with weight and pressure are often the result of malnutrition and the abuse of high-calorieAnd products.Sedentary work and lack of physical activity lead to a slowdown and a disturbance in metabolism.All this does not have the best effect on the work and condition of the body.
As a result of negligent attitude to the diet, a person can get a lot of problems, including the development of diabetes.Choose healthy, natural products and give up harmful preferably in advance for preventive purposes.
Food recommended to diabetics
In diabetics, you need to choose foods in a certain way.Food should slow down the absorption of carbohydrates to prevent an increase in blood glucose levels.Selection of the menu is quite strict, because the further course of the disease depends on it.
If a person has type 2 diabetes, the list of prohibited foods will be quite impressive.However, without this, you can get a full-fledged diet rich in all the necessary vitamins and microelements.
The following food is recommended for use:
The most useful is the use in raw form.However, you can cook with the help of stewing, cooking or baking.We welcome the use of those vegetables that are able to slow the absorption of carbohydrates.These include: cabbage( raw, stewed, pickled), eggplants( stewed or boiled), sweet peppers, tomatoes, cucumbers, greens, onions and garlic.An excellent choice is eggplant caviar.Tasty and healthy.
Boiled carrots and beets are eaten in extremely limited quantities.In this form, these vegetables raise sugar very quickly.But raw carrots will do more for the benefit, but only in a minimal amount.
Of course, meat should be present in the diet of diabetics.Preference should be given to lean beef and chicken breast.Meat can easily be replaced with mushrooms.This product is also recommended for type 2 diabetes.Choose low-fat fish.
Bread can and should be included in the menu.Just choose rye or wheat-rye( wheat flour should be 1 or 2 varieties).
Cereals and pulses
Cereals are a source of vitamins and fiber.The daily portion is 8-10 tbsp.Spoons.You can buckwheat, pearl barley, oats, millet.Beans, lentils and peas are consumed in a boiled form and more restricted.The sides are followed by wheat and rice.
Dairy products, eggs
Ideal – low-fat dairy products, cottage cheese, milk.In small amounts of cheese( fat content up to 30%).For breakfast, a steam omelet or hard-boiled eggs is suitable.
It’s worth to be careful with fruits, many of them are pretty sweet.Eat grapefruits, lemons, cranberries.In small quantities – cherry, apples, tangerines, plums.
Best drinks: compotes without sugar, green tea, tomato juice, mineral water.Occasionally you can pamper yourself with black natural coffee.
The first dish is vegetable soups.Salads are seasoned with lemon juice or a small amount of olive oil.You can eat nuts a little bit.
The diabetics menu should consist mainly of low-calorie products.Food is prepared in a certain way.The best solution is steaming.You can use special sweeteners and sweeteners.They are natural and artificial.However, they do not need to overdo it.
What foods are prohibited for use in type 2 diabetes
If a person has pancreatic diseases( such as treating diabetes), you need to know clearly what you can not eat.Unsuitable food exacerbates the situation, provokes a jump in glucose levels.
Products prohibited for type 2 diabetes are the following.
Of course, the first thing on the “black” list is sugar and products containing it in excess.Should forget about: jam, marmalade, chocolate, ice cream, candy, halva, caramel, jam and other similar sweets.Not recommended and the addition of honey.
Glucose from these products instantly penetrates into the blood.If you really want a sweet, it is better to eat some fruit, baking from wholemeal flour or nuts.
Under the ban of baked bread products – white bread, loaf, rolls, biscuits, muffins, fast food items.
Fatty dishes are slower to digest than carbohydrates.But they are also able to significantly raise the blood sugar level to high marks.In addition, fatty foods contribute to weight gain and obesity.
Refuse should be from: sour cream, cream, mayonnaise, lard, fatty meat( lamb, pork, ducklings).Also exclude fatty cheeses, cottage cheese and sweet yogurt.Do not prepare soups for fatty meat and fish broths.
Semi-finished products in addition to a large amount of fat have a lot of harmful flavor enhancers, flavors and stabilizers.So do not look aside sausages, sausages, wieners, ready-made industrial patties and fish sticks.
Food saturated with trans fats will not benefit either diabetics or healthy people.These foods include: margarine, spreads( butter substitutes), confectionary fat, popcorn, French fries, burgers, hot dogs.
Unfortunately, with diabetes, many fruits and dried fruits are not recommended.Most of them have an impressive amount of fast carbohydrates.Do not include in the diet of bananas, grapes, melon, persimmons, raisins, figs, dates, dried apricots.
Do not eat some vegetables.It is better to refuse or to minimize the consumption of potatoes, beets and carrots.
Some drinks contain a huge amount of sugar and calories.This applies to sweet juices( especially packaged), alcoholic cocktails and soda.Tea should not be sweetened, or resort to the help of sugar substitutes.Juices are better to drink vegetable.Not recommended for use and beer.
Do not add spices and spices, pork, goose or chicken fat when cooking.You will also have to give up semolina and pasta.Do not use sharp or salty sauces.Marinades and pickles are forbidden.Do not be tempted to absorb pancakes, dumplings, pies or dumplings.
Food has a huge impact on people suffering from type 2 diabetes.Moreover, the fact of an increase in glucose in the blood, as consequences, is not so terrible.And these are strokes, heart attacks, vision loss, nervous system disorders.
Tips for preparing dishes
It is important for diabetics to monitor not only the amount of sugar consumed, but also the fat content of the dishes.It is necessary to strictly control your weight and not allow it to be typed.Caloric content of food is largely determined by the method of heat treatment.
Of course, with type 2 diabetes it is worth forgetting about frying in a lot of oil.Also it is worth remembering about portions, not making them too bulky.
Follow the following cooking rules:
- It should be noted that even for cooking vegetables are taken fresh.Do not take frozen and especially canned foods.
- Soups should be cooked on the second broth.After boiling, the first one must be drained and poured again with water.
- The best meat for soup is lean beef.You can boil the broth on the bones.
- Rassolniki, borscht or bean soup are included in the menu no more than once a week.
- In order for the dish to have a more attractive taste, the vegetables are pre-lightly fried in a small amount of butter.
The most useful for diabetics are fresh salads from raw vegetables.This is the most preferred method of preparation.Further on the usefulness is cooking in water and steam.Baking is done after cooking or as an independent method of processing.The least likely to resort to extinguishing.
Nutritionists have the following recommendations for organizing healthy eating for patients with type 2 diabetes:
- During the observance of therapeutic diets, fractional meals are shown.Do not become an exception eating diabetics.The daily ration is better divided into five parts.In this case, the portions should be small.
- Nutritionists are advised to always start a meal with a portion of fresh vegetable salad.This method will help slow the absorption of carbohydrates.
- Despite the low caloric content of meals, the total number of calories per day should be 2000-3000 kcal, provided that physical activity is observed.
- It is necessary to monitor the weight, trying to reduce it with excess.
- Be sure to use slow carbohydrates.Their sources are beans, cereals and leafy vegetables.
- It is necessary to distribute the food load correctly.The maximum amount of carbohydrate meal should be eaten for breakfast.The least calories will be the last meal of the day.
- Have to give up alcohol.In fact, they have a high caloric value and fuels appetite.
To prevent complications of the disease, you can drink broths of some herbs: St. John’s wort, chicory, flaxseed, nettle, blueberry, ginseng.Chicory is a perfect substitute for coffee.These plants do not lead to a breakdown in metabolism, and you can drink them instead of tea.They perfectly tone up the body and normalize the work of the nervous system.
Proper diabetic nutrition should become not just a temporary diet, but a way of life.Only in this case it is possible to count on an effective fight against the disease.In addition to properly selected products, it is worthwhile to monitor the amount of servings and total calorie content.Also an important aspect of treatment is weight loss and exercise.The combination of all elements gives the best result.
Type 2 diabetes mellitus imposes significant restrictions on the diet.In the case of this disease, health and well-being depend directly on proper nutrition.You should be aware of what products are prohibited to eat.
If the rules of eating and eating harmful foods are not respected, the course of the disease can be significantly complicated.It is better to compile an individual diet program with your doctor.
About that.What should be a diet for a diabetic patient – on the video:
Type 1 diabetes typically presents in childhood or early adult life. It can be distinguished from type 2 diabetes by the presence of immune and genetic markers of immune-mediated disease, and delayed diagnosis may result in diabetic ketoacidosis. Immunological changes appear many years before the clinical onset of diabetes, and the condition may respond to immunological intervention in its early stages. The incidence of type 1 diabetes is increasing rapidly worldwide, although it is most common in people of European descent. It is characterised by loss of most (but not necessarily all) of the insulin-secreting beta cells in the pancreas, and therefore requires insulin treatment. The risk of late complications of diabetes increases with cumulative exposure to elevated blood glucose levels, and treatment that returns circulating glucose to near-normal levels protects against these long-term complications. Prospects for future therapy include early prevention, islet or stem cell transplantation, regeneration of surviving beta cells and gene therapy.
The classic childhood form of type 1 diabetes affects 1 in 250–350 people in western countries by the age of 20 years. Presentation is typically acute in children, with a history of thirst, polyuria and weight loss extending over several weeks; a proportion (now well below 25% in most countries) will present with diabetic ketoacidosis. Occasional deaths still occur when diagnosis has been delayed, particularly in the very young.
Clinical presentation in adults is typically less acute, presentation with ketoacidosis is unusual, and the distinction between immune-mediated and non-immune-mediated diabetes may become blurred.
Replacement therapy with insulin sustains many millions of people but fails to restore normal glucose homeostasis. It therefore reduces but does not abolish the risk of late microvascular and macrovascular complications of diabetes. There has been steady improvement in the prognosis of childhood onset type 1 diabetes over recent decades, but results from specialised centres merely emphasise the extent of our failure elsewhere.
The benefits of optimised therapy have yet to reach the majority of affected children worldwide, and as a result some 20–30% will still die of or with diabetic nephropathy, and 50% will develop visual problems or require laser therapy to protect their vision.
Type 1 diabetes may present at any age, but most commonly does so between the age of 5 years and puberty. The diagnosis is suggested by onset in childhood or early adult life, slim build, acute or rapid onset with an early requirement for insulin, and presentation in diabetic ketoacidosis or with ketonuria.
Circulating autoantibodies directed against islet constituents are present in 90–95% of cases, and more than 80% of young patients carry HLA-DR3 and/or -DR4. The diagnosis is not always clear cut, and difficulties may arise in adolescents and young adults with features of type 1 diabetes in association with characteristics of type 2 diabetes such as obesity and insulin resistance; this has been referred to as ‘double diabetes’.
Older people tend to progress more slowly to dependence on insulin, and a slow-onset form known as latent autoimmune diabetes in adults (LADA) has been described. Neonatal diabetes should be considered in children who present under the age of 18 months, and maturity onset diabetes of the young (MODY) should be considered in those with a family history suggestive of dominant inheritance of early-onset diabetes.
Type 1 diabetes affects all ethnic groups, but has in the past been most common in those of European descent, with the world’s highest incidence in Finland, followed by Sardinia. The incidence of type 1 diabetes is rising rapidly, for unknown reasons, with an approximate doubling time in Europe of 20–25 years. Rapid increases have been reported in most other populations around the world. The increase in children under the age of 5 years has been particularly steep. Boys and girls are equally affected under the age of puberty, but men are more commonly affected in young adult life. In contrast to type 2 diabetes, individual lifestyle is not known to influence the risk of type 1 diabetes.
In western populations, each child has a 0.3–0.4% risk of developing diabetes by the age of 20 years; the risk rises 15-fold to 6% in siblings of an affected child. Lifetime risks may be about twice as high as this. Some 50% of the genetic risk of type 1 diabetes is conferred by genes in the human leucocyte antigen (HLA) region on chromosome 6. Many other genes (more than 40) make a minor contribution to type 1 diabetes, and a number of these influence different aspects of immune function. Their ability to predict the development of diabetes is, however, limited.
Type 1 diabetes is an immune-mediated disorder, and there is clinical overlap with a range of other autoimmune disorders. It is characterised by lymphocytic infiltration of the islets (insulitis), and by humoral and cell-mediated immunity directed against islet constituents.
These features have been intensively investigated in animal models of immune-mediated diabetes, most notably the non-obese diabetic (NOD) mouse. Immune intervention can delay beta cell loss in humans.
Type 1 diabetes progresses to severe insulin deficiency, and the consequences include loss of regulation of a range of metabolic processes. Unrestrained gluconeogenesis by the liver results in hyperglycaemia, which is associated with the breakdown of fat and muscle protein.
Accelerated catabolism explains the rapid weight loss characteristic of the condition, and leads to overproduction of ketones by the liver. These are first detected in the urine, but in greater excess can lead to diabetic ketoacidosis.
Insulin is the mainstay of management, but will not be fully effective without due attention to food intake and exercise. Insulin therapy aims to imitate natural secretion of insulin from the pancreas by supplying constant background levels of insulin in conjunction with rapid peaks when food is consumed. This is most commonly achieved by multiple injections of long- and short-acting insulin, but can be more reliably obtained by continuous subcutaneous insulin delivery via a portable external device.
Transplantation of pancreas or isolated islets can reverse insulin dependence for longer or shorter periods of time, but this approach to therapy is limited to a few selected cases by the risks of surgery and immunosuppression, limited availability of donor human pancreas, and cost.
Prospective studies from birth have shown that islet autoantibodies appear in the circulation within the first few years of life. Combinations of two or three antibody types carry a >50% risk of clinical diabetes within 5 years. Evidence of failing beta cell function first appears as loss of the first-phase insulin response to intravenous glucose, and the 5-year risk of diabetes rises to 90% in those who also have circulating antibodies. Oral glucose tolerance deteriorates in parallel, and mild hyperglycaemia may become apparent many months before clinical onset, even when the latter is apparently abrupt.
Prevention may be attempted at three levels: in the general childhood population (primary prevention); in those at increased genetic risk or with predictive markers of diabetes (secondary prevention); and in the attempt to rescue residual beta cell function in the newly diagnosed (tertiary prevention). To date, the role of environmental factors is not well understood, limiting the potential of primary prevention, but a trial of cow’s milk avoidance in infancy is under way. Secondary prevention trials have been undertaken with oral, inhaled or injected insulin, and with nicotinamide, but the results have been disappointing. Many tertiary prevention studies have been undertaken. Ciclosporin A is relatively effective but has unacceptable adverse effects; anti-CD3 antibodies appear more promising and are currently in clinical trials.
The prognosis of type 1 diabetes was transformed by the discovery of insulin, but was nonetheless limited by late complications of diabetes, including renal failure and heart disease. The Diabetes Control and Complications Trial (DCCT) clearly demonstrated that small vessel complications of diabetes affecting the eyes and kidneys could largely be prevented by near-normal glucose control, with a smaller but still useful reduction in coronary risk.
Despite encouraging reports from specialised centres, up to one-third of children are still likely to run the risk of kidney disease, although this can be prevented or delayed by therapies such as angiotensin-converting enzyme (ACE) inhibitors. The outlook for established retinopathy can be greatly improved by antihypertensives and skilled laser therapy.
Preservation and (if possible) restoration of beta cell function remains the Holy Grail of research into type 1 diabetes. Preservation may be achieved by the prevention strategies outlined above. Restoration could ideally be achieved by stem cell therapy, enabling the patient to generate new beta cells. Alternatively, functional beta cells can be supplied by whole pancreas or islet transplantation, but the low availability of donor human pancreas and the need for immunosuppression limit this approach to therapy. Finally, many attempts have been made to grow beta cells in culture and to devise ways in which these might be introduced into the body without provoking their immune destruction.
^ Some authorities define type 1 diabetes in terms of insulin deficiency, and then divide it into type 1A (immune-mediated) and type 1B (non-immune mediated).
What Is It?
Type 1 diabetes is a disease in which the body does not make enough insulin to control blood sugar levels. Type 1 diabetes was previously called insulin-dependent diabetes or juvenile diabetes.
During digestion, food is broken down into basic components. Carbohydrates are broken down into simple sugars, primarily glucose. Glucose is a critically important source of energy for the body’s cells. To provide energy to the cells, glucose needs to leave the blood and get inside the cells.
Insulin traveling in the blood signals the cells to take up glucose. Insulin is a hormone produced by the pancreas. When levels of glucose in the blood rise, like following a meal, the pancreas normally produces more insulin.
Type 1 diabetes occurs when some or all of the insulin-producing cells in the pancreas are destroyed. This leaves the patient with little or no insulin. Without insulin, sugar accumulates in the bloodstream rather than entering the cells. As a result, the body cannot use this glucose for energy. In addition, the high levels of glucose that remain in the blood cause excessive urination and dehydration, and damage tissues of the body.
Type 1 diabetes is an autoimmune disease. This means it begins when the body’s immune system attacks cells in the body. In type 1 diabetes, the immune system destroys insulin-producing cells (beta cells) in the pancreas.
Why the immune system attacks the beta cells remains a mystery. Some people are genetically predisposed to the disease. That does not mean they will necessarily get the disease. It just means that they are more likely to do so. Something in the environment, such as particular viral infections or something about the diet, may trigger this autoimmune disease in people with a genetic predisposition.
Type 1 diabetes is not caused by the amount of sugar in a person’s diet before the disease develops.
Type 1 diabetes is a chronic disease. It is diagnosed most commonly between ages 10 and 16. Type 1 diabetes equally affects males and females.
Symptoms usually come on suddenly and strongly. Typically the most prominent symptoms are excessive urination and extreme thirst. This is because the increased glucose in the blood causes the kidneys to create more urine than usual. Losing more fluid in the urine makes a person dehydrated. And dehydration leads to great thirst. Children may start to wet the bed again.
Weight loss, with no loss of appetite, also is common. The weight loss is due in part to dehydration. Water has weight. Imagine holding a gallon jug of water: it weighs about eight pounds. People with new, uncontrolled type 1 diabetes can lose a gallon of water from dehydration.
Other common symptoms are weakness, fatigue, confusion, nausea and vomiting. These symptoms can be caused both by dehydration and by a condition called ketoacidosis.
Ketoacidosis occurs because cells can’t use the glucose they need for energy. So the cells have to use something else. In response to low insulin levels, the liver produces an alternative fuel called ketones. Ketones are a kind of acid. When they build up in the blood, it’s called ketoacidosis. Ketoacidosis can cause heart problems and affect the nervous system. Within hours, it may put a person at risk of coma or death.
Even after it is diagnosed and treatment is begun, type 1 diabetes can affect all body systems. It is less likely to damage the body, and cause symptoms, if the blood sugar levels are well controlled by treatment.
The serious and potentially life-threatening complications that can occur with type 1 diabetes include:
Eye damage (retinopathy) — Tiny blood vessels of the retina (the back of the eye, the part that senses light) are damaged by high blood sugar. Damage to the vessels can stop the flow of blood to a part of the retina, or cause bleeding into the retina. Both events damage the ability of the retina to sense light. Diabetes also can cause a proliferation of new blood vessels that don’t effectively feed blood to the retina, but that do leak and bleed. Caught early, retinopathy can be stopped by tightly controlling blood sugar and laser therapy. If blood sugar remains high, retinopathy eventually causes blindness.
Nerve damage (neuropathy) — High blood sugar can damage nerves, leading to pain or numbness of the affected body part. Damage to nerves in the feet, legs and hands (peripheral neuropathy) is most common. Nerves that control body functions, such as digestion and urination, also can be damaged.
Foot problems — Sores and blisters commonly occur on the feet of people with diabetes. If peripheral neuropathy causes numbness, a sore may not be noticed. If it is not noticed, it can more easily become infected. Blood circulation can be poor, leading to slow healing. Left untreated, a simple sore can lead to gangrene. Amputation may be necessary.
Kidney disease (nephropathy) — High blood sugar can damage the kidneys. If blood sugar remains high, it can lead to kidney failure.
Heart and artery disease — People with type 1 diabetes are more likely to have heart disease, strokes and problems related to poor circulation.
Hypoglycemia — Low blood sugar (hypoglycemia) can result from treatments to lower blood sugar, either insulin injections or pills (see Treatment section, below). Hypoglycemia may occur if too much sugar-lowering medicine is taken or meals are skipped. Symptoms include:
Blurry or double vision
Hypoglycemia can lead to coma if it is not corrected by eating or drinking carbohydrates. Glucagon is a substance that makes the liver release glucose into the bloodstream. An injection of glucagon can also correct hypoglycemia.
Type 1 diabetes is diagnosed by a combination of symptoms, a person’s age and blood tests. The blood tests include tests for sugar levels and for other substances.
Fasting plasma glucose (FPG) test. Blood is taken in the morning after fasting overnight. Normally, blood sugar levels remain between 70 and 100 milligrams per deciliter (mg/dL). Diabetes is diagnosed if a fasting blood sugar level is 126 mg/dL or higher.
Oral glucose tolerance test (OGTT). Blood sugar is measured two hours after drinking 75 grams of glucose. Diabetes is diagnosed if the 2-hour blood sugar level is 200 mg/dL or higher.
Random blood glucose test. A blood sugar of 200 mg/dL or greater at any time of day combined with symptoms of diabetes is sufficient to make the diagnosis.
Hemoglobin A1C (glycohemoglobin). This test measures the average glucose level over the prior two to three months. Diabetes is diagnosed if the hemoglobin A1C level is 6.5% percent or higher.
Type 1 diabetes currently is a lifelong disease.
People with type 1 diabetes need regular checkups. They must carefully monitor their blood sugar levels every day. They must receive insulin treatment throughout life.
A small number of people can become exceptions to this rule. Some people with diabetes eventually require kidney transplants. A transplant of the pancreas, or of the insulin-producing cells from the pancreas (called “islets”), sometimes is performed at the same time. Since the new pancreas can make insulin, this can cure the diabetes.
On unusual occasions, when someone’s type 1 diabetes is very hard to control with available treatments, pancreas or islet transplantation may be performed even when kidney transplantation is not necessary. However, this approach is still experimental, and is not generally recommended.
Scientists have recently reported exciting but still experimental new ways for encouraging the pancreas to again start producing its own insulin-producing beta cells.
There is no proven way to prevent type 1 diabetes. Vitamin D deficiency, which is very common, may increase the risk of diabetes. However, correcting the deficiency has not been yet shown to prevent diabetes. Likewise, avoiding cow’s milk during infancy may possibly prevent type 1 diabetes in genetically susceptible infants. But there is no definite proof that this prevents the disease.
Treatment of type 1 diabetes requires daily insulin injections. The injected insulin makes up for the insulin that is not produced by the body. Most people with type 1 diabetes need two to four injections per day.
People with type 1 diabetes must properly regulate both their dietary intake and their dose of insulin. If a person takes too much insulin relative to their dietary intake, or if they forget to eat, they can develop dangerous hypoglycemia. If they take too little insulin, or eat too much, they can develop ketoacidosis.
In order to properly regulate their insulin intake, people with type 1 diabetes need to monitor their blood sugar levels several times per day. They do this by testing a sample of blood. They must prick their finger and place a small drop of blood on a test strip. The test strip is inserted into a device called a glucose monitor. An accurate reading of blood sugar levels is returned within seconds.
Newer glucose monitors have test strips that take the blood directly from the spot that was pricked. This process requires less blood. Other monitors allow blood to be taken from the forearm, thigh or the fleshy part of the hand. This can be less painful.
Some people use a syringe for injections. Other patients use semiautomatic injector pens that help to measure precise amounts of insulin.
An increasing number of patients use insulin pumps. Insulin pumps deliver a regulated dose of insulin through a needle implanted under the skin. The insulin pump is worn in a pack on the body. Some pumps include a sensor that constantly measures the level of blood sugar, and adjusts the dose of insulin accordingly. Whether devices with such sensors lead to improved health is not yet certain.
Fast-acting insulin may be taken as needed, depending on the amount of carbohydrates ingested. Your doctor or dietitian will help you determine the best insulin and diet schedule for you or your child.
A healthy diet and regular exercise are important for everyone—but particularly for people with diabetes. A healthy diet for someone with type 1 diabetes not only keeps the amount of glucose in the blood relatively constant. It also includes eating “good carbs” instead of “bad carbs”, “good fats” instead of “bad fats”.
In order to keep blood sugar levels at a normal and relatively constant level, a person with type 1 diabetes typically is advised to eat, exercise and take insulin at about the same times every day. Regular habits help to keep glucose levels within the normal range.
People with type 1 diabetes should get regular exercise. Exercise protects the health of the heart and blood vessels in people with diabetes, as in everyone. In addition, regular exercise helps to control blood sugar by causing muscles to use glucose and by keeping body weight down. Ask your doctor how much and when to exercise to best control your diabetes.
When To Call a Professional
Call your health care professional if you experience a sudden increase in thirst and urination. Unexplained weight loss always should be reported to a physician.
If you or your child has type 1 diabetes, see your doctor regularly to make sure that you are keeping good control of your blood sugar. You should also be checked regularly for early signs of complications such as heart disease, eye problems and skin infections.
Your doctor most likely will suggest that you also visit other specialists regularly. These may include a podiatrist to check your feet and an ophthalmologist to check your eyes for signs of diabetes complications.
People with type 1 diabetes generally adjust quickly to the time and attention that is needed to monitor blood sugar, treat the disease and maintain a normal lifestyle.
As time goes on, the risk of complications is substantial. But it can be reduced greatly if you strictly monitor and control your blood glucose levels.
American Diabetes Association
ATTN: National Call Center
1701 N. Beauregard St.
Alexandria, VA 22311
American Dietetic Association
120 South Riverside Plaza
Chicago, IL 60606-6995
National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892-3560
National Institute of Diabetes & Digestive & Kidney Disorders
Office of Communications and Public Liaison
Building 31, Room 9A04
31 Center Drive, MSC 2560
Bethesda, MD 20892-2560
Weight-Control Information Network
1 Win Way
Bethesda, MD 20892-3665
|T1D, insulin-dependent diabetes, juvenile diabetes|
|A blue circle, the symbol for diabetes.|
|Frequent urination, increased thirst, increased hunger, weight loss|
|Diabetic ketoacidosis, nonketotic hyperosmolar coma, poor healing, cardiovascular disease, damage to the eyes|
|Relatively short period of time|
|Not enough insulin|
|Family history, celiac disease|
|Blood sugar, A1C|
|Insulin, diabetic diet, exercise|
|~7.5% of diabetes cases|
Diabetes mellitus type 1 (also known as type 1 diabetes) is a form of diabetes mellitus in which not enough insulin is produced. This results in high blood sugar levels in the body. The classical symptoms are frequent urination, increased thirst, increased hunger, and weight loss. Additional symptoms may include blurry vision, feeling tired, and poor healing. Symptoms typically develop over a short period of time.
The cause of type 1 diabetes is unknown. However, it is believed to involve a combination of genetic and environmental factors. Risk factors include having a family member with the condition. The underlying mechanism involves an autoimmune destruction of the insulin-producing beta cells in the pancreas. Diabetes is diagnosed by testing the level of sugar or A1C in the blood. Type 1 diabetes can be distinguished from type 2 by testing for the presence of autoantibodies.
There is no known way to prevent type 1 diabetes. Treatment with insulin is required for survival.Insulin therapy is usually given by injection just under the skin but can also be delivered by an insulin pump. A diabetic diet and exercise are an important part of management. Untreated, diabetes can cause many complications. Complications of relatively rapid onset include diabetic ketoacidosis and nonketotic hyperosmolar coma. Long-term complications include heart disease, stroke, kidney failure, foot ulcers and damage to the eyes. Furthermore, complications may arise from low blood sugar caused by excessive dosing of insulin.
Type 1 diabetes makes up an estimated 5–10% of all diabetes cases. The number of people affected globally is unknown, although it is estimated that about 80,000 children develop the disease each year. Within the United States the number of people affected is estimated at one to three million. Rates of disease vary widely with approximately 1 new case per 100,000 per year in East Asia and Latin America and around 30 new cases per 100,000 per year in Scandinavia and Kuwait. It typically begins in children and young adults.
Video explanation of the various types of diabetes
Signs and symptoms
Overview of the most significant symptoms of diabetes
A posterior subcapsular
is an uncommon symptom in those with type 1 DM
The classical symptoms of type 1 diabetes include: polyuria (excessive urination), polydipsia (increased thirst), dry mouth, polyphagia (increased hunger), fatigue, and weight loss.
Many type 1 diabetics are diagnosed when they present with diabetic ketoacidosis. The signs and symptoms of diabetic ketoacidosis include dry skin, rapid deep breathing, drowsiness, increased thirst, frequent urination, abdominal pain, and vomiting.
About 12 percent of people with type 1 diabetes have clinical depression.
About 6 percent of people with type 1 diabetes have celiac disease, but in most cases there are no digestive symptoms or are mistakenly attributed to poor control of diabetes, gastroparesis or diabetic neuropathy. In most cases, celiac disease is diagnosed after onset of type 1 diabetes. The association of celiac disease with type 1 diabetes increases the risk of complications, such as retinopathy and mortality. This association can be explained by shared genetic factors, and inflammation or nutritional deficiencies caused by untreated celiac disease, even if type 1 diabetes is diagnosed first.
Some people with type 1 diabetes experience dramatic and recurrent swings in glucose levels, often occurring for no apparent reason; this is called “unstable diabetes” or “labile diabetes”, and sometimes “brittle diabetes”, although this term is no longer used. The results of such swings can be irregular and unpredictable hyperglycemias, sometimes involving ketoacidosis, and sometimes serious hypoglycemias. Brittle diabetes occurs no more frequently than in 1% to 2% of diabetics.
The cause of type 1 diabetes is unknown. A number of explanatory theories have been put forward, and the cause may be one or more of the following: genetic susceptibility, a diabetogenic trigger, and exposure to an antigen.
Type 1 diabetes is a disease that involves many genes. The risk of a child developing type 1 diabetes is about 5% if the father has it, about 8% if a sibling has it, and about 3% if the mother has it. If one identical twin is affected there is about a 50% chance the other will also be affected. Some studies of heritability has estimated it at 80 to 86%.
More than 50 genes are associated with type 1 diabetes. Depending on locus or combination of loci, they can be dominant, recessive, or somewhere in between. The strongest gene, IDDM1, is located in the MHC Class II region on chromosome 6, at staining region 6p21. Certain variants of this gene increase the risk for decreased histocompatibility characteristic of type 1. Such variants include DRB1 0401, DRB1 0402, DRB1 0405, DQA 0301, DQB1 0302 and DQB1 0201, which are common in North Americans of European ancestry and in Europeans. Some variants also appear to be protective.
Environmental factors can influence expression of type 1. For identical twins, when one twin has type 1 diabetes, the other twin only has it 30%–50% of the time. Thus for 50%–70% of identical twins where one has the disease, the other will not, despite having exactly the same genome; this suggests that environmental factors, in addition to genetic factors, can influence the disease’s prevalence. Other indications of environmental influence include the presence of a 10-fold difference in occurrence among Caucasians living in different areas of Europe, and that people tend to acquire the rate of disease of their particular destination country. Research is ongoing into the role of possible environmental triggers and protective factors, including dietary agents such as proteins in gluten, time of weaning, gut microbiota and viral infections.
Chemicals and drugs
Some chemicals and drugs selectively destroy pancreatic cells. Pyrinuron (Vacor), a rodenticide introduced in the United States in 1976, selectively destroys pancreatic beta cells, resulting in type 1 diabetes after accidental poisoning. Pyrinuron was withdrawn from the U.S. market in 1979 and it is not approved by the Environmental Protection Agency for use in the U.S.Streptozotocin (Zanosar), an antineoplastic agent, is selectively toxic to the beta cells of the pancreatic islets. It is used in research for inducing type 1 diabetes on rodents and for treating metastatic cancer of the pancreatic islet cells in patients whose cancer cannot be removed by surgery. Other pancreatic problems, including trauma, pancreatitis, or tumors (either malignant or benign) can also lead to loss of insulin production.
The pathophysiology in diabetes type 1 is a destruction of beta cells in the pancreas, regardless of which risk factors or causative entities have been present.
Individual risk factors can have separate pathophysiological processes to, in turn, cause this beta cell destruction. Still, a process that appears to be common to most risk factors is an autoimmune response towards beta cells, involving an expansion of autoreactive CD4+ T helper cells and CD8+ T cells, autoantibody-producing B cells and activation of the innate immune system.
After starting treatment with insulin a person’s own insulin levels may temporarily improve. This is believed to be due to altered immunity and is known as the “honeymoon phase”.
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:
- Fasting plasma glucose level at or above 7.0 mmol/L (126 mg/dL).
- Plasma glucose at or above 11.1 mmol/L (200 mg/dL) two hours after a 75 g oral glucose load as in a glucose tolerance test.
- Symptoms of hyperglycemia and casual plasma glucose at or above 11.1 mmol/L (200 mg/dL).
- Glycated hemoglobin (hemoglobin A1C) at or above 48 mmol/mol (≥ 6.5 DCCT %). (This criterion was recommended by the American Diabetes Association in 2010, although it has yet to be adopted by the WHO.)
About a quarter of people with new type 1 diabetes have developed some degree of diabetic ketoacidosis (a type of metabolic acidosis which is caused by high concentrations of ketone bodies, formed by the breakdown of fatty acids and the deamination of amino acids) by the time the diabetes is recognized. The diagnosis of other types of diabetes is usually made in other ways. These include ordinary health screening, detection of hyperglycemia during other medical investigations, and secondary symptoms such as vision changes or unexplained fatigue. Diabetes is often detected when a person suffers a problem that may be caused by diabetes, such as a heart attack, stroke, neuropathy, poor wound healing or a foot ulcer, certain eye problems, certain fungal infections, or delivering a baby with macrosomia or hypoglycemia (low blood sugar).
A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat of any of the above-listed methods on a different day. Most physicians prefer to measure a fasting glucose level because of the ease of measurement and the considerable time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test. According to the current definition, two fasting glucose measurements above 126 mg/dL (7.0 mmol/L) is considered diagnostic for diabetes mellitus.
In type 1, pancreatic beta cells in the islets of Langerhans are destroyed, decreasing endogenous insulin production. This distinguishes type 1’s origin from type 2. Type 2 diabetes is characterized by insulin resistance, while type 1 diabetes is characterized by insulin deficiency, generally without insulin resistance. Another hallmark of type 1 diabetes is islet autoreactivity, which is generally measured by the presence of autoantibodies directed towards the beta cells.
The appearance of diabetes-related autoantibodies has been shown to be able to predict the appearance of diabetes type 1 before any hyperglycemia arises, the main ones being islet cell autoantibodies, insulin autoantibodies, autoantibodies targeting the 65-kDa isoform of glutamic acid decarboxylase (GAD), autoantibodies targeting the phosphatase-related IA-2 molecule, and zinc transporter autoantibodies (ZnT8). By definition, the diagnosis of diabetes type 1 can be made first at the appearance of clinical symptoms and/or signs, but the emergence of autoantibodies may itself be termed “latent autoimmune diabetes”. Not everyone with autoantibodies progresses to diabetes type 1, but the risk increases with the number of antibody types, with three to four antibody types giving a risk of progressing to diabetes type 1 of 60%–100%. The time interval from emergence of autoantibodies to clinically diagnosable diabetes can be a few months in infants and young children, but in some people it may take years – in some cases more than 10 years. Islet cell autoantibodies are detected by conventional immunofluorescence, while the rest are measured with specific radiobinding assays.
Type 1 diabetes is not currently preventable. Some researchers believe it might be prevented at the latent autoimmune stage, before it starts destroying beta cells.
Cyclosporine A, an immunosuppressive agent, has apparently halted destruction of beta cells (on the basis of reduced insulin usage), but its kidney toxicity and other side effects make it highly inappropriate for long-term use.
Anti-CD3 antibodies, including teplizumab and otelixizumab, had suggested evidence of preserving insulin production (as evidenced by sustained C-peptide production) in newly diagnosed type 1 diabetes patients. A probable mechanism of this effect was believed to be preservation of regulatory T cells that suppress activation of the immune system and thereby maintain immune system homeostasis and tolerance to self-antigens. The duration of the effect is still unknown, however. In 2011, Phase III studies with otelixizumab and teplizumab both failed to show clinical efficacy, potentially due to an insufficient dosing schedule.
An anti-CD20 antibody, rituximab, inhibits B cells and has been shown to provoke C-peptide responses three months after diagnosis of type 1 diabetes, but long-term effects of this have not been reported.
Some research has suggested breastfeeding decreases the risk in later life and early introduction of gluten-containing cereals in the diet increases the risk of developing islet cell autoantibodies; various other nutritional risk factors are being studied, but no firm evidence has been found. Giving children 2000 IU of vitamin D daily during their first year of life is associated with reduced risk of type 1 diabetes, though the causal relationship is obscure.
Children with antibodies to beta cell proteins (i.e. at early stages of an immune reaction to them) but no overt diabetes, and treated with niacinamide (vitamin B3), had less than half the diabetes onset incidence in a seven-year time span than did the general population, and an even lower incidence relative to those with antibodies as above, but who received no niacinamide.
People with type 1 diabetes and undiagnosed celiac disease have worse glycaemic control and a higher prevalence of nephropathy and retinopathy. Gluten-free diet, when performed strictly, improves diabetes symptoms and appears to have a protective effect against developing long-term complications. Nevertheless, dietary management of both these diseases is challenging and these patients have poor compliance of the diet.
Diabetes is often managed by a number of health care providers including a dietitian, nurse educator, eye doctor, endocrinologist, and podiatrist.
A low-carbohydrate diet, exercise, and medications is useful in type 1 DM. There are camps for children to teach them how and when to use or monitor their insulin without parental help. As psychological stress may have a negative effect on diabetes, a number of measures have been recommended including: exercising, taking up a new hobby, or joining a charity among others.
Injections of insulin—either via subcutaneous injection or insulin pump— are necessary for those living with type 1 diabetes because it cannot be treated by diet and exercise alone. Insulin dosage is adjusted taking into account food intake, blood glucose levels and physical activity.
Untreated type 1 diabetes can commonly lead to diabetic ketoacidosis which is a diabetic coma which can be fatal if untreated. Diabetic ketoacidosis can cause cerebral edema (accumulation of liquid in the brain). This is a life-threatening issue and children are at a higher risk for cerebral edema than adults, causing ketoacidosis to be the most common cause of death in pediatric diabetes.
Treatment of diabetes focuses on lowering blood sugar or glucose (BG) to the near normal range, approximately 80–140 mg/dl (4.4–7.8 mmol/L). The ultimate goal of normalizing BG is to avoid long-term complications that affect the nervous system (e.g. peripheral neuropathy leading to pain and/or loss of feeling in the extremities), and the cardiovascular system (e.g. heart attacks, vision loss). This level of control over a prolonged period of time can be varied by a target HbA1c level of less than 7.5%.
There are four main types of insulin: rapid acting insulin, short-acting insulin, intermediate-acting insulin, and long-acting insulin. The rapid acting insulin is used as a bolus dosage. The action onsets in 15 minutes with peak actions in 30 to 90 minutes. Short acting insulin action onsets within 30 minutes with the peak action around 2 to 4 hours. Intermediate acting insulin action onsets within one to two hours with peak action of four to 10 hours. Long-acting insulin is usually given once per day. The action onset is roughly 1 to 2 hours with a sustained action of up to 24 hours. Some insulins are biosynthetic products produced using genetic recombination techniques; formerly, cattle or pig insulins were used, and even sometimes insulin from fish.
People with type 1 diabetes always need to use insulin, but treatment can lead to low BG (hypoglycemia), i.e. BG less than 70 mg/dl (3.9 mmol/l). Hypoglycemia is a very common occurrence in people with diabetes, usually the result of a mismatch in the balance among insulin, food and physical activity. Symptoms include excess sweating, excessive hunger, fainting, fatigue, lightheadedness and shakiness. Mild cases are self-treated by eating or drinking something high in sugar. Severe cases can lead to unconsciousness and are treated with intravenous glucose or injections with glucagon. Continuous glucose monitors can alert patients to the presence of dangerously high or low blood sugar levels, but technical issues have limited the effect these devices have had on clinical practice.
As of 2016 an artificial pancreas looks promising with safety issues still being studied.
In some cases, a pancreas transplant can restore proper glucose regulation. However, the surgery and accompanying immunosuppression required may be more dangerous than continued insulin replacement therapy, so is generally only used with or some time after a kidney transplant. One reason for this is that introducing a new kidney requires taking immunosuppressive drugs such as cyclosporine, which allows the introduction of a new pancreas to a person with diabetes without any additional immunosuppressive therapy. However, pancreas transplants alone may be beneficial in people with extremely labile type 1 diabetes mellitus.
Islet cell transplantation
Islet cell transplantation may be an option for some people with type 1 diabetes that are not well controlled with insulin. Difficulties include finding donors that are a compatible, getting the new islets to survive, and the side effects from the medications used to prevent rejection. Success rates, defined as not needing insulin at 3 years follow the procedure occurred in 44% in on registry from 2010.
Complications of poorly managed type 1 diabetes mellitus may include cardiovascular disease, diabetic neuropathy, and diabetic retinopathy, among others. However, cardiovascular disease as well as neuropathy may have an autoimmune basis, as well. Women with type 1 DM have a 40% higher risk of death as compared to men with type 1 DM. The life expectancy of an individual with type 1 diabetes is 11 years less for men and 13 years less for women.
Urinary tract infection
People with diabetes show an increased rate of urinary tract infection. The reason is bladder dysfunction that is more common in diabetics than in non-diabetics due to diabetic nephropathy. When present, nephropathy can cause a decrease in bladder sensation, which in turn, can cause increased residual urine, a risk factor for urinary tract infections.
Sexual dysfunction in diabetics is often a result of physical factors such as nerve damage and/or poor circulation, and psychological factors such as stress and/or depression caused by the demands of the disease.
The most common sexual issues in diabetic males are problems with erections and ejaculation: “With diabetes, blood vessels supplying the penis’s erectile tissue can get hard and narrow, preventing the adequate blood supply needed for a firm erection. The nerve damage caused by poor blood glucose control can also cause ejaculate to go into the bladder instead of through the penis during ejaculation, called retrograde ejaculation. When this happens, semen leaves the body in the urine.” Another cause for erectile dysfunction are the reactive oxygen species created as a result of the disease. Antioxidants can be used to help combat this.
While there is less material on the correlation between diabetes and female sexual dysfunction than male sexual dysfunction, studies have shown there to be a significant prevalence of sexual problems in diabetic women. Common problems include reduced sensation in the genitals, dryness, difficulty/inability to orgasm, pain during sex, and decreased libido. In some cases diabetes has been shown to decrease oestrogen levels in females, which can affect vaginal lubrication.
Oral contraceptives can be taken by diabetics. Sometimes, contraceptive pills can cause a blood sugar imbalance, but this usually can be corrected by a dosage change. As with any medication, side effects should be taken into account and monitored to prevent serious complications with diabetes.
Women with type 1 diabetes show a higher than normal rate of polycystic ovarian syndrome (PCOS). The reason may be that the ovaries are exposed to high insulin concentrations since women with type 1 diabetes can have frequent hyperglycemia.
Type 1 diabetes makes up an estimated 5–10% of all diabetes cases or 11–22 million worldwide. In 2006 it affected 440,000 children under 14 years of age and was the primary cause of diabetes in those less than 10 years of age. The incidence of type 1 diabetes has been increasing by about 3% per year.
Rates vary widely by country. In Finland, the incidence is a high of 57 per 100,000 per year, in Japan and China a low of 1 to 3 per 100,000 per year, and in Northern Europe and the U.S., an intermediate of 8 to 17 per 100,000 per year.
In the United States, type 1 diabetes affected about 208,000 youths under the age of 20 in 2015. Over 18,000 youths are diagnosed with Type 1 diabetes every year. Every year about 234,051 Americans die due to diabetes (type I or II) or diabetes-related complications, with 69,071 having it as the primary cause of death.
Type 1 diabetes was described as an autoimmune disease in the 1970s, based on observations that autoantibodies against islets were discovered in diabetics with other autoimmune deficiencies. It was also shown in the 1980s that immunosuppressive therapies could slow disease progression, further supporting the idea that type 1 diabetes is an autoimmune disorder. The name juvenile diabetes was used earlier as it often first is diagnosed in childhood.
In Australia, approximately one million Australians have been diagnosed with type 1 diabetes and Australia ranks 7th-highest in the world with children under 14 years of age. Between 2000 and 2013, 31,895 new cases were established, with 2,323 in 2013, a rate of 10–13 cases per 100,00 people each year. Aboriginals and Torres Strait Islander people are less affected.
Society and culture
The disease was estimated to cause $10.5 billion in annual medical costs ($875 per month per diabetic) and an additional $4.4 billion in indirect costs ($366 per month per person with diabetes) in the U.S. In the United States $245 billion every year is attributed to diabetes. Individuals diagnosed with diabetes have 2.3 times the health care costs as individuals who do not have diabetes. One in 10 health care dollars are spent on individuals with diabetes.
Funding for research into type 1 diabetes originates from government, industry (e.g., pharmaceutical companies), and charitable organizations. Government funding in the United States is distributed via the National Institute of Health, and in the UK via the National Institute for Health Research or the Medical Research Council. JDRF, founded by parents of children with type 1 diabetes, is the world’s largest provider of charity based funding for type 1 diabetes research. Other charities include the American Diabetes Association, Diabetes UK, Diabetes Research and Wellness Foundation,Diabetes Australia, the Canadian Diabetes Association.
A number of approaches have been explored to understand causes and provide treatments for type 1.
Data suggest that gliadin (a protein present in gluten) might play a role in the development of type 1 diabetes, but the mechanism is not fully understood.Increased intestinal permeability caused by gluten and the subsequent loss of intestinal barrier function, which allows the passage of pro-inflammatory substances into the blood, may induce the autoimmune response in genetically predisposed individuals to type 1 diabetes. There is evidence from experiments conducted in animal models that removal of gluten from the diet may prevent the onset type 1 diabetes but there has been conflicting research in humans.
One theory proposes that type 1 diabetes is a virus-triggered autoimmune response in which the immune system attacks virus-infected cells along with the beta cells in the pancreas. Several viruses have been implicated, including enteroviruses (especially coxsackievirus B), cytomegalovirus, Epstein–Barr virus, mumps virus, rubella virus and rotavirus, but to date there is no stringent evidence to support this hypothesis in humans. A 2011 systematic review and meta-analysis showed an association between enterovirus infections and type 1 diabetes, but other studies have shown that, rather than triggering an autoimmune process, enterovirus infections, as coxsackievirus B, could protect against onset and development of type 1 diabetes.
Pluripotent stem cells can be used to generate beta cells but previously these cells did not function as well as normal beta cells. In 2014 more mature beta cells were produced which released insulin in response to blood sugar when transplanted into mice. Before these techniques can be used in humans more evidence of safety and effectiveness is needed.
Vaccines to treat or prevent Type 1 diabetes are designed to induce immune tolerance to insulin or pancreatic beta cells. While Phase II clinical trials of a vaccine containing alum and recombinant GAD65, an autoantigen involved in type 1 diabetes, were promising, as of 2014 Phase III had failed. As of 2014, other approaches, such as a DNA vaccine encoding proinsulin and a peptide fragment of insulin, were in early clinical development.
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- Diabetes mellitus type 1 at Curlie (based on DMOZ)
- Kids and Teens: Type 1 Diabetes at Curlie (based on DMOZ)
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) – Diabetes in America Textbook (PDFs)
- IDF Diabetes Atlas
- type 1 Diabetes at the American Diabetes Association
- Chamberlain, James J.; Kalyani, Rita Rastogi; Leal, Sandra; Rhinehart, Andrew S.; Shubrook, Jay H.; Skolnik, Neil; Herman, William H. (12 September 2017). “Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes”. Annals of Internal Medicine. doi:10.7326/M17-1259.