Type 1 Diabetes Mellitus
Diabetes Mellitus and its types
Diabetes Mellitus (DM) is a common and potentially serious, chronic metabolic condition which is characterized predominantly by hyperglycemia and other manifestations. Diabetes can be a devastating condition with long lasting hazardous consequences, since due to its chronicity it affects almost all the major organs of the body including the eyes, the kidneys, the nerves, heart and blood vessels (Jennifer, 1998). DM was classified into two major subtypes viz. Insulin Dependent Diabetes Mellitus (IDDM) and Non-Insulin Dependent Diabetes Mellitus (NIDDM) in 1979 by the National Diabetes Data Group and this classification was later endorsed by WHO (Jennifer, 1998). However, this classification had certain limitations and therefore the recent guidelines classify DM into four main groups viz. type 1 DM, type 2 DM, “other specific types” and gestational diabetes (Jennifer, 1998).
Type 1 DM (TID) is a condition that typically manifests itself in early childhood and is characterized by an autoimmune destruction of beta cells located in the pancreatic islets (Zipris, 2009). It is estimated that this subtype of DM afflicts almost one million individuals in the United States alone (Notkins, 2002). The development of Type 1 DM has been shown to be genetically determined and several HLA alleles have found to be implicated in the causation of this disorder (Redondo, Fain and Eisenbarth, n.d.). However, more recently, due to the rapid increase in the incidence of TID, it has been postulated that in addition to genetic susceptibility, environmental factors also contribute towards the development of TID (Zipris, 2009). These include factors such as diet, advanced maternal age and viral infections amongst others (Zipris, 2009). Moreover, the role of triggers such as certain proteins in cow’s milk has been postulated and is under research (Nucci, Horn, Becker, Virtanen, & Akerblom, n.d.). On the other hand, Type 2 DM, which affects more than 16 million people in the United States (Notkins 43545) is heterogeneous in nature in that it results from an interplay between genetics and environmental factors. Diabetes Mellitus has several potentially serious complications including blindness, amputations, and end-stage renal disease (Kantárová and Buc 255).
Epidemiology of Type 1 DM – The magnitude of the problem
As estimated by the International Diabetes Federation, in the year 2006 there were around 440,000 individuals aged less than 14 years in the world who were suffering from Type1 DM. Moreover, it has been projected that each year almost 70,000 new cases of TID develop (Zipris, 2009). The countries with the highest prevalence of DM include India, China, and the United States of America (Narayan, Gregg, Fagot-Campagna, Engelgau, & Vinicor, 2000).In the United States, DM is the fifth leading cause of death by disease and in the year 2002, it was estimated that around 132 billion dollars could be attributed to the direct and indirect expenditures of DM (Hogan, Dall, & Nikolov, 2003). This reflects the enormity of the problem faced and thus it becomes imperative to intervene, where possible to keep this ever-increasing incidence of TID under check.
Nutritional support required in the treatment and prevention of TID
Nutrition plays an important role in achieving and maintaining glycemic control in diabetic patients and to prevent diabetes-related complications. Proper nutritional planning and intake integrated with adequate exercise along with timely administration of insulin and is the cornerstone of diabetic management (GSEDNu, 2006). According to the American Diabetic Association (ADA) guidelines, the appropriate diabetic diet should be comprised predominantly of monounsaturated fatty acids (MUFAs) and carbohydrates which should provide almost 60-70% of the energy intake, almost 15-20% of the energy intake should be provided by proteins while saturated and polyunsaturated fatty acids should contribute minimally to the energy intake (~ 10% each) (GSEDNu, 2006). Therefore, it is imperative for the government officials and health care professionals to develop strategies to promote implementation of these nutritional guidelines. Moreover, nutritional education via media and professionals such as nutritional educators and dieticians should be made available for diabetic individuals to provide guidance regarding meal planning and lifestyle modifications (Paul, 2002).
Factors influencing the development and progression of TID – the impact of lactation, access to care, physical activity and media
In addition to nutritional support, there are several social and economic factors which play a role in the development and progression of TID. For instance, access to health care is an important factor which plays a role in the control of diabetes and prevention of its complications. Access to health care is determined by several factors such as one’s socioeconomic status, gender and ethnicity, the costs of management of DM and its complications and the availability of health care services (Walsh, Zgibor, Songer, Borch-Johnsen, & Orchard, 2005).
Similarly, media plays an important role in bringing about public awareness. Education regarding the disease and awareness about its presentations, management and potential complications can play an important role in the early detection and timely management of DM and its complications. This can be brought about by advertisements, media campaigns and health awareness and promotion programs.
The role of exercise and physical activity in the control of DM, the prevention of its complications and the maintenance of adequate glycemic control has long been established. The American Department of Health and Human Services recommends moderate physical activity for at least 30 min daily and an intense activity for at least 20 min thrice a week (Valerio, Spagnuolo, Lombardi, Spadaro, Siano, & Franzese, 2007). The implementation of these guidelines in the general population and in particular in diabetic individuals is important from a public health perspective. Exercise also has the added advantage of being a cost free intervention and provides a means of recreation. Thus, development of strategies which promote physical activities amongst diabetic individuals can prove to be beneficial from both clinical, social and economic perspectives.
Another important factor is breastfeeding, the role of which in the prevention of the occurrence of Type 1 DM is discussed below.
Breastfeeding and Type 1 DM
The concept and practice of breastfeeding has been present in all societies since times immemorial. The advantages of breastfeeding for the mother and the child, as well as the society at large, are numerous and renowned, with breastfed infants having lower morbidity and mortality rates as opposed to their formula-fed counterparts (Lawrence, 1989). Studies have shown that breast milk contains all the nutrients required by an infant in balanced proportions and also has the added advantage of conferring immunity to the baby in the first few months of life, by the virtue of containing maternal immunoglobulins. This leads to lower rates of infectious diseases such as diarrhea, meningitis, otitis media, pneumonia and upper respiratory tract infections amongst breastfed infants (Lawrence, 2000).
Research has proven that earlier initiation of weaning, the use of milk substitutes such as formula milk and the use of cow’s milk are factors which increase an individual’s risk of developing DM later in life (Sadauskait-Kuehne, Ludvigsson, Padaiga, Jainskien, & Samuelsson, 2004). This is especially true of individuals who are genetically predisposed to and have a family history of DM. It has been proven that there is a 40% increase in risk for the development of TID in individuals who are breastfed for less than 3 months and a 40% increase in the risk if cow’s milk is introduced before four months of age (Norris & Scott, 1996). A proposed mechanism for the predisposition to the development of TID in formula-fed infants is the accelerated weight gain and growth and higher intake of energy associated with formula milk consumption leading to increased insulin demand and thus the development of DM (Virtanen & Knip, 2003).
The protective effect of breast feeding on TID is thought to be brought about by a number of factors including the protection against infections which is conferred via breastfeeding, increased ?-cell proliferation, delayed exposure to foreign antigens and higher concentrations of insulin found in breast milk (Virtanen & Knip, 2003).
The important role of breastfeeding in the prevention of the occurrence of TID has several public health implications. Although a lot of programs and measures exist to improve the rates of breastfeeding initiation and maintenance, the rates of breastfeeding in the U.S population are still low and there exist some gaps and limitation in the policies regarding breastfeeding which need to be overcome. The most important intervention required is the increase in awareness and education regarding the importance and advantages of breastfeeding, with particular emphasis on its protective effects on diseases like DM. Other steps which can be taken to improve the existing breastfeeding rates include the continuation of the existing interventions with increased support from the government, the inclusion of breastfeeding care and services, provision of insurance coverage for lactation care and services and the development of legislations supporting exclusive breastfeeding for the first 6 months of life, with introduction of weaning after the first 6 months of life, amongst others (USBC, 2002).
The path ahead – Preventing TID and minimizing complications
The increasing incidence of diabetes and its related complications and the health burden it poses underscores the importance of the implementation of strategies for the prevention of DM and minimization of its complications. Recently the role of environmental factors in the development of Type 1 DM has been elucidated and thus control of environmental factors such as infections in early childhood, early initiation of formula milk and weaning and a sedentary lifestyle is imperative in the prevention of the development of TID. Moreover, complications can be minimized via adequate glycemic control which is brought about an integration of proper nutrition, administration of insulin and exercise. Moreover, regular medical checkups and follow-ups, monitoring of blood sugar levels, proper foot care, routine eye examination and screening for complications are also effective strategies in complication reduction (Narayan, Gregg, Fagot-Campagna, Engelgau, & Vinicor, 2000).
Another important concept in the effective control of TID in order to minimize complications is the promotion of self-management programs whereby individuals are educated regarding their disease and encouraged to play an active role in its management. Such programs have been shown to be effective in increased the level of awareness and knowledge and bringing about changes in dietary habits, weight, glucose monitoring frequency and glycemic control of diabetic individuals. Therefore, it is imperative to promote such programs to improve diabetes control rates and minimize complications (Shah & Booth, 2009).
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