Diabetes Family Education. Understanding the types of diabetes, insulin, hyperglycemia and ketones by
the Diabetes Education Program at The Hospital for Sick Children. This video explains what diabetes is,
its symptoms and how it is managed. Please note, the images in this video are for illustrative purposes
only and do not constitute the hospital's endorsement of a specific brand or product.
Types of diabetes mellitus. There are two types of diabetes mellitus. Approximately 10 percent
of people with diabetes have type 1 diabetes and 90 percent have type 2 diabetes. Type 1 diabetes
used to be called juvenile or insulin-dependent diabetes because most cases occurred in children.
There is an autoimmune destruction of the insulin-producing cells in the pancreas,
meaning the body's immune system attacks the cells by mistake. The exact reason is unknown,
but it is believed to be a combination of genetic chance and environmental triggers. It results in
no insulin being produced. About 10 percent of people with diabetes have type 1 diabetes.
Type 2 diabetes was previously called adult-onset or non-insulin dependent diabetes.
The occurrence of this type of diabetes increases with age and is more common in certain populations.
It is often related to lifestyle factors that affect a person's weight. In type 2 diabetes, the insulin
does not work well and/or there is not enough insulin being made. Ninety percent of people with diabetes
have type 2 diabetes. Management of diabetes. Type 1 diabetes is managed by replacing insulin. Type 2
diabetes is managed by lifestyle management, oral pills, insulin and or other injectable medications.
The goal when managing diabetes is to achieve as close to normal blood sugar control as possible.
How the body manages blood sugar. Sugar is important for all the cells in our
body. The body must constantly work to keep blood sugar levels in balance.
The pancreas plays an important role in this.
The pancreas is a long flat gland that lies in the abdomen behind the stomach.
It makes enzymes that help digest food. It also makes hormones such as insulin and glucagon.
Hormones are chemical substances that act like messengers.
They travel to other parts of the body where they affect how cells and organs work.
The hormones insulin and glucagon are important for balancing blood sugar and are produced
by islets in the pancreas. The islets are made up of clusters of alpha and beta cells.
The alpha cells make the hormone glucagon.
Glucagon tells the liver to move glucose into the blood when blood sugar levels are decreasing.
The beta cells make the hormone insulin. Insulin helps to transport sugar into the cells.
In a person without diabetes, glucagon and insulin work together
to keep blood sugar levels balanced between 3.3 and 7.8 millimoles per liter.
Let's take a closer look at insulin.
Here is how it works. The carbohydrates in the foods we eat break down into sugar. This sugar,
or glucose, gets absorbed into the blood. Sugar in the blood is called the blood glucose level.
A gland called the pancreas releases insulin in response to the glucose. Insulin helps
the glucose enter the cells and the cells get energy from the glucose to fuel their activity.
How insulin works. Like a key, insulin opens the channels into the cell.
This allows sugar to enter the cell and be used for energy. If the body does not need the
energy right away, then insulin also allows the sugar to be stored in the liver for future use.
In type 1 diabetes, the insulin-producing beta cells in the pancreas are destroyed
and this results in no insulin being produced. The honeymoon phase. Usually at diagnosis
85 to 90 percent of insulin-producing beta cells have been destroyed.
Once treatment begins, the blood sugar levels come down and the remaining 10 to 15
of beta cells start to release insulin. This is called the honeymoon phase because less insulin is
needed to balance blood sugar levels. The honeymoon phase typically lasts from 6 to 12 months.
At the end of the honeymoon phase, all the remaining beta cells will be destroyed and
treatment will need to change again. Insulin doses will need to increase as blood sugar levels rise.
Why is insulin important? Imagine the body is like a neighborhood, where the
bloodstream represents a street. The street leads to houses that are made up of the cells of organs
such as the lungs, eyes, stomach and muscles. The sugar travels in the street to get to each organ
but the doors to the organ cells are locked. The key that opens the doors to the organ cells is
insulin. The insulin keys are released by the pancreas. The sugar goes through the doors and
the cells of the organs have the energy they need to work properly. When there is less sugar in the
street, the pancreas slows production of insulin. Type 1 diabetes is a condition where something
goes wrong with the production of the insulin in the pancreas. The sugar gets locked out and
cannot enter the cells since there is no insulin to open the cell doors. This results in sugar, or
glucose, building up in the blood causing high blood sugar levels or hyperglycemia.
High blood sugar (hyperglycemia) symptoms.
When blood sugar levels rise, the following symptoms of hyperglycemia may occur:
More peeing. This is usually the first symptom that the body is trying to bring down blood
sugar levels. The body tries to get rid of excess glucose by flushing it out in the urine.
Your child will be peeing more both in frequency and amount. They may start bedwetting at night,
will lose fluid and calories (as the body loses sugar along with fluid) and may lose weight.
More drinking. People often think that the increased drinking
is the cause of the frequent peeing, but it is actually the loss of fluids by peeing
that leads to your child's thirst. Even when your child is drinking more,
they are unable to keep up with the amount of fluid being lost and dehydration begins.
Your child will be more tired without being able to use glucose for energy
the cells start to become tired. Your child may not want to participate in activities
and they may sleep longer, be grumpy and moody and not be able to concentrate in school.
They may also have increased hunger because the cells are not being fed glucose.
What happens next: Ketone production. The body is always trying to balance blood sugar levels
and provide the cells with the glucose they need. If there is not enough insulin in the
body, then the doors to the organ cells cannot be opened. This results in a new set of events.
The body breaks down fat stores for energy. Ketones are a toxic waste product of this process.
Ketones are an acetone and when they build up in the blood, they are dangerous. They
can make the blood too acidic, cause nausea, vomiting and dehydration. Ketones can appear
when diabetes is diagnosed, during periods of illness, or when insulin injections are missed.
When to check for ketones. Check for ketones when your child's blood sugar is above 14
millimole per liter three times in a row, if they are having high blood sugar symptoms
or if they are sick. The presence of ketones tells us the body does not have any insulin working.
If you see ketones, contact your diabetes team immediately.
Diabetic ketoacidosis (DKA). DKA is the combination of hyperglycemia, or high blood sugar, acidosis,
which is excess acid in the body, and ketosis, where ketones are present in the blood or urine.
DKA is a medical emergency that must be dealt with right away. Call your diabetes team signs of DKA
include abdominal pain, headache, nausea, vomiting, lethargy, fruity odor to the breath, worsening
dehydration, fast laboured breathing confusion or coma. Treatment of DKA. DKA is reversed by giving
insulin. This will bring blood sugar back to the normal range, stop any vomiting or heavy breathing,
will help with rehydration through less peeing and a normal level of thirst and will improve energy.
Symptoms will start to improve first and then the blood sugar levels will come back into the
normal range. To prevent DKA from happening in the future, never stop giving insulin. Always have
non-expired ketone strips at home and check for ketones if you see consistent high readings
and/or hyperglycemia symptoms. Follow illness guidelines and do more blood glucose and ketone
monitoring during these times, and reach out to your diabetes team urgently if you see ketones.
Let's check your ketone knowledge. Your child is feeling well, and you give them their usual dose
of fast-acting insulin with their dinner. Since it was their sister's birthday, your child had
a piece of cake for dessert. When you check your child's blood sugar level before bed,
it is 15.1 millimole per liter. Should you now check for ketones? A - Yes it is a high reading,
B - Maybe. I will call the doctor on call to see what they think or C - no, this isn't necessary because
we know why the blood sugar level is high and your child is feeling well. If you guessed C, you
are correct. Your child's blood sugar reading was higher than normal because they ate cake.
It will get easier. Learning to care for a a child with type 1 diabetes can be stressful,
but with practice diabetes is a manageable condition. With time, you and your family
will learn how to handle the ups and downs of life with type 1 diabetes.
We are here to help. If you have questions or need further tips, please contact your diabetes team.