The full name of a chronic condition known to its practitioners as 'IDDM', 'Type 1' diabetes, or something similar to 'that injection thing you do'. It is distinct from the more common diabetic condition known as 'Non-Insulin Dependent Diabetes Mellitus¹'.

This illness, affecting a far greater proportion, around 90% of people who can call themselves 'diabetic', does not often require injected insulin in its control - the sufferer's body can still typically produce insulin. The insulin so produced may not be sufficiently effective, or may not be produced in sufficient quantity, to allow the body to avoid presenting diabetic symptoms.

Insulin is a hormone, produced by the islets of Langerhans² in the pancreas of a normal individual, which effects the transport of glucose within the body from blood solution across cell membranes. IDDM is called 'insulin dependent' because, although the sufferer can be kept alive quite well using injected insulin, if the subject is forced to go without insulin he or she is likely to die after a comparatively short period of time. The reason for death or near fatal consequences in diabetics with hyperglycemia is 'acidosis' caused by the breakdown of alternative energy sources by the body (eg fat) resulting in the production of ketones which are complex acid type molecules. This acidosis results in a failure of normal cell function and metabolism, eventual coma and if not treated death.

'Diabetes'

Diabetes, although well known for thousands of years³ is still a broad classification for a metabolic disorder which is not completely understood - although controllable - even today. Only in the last 80 years, since the isolation of insulin in 1921 by Canadian medical researchers Frederick Banting and Charles Best, has the distinction between IDDM and NIDDM been possible. Almost all that is definitely understood about diabetes between cultures is that it is a condition of affluence: it is very difficult to have too much sugar in your blood when you can't find enough of anything to eat. This helps explain why the condition was first diagnosed by affluent cultures such as the ancient Egyptians and Chinese. In more recent times it has found its way into modern Western societies.

The initial signs of IDDM are usually present as a subset of a general diabetic symptomatic group. The potential sufferer is likely have one or more of these typical symptoms. Abnormal frequency in excreting large quantities of sweet smelling urine, sweating, flushing, cardiovascular impairment, weight loss, acetol breath⁴, and tiredness or lethargy. The only reliable indicator of the condition, however, is a significantly elevated blood sugar level⁵ which must be observed in combination with one or more of these secondary symptoms, and to continue for several hours after an initial observation.

The sub-condition which is IDDM may be diagnosed at almost any stage of a sufferer's life⁶ This condition is generally understood to be the result of an autoimmune process, which exterminates the pancreatic beta cells which a healthy human body uses to produce insulin. Other factors, such as injury, may also influence the destruction of pancreatic beta cells, but the autoimmune process is thought to be the most common cause of IDDM. Exactly what triggers the autoimmune process is not known, although suspicion has focused, at times, on trauma or shock, viral infection and genetic predisposition. The other digestive functions of the pancreas are typically unaffected by this process, resulting in a body which is perfectly capable of keeping itself fed, but not capable of actually using its food to supply the body's energy requirements.

Diabetic Control

This is the part of diabetes which diabetics themselves usually detest - because of the never-ending nature of its necessity. Constant monitoring of BSLs, the ceaseless gauging of time and dosage for next injections, all without an objective criterion for 'doing it right', can become wearing, even when dealt with by a full support team of medical personnel.

Diabetic control is the art⁷ of maintaining BSLs within a 'normal' range This potentially allows premium conditions for the diabetic's body to get on with all the other things it needs to do: digest, exercise, breathe, stay alive and so on. It is a lifetime pursuit once the sufferer has been diagnosed with IDDM - no breaks, no holidays, only consequences. The universally recognised medical tools for doing this are the Blood Glucose Meter⁸, the insulin syringe, pen, pump or dermal gas gun⁹, diet, and exercise. All of these tools are supplemented by others, for use in cases of exaggerated symptoms caused by elevated BSLs or other incidentals like an unrelated illness. Diabetic control can also be complicated by a number of circumstantial factors.

The first and most important of these is that the testing and recording of BSLs is obsolete the moment measurements are taken. This reflects the fact that a measurement illustrates only one moment in an ongoing process: BSLs are never static, even in healthy individuals - the fluctuations of BSL in healthy people occur within a much more limited range. Although a rising BSL can escalate very quickly into a high BSL, potentially resulting in a series of symptoms similar to those present at diagnosis, the person with diabetes still cannot know from a single blood glucose test which way the BSL is going. This can result in some potentially disastrous consequences - particularly if the BSL is falling, which may result in a phenomenon known as the 'insulin reaction' or 'hypoglycemic attack'.

The maintenance of BSLs thus can become something of a lottery in some circumstances, and may be compromised by something as simple as forgetting to do a blood test. The consequence of such compromises is usually fairly short-term if BSLs are going down at the time, but they can build up over long periods of inadvertently elevated BSLs.

From a longer-term perspective, it is not known how high BSLs can be allowed to be maintained, nor how low they can be allowed to be maintained, before permanent damage to the body results. Such damage, called 'diabetic complications', is known to result from maintaining average BSLs which are 'too high', but exactly how high is 'too high' is still not known. Medical science does know death can result from BSLs which are 'too low' for an extended period of time¹⁰, but exactly how low 'too low' is, is not known. No BSL threshold for complications development is known - although, again, several are suspected - and as a result complications are continuously feared, but difficult to deliberately avoid. It is also difficult to maintain both a short-term perspective and a long-term perspective on BSL control. The short-term perspective allows the next BSL to be manipulated in a way which will benefit the diabetic in the next few hours, but the long-term perspective would allow a much greater appreciation of exactly how much short-term manipulation is necessary to keep the diabetic alive and healthy.

In addition, other life factors impact on the maintenance of BSLs. How much you eat, what you do, what you're feeling about what you do, and so on, are all likely to be unpredictable parts of a typical lifestyle, and the necessity of being aware of such things on an ongoing basis is often resented by insulin-dependent individuals even more than the imposition of injections and blood tests. The combination of factors involved in controlling BSLs can involve controlling numerous other parts of a life, and the resultant restriction of 'spontaneity' is often perceived as one of the chief impediments of the condition. So many things, in fact, can impact on BSLs that the maintenance of a given BSL - or of BSLs within a certain, limited, range - is virtually impossible, yet this is what the diabetic seeking control is encouraged to achieve. These 'other factors' can be instrumental in bringing about the widely acknowledged tendency of insulin-dependent diabetics to episodes of depression.

All in all, it must be stressed that good glycemic control (good blood sugar control) can be attained by doing regular blood sugar tests during the day, specifically before and after meals and there is now sufficient evidence that tight blood sugar control improves the short and long term risks of diabetic complications. See the following New England Journal of Medicine article.

Diabetic Complications

These are some of the main negative consequences of the attempt to control the diabetic condition - the principal aim being good health, which it is sometimes difficult to appreciate as a significant achievement.

The main complication of 'over-control' is hypoglycemia, which can really ruin your day - and the days of the people around you. Such complications are typically short-term, however, as it is comparatively easy to treat by the consumption of sugary food or drink. As it's very difficult to maintain a normal lifestyle when continuously twitching, soaked in sweat and unable to control your limbs your diabetic sufferer will, hopefully, be prepared for this eventuality.

Not all hypo-incidents are quite so severe, but IDDM hypos are typically more dramatic than NIDDM hypos, due to the larger doses of insulin involved. The 'secondary complications' of hypoglycemia are not so easy to treat. Injuries due to car crashes undergone while under the influence of hypoglycemia, for example, are difficult to dismiss, and it is quite easy to smash your own head open while banging it on the ground in a fit of hypoglycemic frustration.

A related complication of hypoglycemia is the phenomenon known as 'hypoglycemic unawareness', which, typically, affects insulin-dependent individuals undergoing intensive therapy. Widely encountered by insulin-dependants after the introduction of 'human' - or genetically engineered - insulin analogues during the 1980s¹¹, this phenomenon eliminates native adrenal responses to an approaching hypo, meaning that the diabetic cannot 'see them coming'. With habituation to lower BSLs, this also means that diabetics on intensive therapy are more prone to lose the behavioural symptoms which might characterise a hypoglycemic episode from the 'outside' until the episode is so well advanced that it is difficult to resolve without medical attention. As intensive therapy implies more injections¹² - and requires more blood testing - than would occur otherwise, this phenomenon increases the number of hypoglycemic episodes that the diabetic is likely to have. As a result, due to the increasing popularity of intensive therapy in preventing other complications, hypoglycemia has become a more visible and feared issue in the treatment of IDDM than it was previously.

The notable potential complications of 'under-control', or maintaining BSLs which are too high, are generally longer-term, and include diabetic retinopathy¹³, diabetic neuropathy, diabetic nephropathy¹⁴, gangrene and subsequent amputation, impotence¹⁵ and lesser circulatory disorders. In the shorter term, a high BSL can make you feel bad - moody, short-tempered, lethargic, prone to urination - but there are fairly straightforward ways of dealing with this problem. Only if the high BSLs become habitual do you have cause to be overly-concerned.

It is widely believed diabetic complications are the direct consequence of the medical profession's increasing ability to treat the diabetic condition, and apply as outcomes across all types of diabetes. They occur in insulin-dependent diabetics mostly because the administration of insulin allows them to live long enough for the complications to present, rather than simply to be killed by the condition itself. Diabetic complications are one of the chief burdens on the hospital systems of several developed countries, and the public health strategies of these countries for dealing with IDDM typically involve addressing a potential immunisation against the condition and instruction in the avoidance of complications, rather than a 'cure' for IDDM itself, as most sufferers hope for. Some of the complications may also apply to insulin-dependent individuals who remain untreated, although IDDM more often causes death before the complications become a burden - as they do to treated individuals. Although a definite link between chronically high BSLs and complications has been established, the link is not definitely causal - so some people can 'get away with' much higher BSLs than would be possible for others to do. The actual occurrence of complications can also frequently appear completely arbitrary, no matter how well-controlled the diabetic who suffers them.

Latest Research

At the time of writing, new research has just been published on pancreatic islet cell transplantation for insulin dependent diabetes.

The research reports on a new regimen for transplanting pancreatic islet cells from cadaveric donors (victims of road accidents etc, who are brain dead) using new immunosuppressants to decrease rejection of transplanted tissue. It was found that all of the seven people in the study remained free form the need for insulin injections (average follow up at the time of writing so far is 11 months). The main drawback is that each individual has had to have at least two transplants. The transplant procedure involved inserting a small catheter into one of the neck veins, passing it down and through the liver into the veins near the pancreas and injecting the islet cell preparation into the vessels around the pancreas. This can be done under light sedation and does not need a general anaesthetic.