By Dr Shrinath Shetty
Diabetes mellitus, a disease common in elderly population which is characterized by
increased blood sugar, is seen due to insufficiency of insulin- either due to insulin resistance
seen in Type 2 diabetes or due to insulin deficiency which is seen in Type 1 diabetes.
Persistently high blood sugars leads to changes in our vascular tree leading to complications
such as diabetic kidney disease, neuropathy and diabetic retinopathy. There is also an
increase in risk of vascular events such as stroke or heart attacks in patients with poorly
controlled diabetes. Diabetes mellitus (DM) can be of many types, however it broadly divided
into Type 1 diabetes and Type 2 Diabetes. More than 90% of the patients with diabetes have
Type 2 Diabetes Mellitus (T2DM) where the insulin produced by the pancreas is not efficient
for bodily functions, which is called insulin resistance. These patients are thus treated with
medications, which either increase insulin production from pancreas or improve the insulin
sensitivity. When these drugs do not work or if there is an emergency in bringing down the
blood sugar levels, insulin is used.

Type 1 Diabetes Mellitus (T1DM) on the other hand is characterized by absolute deficiency of
insulin from the pancreas, because of which they require insulin from the point of diagnosis.
They do not respond to the tablets that are commonly used in patients with T2DM. Hence, it
is also known as Insulin dependent Diabetes Mellitus (IDDM). Similarly type 1 diabetes is
called juvenile diabetes because it was common in children below 18 years of age. It is most
common in the 4-7 years age group followed by 10-16 years age group. In the past few
years, patients who were previously classified as juvenile diabetic were later found to have
pancreatic diabetes or Maturity onset diabetes of young (MODY), which are not very
uncommon in India. Hence juvenile diabetes has been slowly replaced by the term Type 1
Diabetes Mellitus to make diagnosis clearer for the treating doctor. In recent years it has
become clear that Type 1 diabetes mellitus can also be present at later age and Type 2
diabetes mellitus can be detected during childhood due to poor lifestyle choices. Many
patients have a mix of features- there can be insulin resistance in patients with T1DM and
similarly patients initially managed as T2DM may suddenly shift to T1DM like presentation. At
present, patients diagnosed with diabetes before the age of 30-40 years are evaluated in
detail and then classified to treat them appropriately , rather than making diagnosis of T1DM
or T2DM solely based on age.

Type 1 Diabetes is a auto immune disease similar to vitiligo, rheumatoid arthritis, SLE,
Hashimoto’s thyroiditis ,etc. Antibodies are substances produced by our white blood cells
(WBCs) to kill or neutralize bacteria or viruses. However, auto immune diseases are
characterized by presence of antibodies which are directed towards self rather than the
bacteria or viruses, known as autoantibodies. These autoantibodies attack the organ they are
directed to and produce different diseases based on the organ involved. T1DM is
characterized by presence of autoantibodies such as Anti-GAD antibody, insulin auto
antibodies (IAA), ICA (islet cell antibodies) and Zinc transporter 8 (ZnT8) in 60-80% of the
patients.

In the recent past there has been a trend towards increase in diabetes in young. Patients
aged less than 30 years are more often presenting to Outpatient department (OPD) services
with diabetes. Though previously such patients were more often categorized as T1DM ,
detailed evaluation of such patients have more often lead to mixed bag of early T2DM, T1DM
,Pancreatic diabetes and MODY. In a study done at CMC, Vellore- patients presenting with
gestational diabetes were more often found to have undiagnosed MODY , than it was
expected. Whereas the therapeutic option for T1DM is usually limited to Insulin, diagnosis of
other forms of diabetes opens the door to other forms of oral therapy – thus simplifying
therapy for such patients.

The increase in incidence of diabetes in young in multifactorial in nature. Many of them are a
single child in the family, who have easy access to food with high carbohydrate (soft drinks
and snacks ) combined with poor physical activity. Due to covid 19 pandemic many of these
children had to manage with online classes, further reducing their physical activity. Many of
the parents also had to work from home – so managing children with food restrictions
became difficult. Hence, we see an increase in the incidence of obesity and hence early
T2DM in such population. Markers of insulin resistance such as acanthosis nigricans
(thickening and blackening of skin) around the neck is a common feature in such children.
These children can present with incidentally detected diabetes during routine check up for
obesity or sometimes present to Emergency department (ED) with severe hyperglycemia
requiring admission to ICU. Initial insulin combined with diet restriction and good physical
activity works wonder with such patients.

Patients with T1DM are also being detected more often than before. Around 60-80% have a
severe sudden increase in blood sugar levels requiring admission to the hospital. They
require frequent insulin shots (3-4 times /day) compared to T2DM because they do not have
any insulin reserve in the pancreas. However unfortunately it hits children who are not able to
take care of themselves and thus diabetes education and awareness of the parents becomes
very important. We are seeing an increase in diagnosis of T1DM recently in Mangalore in the
past 2 years due to multiple reasons- (1) Increased awareness and early detection (2) Covid
19 infection like some other respiratory viruses can precipitate T1DM due to triggering of the
immune system. (3) Covid 19 virus is known to directly reduce insulin release from pancreas
(4) Environmental factors (5) Referral from peripheral remote places.

Managing T1DM is more difficult than T2DM in young because it is more brittle than T2DM.
They require more frequent insulins injections which makes giving insulin shots at school
more difficult either due to social stigma or logistic issue. Family and social support plays a
vital role in the mental and physical well being of the child because even if 1 insulin shot is
missed, patient can land up in the hospital. Similarly, slight delay in the food timings can
cause of severe hypoglycemia and unconsciousness. Monitoring sugars is an important part
of management of these children. However, with better technological advances like
Continuous glucose monitoring devices (CGMS) and insulin pump these children can be
managed with less complications. If these children are not monitored closely, they can have
problems like growth delay, intellectual impairment, early eye and kidney problems.

By Dr Shrinath Shetty, Consultant Endocrinologist & Diabetologist, KMC Hospital , Mangalore

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