- What Is Type 1 Diabetes?
- Type 1 vs. Type 2 Diabetes
- Type 1 Diabetes Prevalence
- Causes and Risk Factors
- Type 1 Diabetes Life Expectancy
- Men ‘develop diabetes more easily’
- Where did the story come from?
- What kind of research was this?
- What did the research involve?
- What were the basic results?
- How did the researchers interpret the results?
- Links to the headlines
- Links to the science
- What is Type 2 Diabetes?
- Risk Factors
- Type 2 diabetes is strongly inherited
- The progression from having a genetic predisposition to type 2 diabetes and the development of an elevated blood sugar or overt diabetes is affected by environmental factors
- Is Type 2 diabetes increasing?
- Other conditions associated with type 2 diabetes
- Self-assessment Quiz
- Type 1, type 2, and gestational diabetes risk factors
- Type 1 Diabetes Risk Factors
- Prevalence of Type 1 Diabetes Among People Aged 19 and Younger in the United States
- Data Sources and Map Logistics
- Author Information
What Is Type 1 Diabetes?
Type 1 vs. Type 2 Diabetes
There are several types of diabetes: Type 1 and type 2 diabetes are the most common.
Type 1 diabetes develops when the body produces little to no insulin. It’s considered an autoimmune disorder, meaning that the immune system erroneously attacks and destroys the pancreatic beta cells that produce insulin.
Type 1 — previously known as insulin-dependent diabetes, or juvenile-onset diabetes (because it often develops at a young age) — accounts for about 5 percent of all diabetes diagnoses, according to the Centers for Disease Control and Prevention (CDC).
Type 2 diabetes develops when liver, muscle, and fat cells don’t respond properly to insulin and become “insulin resistant.” Glucose doesn’t enter the cells as efficiently as before, and instead builds up in the bloodstream.
In type 2, the pancreas responds to these increased blood glucose levels by producing more insulin. Eventually, however, it can no longer make enough insulin to handle spikes in glucose levels — such as what happens after meals.
Type 2 diabetes accounts for 90 to 95 percent of all diagnosed cases of diabetes, according to the CDC.
Type 1 Diabetes Prevalence
In 2012, an estimated 29.1 million people in the United States — 9.3 percent of the population — had diabetes, according to the American Diabetes Association.
However, of these cases, only 1.25 million were type 1 diabetes.
Type 1 diabetes is one of the most common chronic diseases of childhood, according to a 2014 report in The Lancet journal.
It most often arises in children 5 to 7 years old, and near or during puberty, but can strike at any age from infancy on.
Some data suggests that type 1 diabetes affects males and females equally, but it may be slightly more common in males, according to the 2014 report.
Causes and Risk Factors
It’s unknown exactly what causes type 1 diabetes.
Studies suggest that people with the disorder have a defect in their immune system — specifically in the bone marrow and thymus (an organ of the immune system) — and in pancreatic beta cells, all of which contribute to the loss of insulin production, according to the report in The Lancet.
Possible risk factors for type 1 diabetes include:
- Family history
- Vitamin D deficiency
- Early introduction to cow’s milk
- Other autoimmune diseases, including thyroid disease, Addison’s disease, celiac disease, and autoimmune gastritis
- Viral infections early in life
- Early (before 4 months) or late (after 7 months) dietary introduction of cereal and gluten
- Being born to an older mother, or one who had preeclampsia — a condition in pregnancy marked by high blood pressure
Type 1 Diabetes Life Expectancy
Overall, people with type 1 diabetes have a decreased life expectancy, according to a 2015 study in the Journal of the American Medical Association (JAMA).
More specifically, men with type 1 diabetes have a life expectancy about 11 years shorter than that of men who don’t have the disease. For women, this decrease in life expectancy is 13 years, the JAMA study found.
But life expectancy may depend on how well the condition is managed.
In a separate JAMA study, also from 2015, researchers found that people with type 1 diabetes who underwent intensive treatment for 6.5 years experienced a modestly reduced risk of complications and a lower overall risk of death.
Learn More About Type 1 Diabetes Symptoms and Diagnosis
Learn More About Type 1 Diabetes Treatment
Learn More About Type 1 Diabetes Complications
THURSDAY, Feb. 5, 2015 (HealthDay News) — Women with type 1 diabetes have a nearly 40 percent greater risk of dying from any cause and more than double the risk of dying from heart disease than men with type 1 diabetes, Australian researchers report.
In an analysis of 26 studies that included more than 200,000 people, researchers found that women with type 1 diabetes had a 37 percent higher risk of dying from stroke compared to men with type 1 diabetes. The researchers also found that women with type 1 diabetes had a 44 percent greater risk of dying from kidney disease than men with type 1 diabetes.
“Type 1 diabetes increases the risk of premature death in both women and men, but type 1 diabetes is much more deadly for women than men with the condition,” said lead researcher Rachel Huxley, director of the Queensland Clinical Trials and Biostatistics Center at the University of Queensland in Herston, Australia.
The report was published in the Feb. 6 online edition of The Lancet Diabetes & Endocrinology.
Type 1 diabetes an autoimmune disease that destroys insulin-producing cells in the pancreas. Insulin is a hormone needed to convert sugars, starches and other foods into energy. The worldwide incidence of type 1 diabetes in children 14 and younger has risen by 3 percent every year since 1989. In the United States, about 15,000 children and 15,000 adults are diagnosed with type 1 diabetes each year, according to the researchers.
Because people with type 1 diabetes don’t produce their own insulin, they must replace the hormone through multiple daily injections or with an insulin pump that has a tiny tube inserted underneath the skin to deliver the insulin.
However, insulin needs change constantly, depending on foods eaten, activity levels and even stress. This makes it difficult to get the dose just right. When too little insulin is given, blood sugar levels rise. Over time, this can cause dangerous complications, such as an increased risk of heart disease.
But, too much insulin can cause low blood sugar levels (hypoglycemia), which can quickly cause a number of uncomfortable symptoms, such as sweating, nausea, irritability and confusion. Left untreated, hypoglycemia can lead to unconsciousness and even death, according to JDRF (formerly the Juvenile Diabetes Research Foundation).
Men ‘develop diabetes more easily’
Researchers may have discovered why men may be more likely to develop type 2 diabetes than women, BBC News has reported. The broadcaster said that a new study has found men are biologically more susceptible and need to gain far less weight than women to develop the condition.
In the study, Scottish researchers examined the records of 95,057 men and women with type 2 diabetes (a condition caused by too much glucose, a type of sugar, in the blood), looking at their ages and body mass index (BMI) scores at the time of diagnosis. A clear trend was found in their results, with men developing type 2 diabetes at a lower BMI than women of a similar age.
The researchers have speculated on why this may be the case, and have offered theories that men may be less sensitive to insulin than women or that males tend to store fat around their organs rather than under the skin as women do. However, the proposed reasons are only theories and cannot be confirmed by this study, which examined a limited range of factors at a single point in time.
Overall, the observation that men seem to develop type 2 diabetes at a lower BMI than women of the same age is worthy of further exploration. As Dr Victoria King, Head of Research at Diabetes UK, told the BBC: “It is worrying that men develop type 2 diabetes at a higher rate than their female counterparts. Research like this will help us understand reasons why and provide greater insight into what we can do to improve prevention of type 2 diabetes.”
Where did the story come from?
The study was carried out by researchers from several Scottish research institutes, including the Scottish Diabetes Research Network Epidemiology Group at the University of Glasgow. The research received funding from the Wellcome Trust.
The study was published in the peer-reviewed medical journal Diabetologia.
BBC News provided balanced coverage of this research.
What kind of research was this?
This was a cross-sectional study that looked at the associations between age, gender and BMI in men and women at the time of diagnosis of type 2 diabetes. The researchers wanted to test the hypothesis that men diagnosed with type 2 diabetes tend to have a lower average BMI than women diagnosed at a similar age, in other words, it that it takes less excess weight to trigger the condition in men than in women. The researchers said that this hypothesis was based on the fact that several recent studies have observed that European middle-aged men are at higher risk of diabetes than European middle-aged women. To test their theory they examined data on a large group of men and women from a population-based diabetes register in Scotland.
While this sort of study can observe trends in age and BMI at time of diagnosis and compare differences between men and women, it cannot tell us a great deal more than this. For example, it is not possible to determine the biological reasons why the men and women developed diabetes at the time they did, and the researchers’ interpretations of their data are only theories at this stage. These theories provide an interesting discussion of the results and highlight areas for further study, but cannot be proven by this particular set of results.
What did the research involve?
The researchers looked at a 2008 snapshot of data held in the Scottish Care Information Diabetes Collaboration (SCI-DC) dataset, a population-based register holding information on people diagnosed with diabetes in Scotland. They were specifically interested in individuals with diabetes who had had their BMI measured within one year of diagnosis. Information on smoking status and blood glucose levels was also collected.
The researchers excluded data on individuals with a BMI of less than 25 and those diagnosed with diabetes before the age of 30 in order to try and limit inclusion of people with type 1 diabetes. They also excluded any remaining individuals who were missing data on key measures such as BMI, leaving them with a sample of 51,920 men and 43,137 women – representative of only 35.1% of the entire eligible dataset.
The researchers then used graphical models to plot BMI at the time of diagnosis against age at the time of diagnosis. Plotting separate graphs for men and women allowed them to compare whether associations between age and BMI at the time of diagnosis were different in men and women.
What were the basic results?
In the included sample of 95,057 individuals, men were on average significantly younger than women (average age 59.2 years versus 61.6 in women). The mean BMI recorded within a year of diagnosis of type 2 diabetes was 31.83kg/m2 in men and 33.69kg/m2 in women (a BMI of 25-29.9 indicates a person is overweight, and a BMI of 30 or above indicates obesity).
When the researchers plotted a graph of the relationship between average BMI and age at time of diagnosis, they observed clear trends: people with a higher BMI tended to develop type 2 diabetes at a younger age, and the BMI of women at the time of their diagnoses was consistently greater than that of men. This indicates that at a comparable age, men are developing diabetes at a lower BMI than women.
The researchers also adjusted their analysis to account for other factors that could have influenced the relationship. When they made adjustments to account for participants’ smoking they found it had no effect on their results. Men and women also had comparable blood glucose levels at the time of diagnosis, suggesting that these findings were not a consequence of men being diagnosed at an earlier stage of their condition.
The BMI gap between men and women was most significant at younger ages. According to the researchers’ graph, men who developed diabetes at age 40 had a BMI of around 34-35 versus 38-39 in women who developed diabetes at age 40. The gap gradually diminished as people got older, until eventually men and women who developed diabetes around the age of 80 of older had comparable BMI scores.
How did the researchers interpret the results?
From their analysis of a Scottish population of people with type 2 diabetes the researchers conclude that men are diagnosed with the condition at lower BMI than women of the same age. They suggest this observation could explain why type 2 diabetes is more common among middle-aged men in European populations.
This study is of scientific and medical interest and uses a large and reliable dataset to examine the associations between gender, age and BMI at the time of development of type 2 diabetes. The trend in the results is quite clear and supports previous studies which have observed that, despite higher prevalence of obesity in women, the prevalence of diabetes in middle-aged men exceeds that of women in some populations.
The study prompts further speculation about why this may be the case. For example, the researchers consider that for any given BMI, men may be less sensitive to insulin than women are. They also consider that it may be something to do with fat distribution, as men tend to distribute fat more readily around the liver and other body organs, while women tend to deposit fat under the skin (for example, around the hips and middle).
With regard to this latter theory, the researchers note a limitation of their study in that they did not have information on waist circumference. They say a previous study has suggested that women develop diabetes at a higher waist circumference than men.
However, the theories put forward cannot be proven by this study, which provides a snapshot of certain factors at the point of diagnosis but not an analysis of key factors that may have caused the condition to occur. In short, it is not possible to determine the reasons why these individuals developed diabetes when they did: to do so, other aspects of the individuals’ medical, lifestyle and family history would need to have been examined. The study paper also does not mention any analyses of dietary habits or alcohol consumption, which may be a key difference between males and females and also influence the way that individuals gain weight.
Also, it is not known whether the same findings would be observed in other populations. In particular, as the researchers note, it is not known whether the same pattern would be observed in people of other ethnic groups, as the Scottish sample included predominantly people of white European ancestry.
It is also worth noting again that, despite the large size of this Scottish sample it is still representative of only 35% of the total eligible dataset (the remainder being excluded as they were missing relevant data), and examining the whole sample could have given different findings.
Overall, the observation that men seem to be diagnosed with type 2 diabetes at a lower BMI than women of the same age is important, and warrants further study to establish why this may be the case.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
Men ‘more prone to type 2 diabetes’
BBC News, 5 October 2011
Links to the science
Logue J, Walker J, Colhoun HM et al.
Do men develop type 2 diabetes at lower body mass indices than women?
Diabetologia, Published online: September 30 2011
What is Type 2 Diabetes?
You have Type 2 diabetes if your tissues are resistant to insulin, and if you lack enough insulin to overcome this resistance. Type 2 diabetes is the most common form of diabetes of diabetes worldwide and accounts for 90-95% of cases.
Your risk of type 2 diabetes typically increases when you are:
- Less active
- Overweight or obese
Other risk factors are:
- Family history of diabetes in close relatives
- Being of African, Asian, Native American, Latino, or Pacific Islander ancestry
- High blood pressure
- High blood levels of fats, known as triglycerides, coupled with low levels of high-density lipoprotein, known as HDL, in the blood stream
- Prior diagnosis of pre-diabetes such as glucose intolerance or elevated blood sugar
- In women, a history of giving birth to large babies (over 9 lbs) and/or diabetes during pregnancy
Type 2 diabetes is strongly inherited
These are some of the statistics:
- 80-90% of people with Type 2 diabetes have other family members with diabetes.
- 10-15% of children of a diabetic parent will develop diabetes.
- If one identical twin has type 2 diabetes, there is up to a 75% chance that the other will also be diabetic.
- There are many genetic or molecular causes of type 2 diabetes, all of which result in a high blood sugar.
- As yet, there is no single genetic test to determine who is at risk for type 2 diabetes.
- To develop type 2 diabetes, you must be born with the genetic traits for diabetes.
- Because there is a wide range of genetic causes, there is also a wide range in how you will respond to treatment. You may be easily treated with just a change in diet or you may need multiple types of medication.
The hallmark of type 2 diabetes is resistance to the action of insulin and insufficient insulin to overcome that resistance
Insulin resistance and insufficient insulin production
Insulin resistance in type 2 diabetes means the signal insulin gives to a cell is weakened. This results in less glucose uptake by muscle and fat cells and a reduction in insulin mediated activities inside cells. Compounding this problem of resistance, there is additional defect in insulin production and secretion by the insulin producing cells, the beta cells in the pancreas.
As a group, everyone with with type 2 diabetes has both insulin resistance and an inability to overcome the resistance by secreting more insulin. But any given individual with type 2 may have more resistance than insulin insufficiency or the opposite, more insulin insufficiency than resistance. And the problems may be mild or severe. It is believed that the wide range of clinical presentation is because there are many, many genetic causes – and combinations of genetic causes – of type 2 diabetes. At present there is no single genetic test for type 2 diabetes. The diagnosis is made on the basis of the individual having clinical features consistent with type 2 diabetes, and by excluding other forms of diabetes.
The progression from having a genetic predisposition to type 2 diabetes and the development of an elevated blood sugar or overt diabetes is affected by environmental factors
Development of type 2 diabetes
The development of type 2 diabetes is thought to be a progression from normal blood sugars to pre-diabetes to a diagnosis of overt diabetes. These stages are defined by blood sugar levels.
The timeline to developing an elevated blood sugar depends on many environmental factors (such as being overweight, physical activity, age, diet, illness, pregnancy, and medication) and also on how strong the gene traits are for diabetes. Ultimately, pre-diabetes and diabetes occur when the pancreas cannot make enough insulin to overcome the insulin resistance. Historically pre-diabetes and type 2 diabetes has been diagnosed when individuals are older; however, because of a wide-spread epidemic of obesity which causes insulin resistance, the diagnosis of type 2 diabetes is occurring more frequently at younger and younger ages.
People born with the genetic traits for diabetes are considered to be pre-disposed. Genetically predisposed people may have normal blood sugar levels, but many will have other markers of insulin resistance such, as elevated triglycerides and hypertension. When environmental factors are introduced, such as weight gain, lack of physical activity, or pregnancy, they are likely to develop diabetes.
Some individuals with other types of diabetes may be misdiagnosed as having type 2 diabetes. Up to 10% of individuals who are initially diagnosed with type 2 diabetes may actually have an adult onset of type 1 diabetes also known as LADA or Latent Autoimmune Diabetes of Adults.
Pre-diabetes is a stage between not having diabetes and having type 2 diabetes. You have pre-diabetes when your blood sugars are above normal, but not so high as to meet the diagnostic criteria for type 2 diabetes. One in three people with pre-diabetes will go on to develop type 2 diabetes; however, with the correct lifestyle changes, including exercise, weight loss, a healthy diet, and the correct medications, the odds decrease so that only one in nine pre-diabetic people develop type 2 diabetes. In some cases, your blood sugar levels can return to normal. However, even if blood sugar levels return to normal, the genetic risk for type 2 diabetes remains unchanged – you must continue positive lifestyle changes, and medication or risk the return of elevated blood sugar levels.
Is Type 2 diabetes increasing?
Type 2 diabetes is increasing at an epidemic rate, and is being diagnosed at younger and younger ages. The most likely reason for this increase is that individuals with a genetic susceptibility to type 2 diabetes are developing the disease due to lifestyle changes – namely less physical activity, weight gain, and longer life span.
The good news is that scientific research confirms that by eating healthy foods, exercising regularly and maintaining an ideal body weight, you can delay or prevent the onset of type 2 diabetes.
Other conditions associated with type 2 diabetes
The insulin resistance syndrome
Individuals with type 2 diabetes are more likely to be diagnosed with other medical problems such as atherosclerosis, coronary artery disease, hypertension, obesity and dyslipidemia. Insulin resistance is thought to worsen and possibly directly cause these problems. The optimal medical care of type 2 diabetes includes not only controlling the blood glucose but also treating high blood pressure, high cholesterol or triglycerides, reducing excess weight and staying physically fit.
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Type 1, type 2, and gestational diabetes risk factors
Type 2 diabetes is the most common form of diabetes. In type 2, the body can still make some insulin but is not able to use the hormone as effectively as it should.
Insulin usually allows cells to absorb glucose. However, the cells can become less sensitive to insulin, leaving more sugar in the blood. If blood sugar is permanently high, a person may have developed type 2 diabetes.
An increase in blood sugar can lead to damage in the body. Type 2 diabetes often moves through a stage called prediabetes during which a person can reverse the progress of the condition with healthful lifestyle choices.
Unlike type 1 diabetes, people often treat type 2 with oral, non-insulin medications. However, insulin injections may still be necessary if type 2 diabetes does not respond to these alternatives.
Type 2 diabetes has two types of risk factor, or those a person can take steps to avoid and those they cannot.
There are various risk factors for type 2 diabetes, some of which people cannot avoid, including:
- family history of the disease
- race, as African Americans, Asian Americans, Latino Hispanic Americans, Native Americans, or Pacific Islanders all have a higher risk for type 2 diabetes than other groups
- being over 45 years of age
- acanthosis nigricans, a condition where dark, thick, velvety skin develops around the neck or armpits
- a history of gestational diabetes
- having a baby that weighs over 9 pounds at birth
- having polycystic ovary syndrome (PCOS)
Preventable risk factors
Share on PinterestA sedentary lifestyle can increase the risk of diabetes.
There are some risk factors for type 2 diabetes that people can take steps to try and avoid, including:
- getting little or no exercise
- hypertension, or high blood pressure
- obesity or being overweight, especially having excess weight around the midriff
- heart or blood vessel disease and stroke
- low levels of “good” cholesterol, or high-density lipoprotein (HDL)
- high levels of the fats called triglycerides
People can reduce the risk of type 2 diabetes by altering some of these lifestyle factors, especially by improving their diet and exercise regimen.
Calculating type 2 diabetes risk
The National Institute of Diabetes and Digestive Kidney Disorders (NIDDK) has a tool that people can use to calculate their risk of type 2 diabetes.
The test takes seven risk factors, including weight and height, into account to calculate a person’s body mass index (BMI) score.
BMI is a crucial aspect of diabetes risk. While BMI is not the most accurate measure of health, a high BMI can give an indicator of diabetes risk.
Type 1 Diabetes Risk Factors
There are several risk factors that may make it more likely that you’ll develop type 1 diabetes—if you have the genetic marker that makes you susceptible to diabetes. That genetic marker is located on chromosome 6, and it’s an HLA (human leukocyte antigen) complex. Several HLA complexes have been connected to type 1 diabetes, and if you have one or more of those, you may develop type 1. (However, having the necessary HLA complex is not a guarantee that you will develop diabetes; in fact, less than 10% of people with the “right” complex(es) actually develop type 1.)
Other risk factors for type 1 diabetes include:
Viral infections: Researchers have found that certain viruses may trigger the development of type 1 diabetes by causing the immune system to turn against the body—instead of helping it fight infection and sickness. Viruses that are believed to trigger type 1 include: German measles, coxsackie, and mumps.
Race/ethnicity: Certain ethnicities have a higher rate of type 1 diabetes. In the United States, Caucasians seem to be more susceptible to type 1 than African-Americans and Hispanic-Americans. Chinese people have a lower risk of developing type 1, as do people in South America.
Geography: It seems that people who live in northern climates are at a higher risk for developing type 1 diabetes. It’s been suggested that people who live in northern countries are indoors more (especially in the winter), and that means that they’re in closer proximity to each other—potentially leading to more viral infections.
Conversely, people who live in southern climates—such as South America—are less likely to develop type 1. And along the same lines, researchers have noticed that more cases are diagnosed in the winter in northern countries; the diagnosis rate goes down in the summer.
Family history: Since type 1 diabetes involves an inherited susceptibility to developing the disease, if a family member has (or had) type 1, you are at a higher risk.
If both parents have (or had) type 1, the likelihood of their child developing type 1 is higher than if just one parent has (or had) diabetes. Researchers have noticed that if the father has type 1, the risk of a child developing it as well is slightly higher than if the mother or sibling has type 1 diabetes.
Early diet: Researchers have suggested a slightly higher rate of type 1 diabetes in children who were given cow’s milk at a very young age.
Other autoimmune conditions: As explained above, type 1 diabetes is an autoimmune condition because it causes the body’s immune system to turn against itself. There are other autoimmune conditions that may share a similar HLA complex, and therefore, having one of those disorders may make you more likely to develop type 1.
Other autoimmune conditions that may increase your risk for type 1 include: Graves’ disease, multiple sclerosis, and pernicious anemia.
Updated on: 03/01/16 Continue Reading Diagnosing Diabetes View Sources
- American Diabetes Association. Standards of Medical Care in Diabetes—2009. Diabetes Care. 2009;32:S13-61.
Prevalence of Type 1 Diabetes Among People Aged 19 and Younger in the United States
Suggested citation for this article: Rogers MA, Rogers BS, Basu T. Prevalence of Type 1 Diabetes Among People Aged 19 and Younger in the United States. Prev Chronic Dis 2018;15:180323. DOI: http://dx.doi.org/10.5888/pcd15.180323external icon.
Figure. Prevalence rate per 10,000 person-years of type 1 diabetes among people aged 19 or younger with private health insurance, by state, 2001–2016. Rates were mapped by quantiles (frequency distribution with equal groups). Rates were highest in Vermont, Hawaii, Maine, Alaska, and Montana. The lowest rates were in California, the District of Columbia, Maryland, Texas, and Louisiana. Data source: Clinformatics Data Mart Database (OptumInsight), Eden Prairie, Minnesota.
Large national surveys that use telephone or in-person interviews have been the source of population-based estimates of diabetes prevalence (1,2). Such surveys in the United States usually do not distinguish between types of diabetes; therefore, maps of type 1 diabetes have been difficult to generate. The advent of large, nationwide databases from health insurers has enabled researchers to investigate geographic variations in disease among the privately insured population. By using such a database, we designed an epidemiologic study to examine the prevalence of type 1 diabetes among people aged 19 or younger across all 50 states and Washington, DC.
Data Sources and Map Logistics
We used data from January 1, 2001, through June 30, 2016, from the Clinformatics Data Mart Database (OptumInsight). This nationwide database contains integrated longitudinal health information on 73 million Americans with private health insurance, including demographic data, membership information, prescription medications, and outpatient and inpatient services.
We determined eligibility criteria for type 1 diabetes by using a validated procedure (3). First, data on people with a ratio of 0.6 or more type 1 diabetes diagnoses to type 2 diagnoses were extracted from inpatient and outpatient files. This algorithm had a positive predictive value of 98.7% for detecting type 1 diabetes (3). Second, people without any type 2 diabetes diagnosis and with only type 1 diagnoses were extracted; this algorithm had a positive predictive value of 99.3% for ascertaining type 1 diabetes (3).
We had no sex or racial/ethnic restrictions. We included only people aged 19 or younger at the time of enrollment in a health insurance plan. Rates were calculated as the total number of diagnoses of type 1 diabetes in a state from 2001 through 2016 (numerator) divided by the person-years of the underlying insured members in each state during the same period (denominator). Prevalence rates were expressed as cases (both existing and incident) per 10,000 person-years. Because this database constitutes a sample of people with private health insurance in each of the 50 states and the District of Columbia, we estimated the number of people aged 19 or younger with type 1 diabetes in the reference population (privately insured) for each state in 2015 by using the state-specific prevalence rates and the number of people aged 19 or younger with private health insurance in each state (4). Analyses were conducted by using Stata/MP version 15.1 (StataCorp LLC) and mapped by using QGIS Geographic Information System, version 2.18 (QGIS.org).
In our nationwide sample of people covered by private health insurance from 2001 through 2016, we identified 45,047 people aged 19 or younger who had type 1 diabetes. Vermont had the highest prevalence rate of type 1 diabetes (79.6/10,000 person-years) followed by Hawaii, Maine, Alaska, Montana, South Dakota, Wyoming, and New Hampshire (Table). The lowest prevalence rates of type 1 diabetes among people aged 19 or younger were in California, the District of Columbia, Maryland, Texas, and Louisiana. We found a 14.7-fold difference in prevalence rates across all 50 states (79.6/5.4). States with large populations had the greatest number of privately insured young people with type 1 diabetes, with Pennsylvania, Texas, New York, California, Michigan, Illinois, Florida, and Ohio ranking the highest (Table).
Public health efforts to prevent disease and develop interventions often begin with an assessment of where the disease occurs. We conducted a large, nationwide assessment of the prevalence of type 1 diabetes among young people with private health insurance in the United States. We found considerable variation in the prevalence rate of type 1 diabetes across the 50 states, with a nearly 15-fold difference from the highest to lowest prevalence rates. Previously, data from the National Health and Nutrition Examination Survey were used to estimate the prevalence of type 1 diabetes, but with a sample of 123 people with the disorder aged younger than 30, precise state-specific rates could not be calculated (5). In the SEARCH for Diabetes in Youth study, data were collected from locations in only 5 states and from selected Native American sites, not for all 50 states (6). Although our study does include all 50 states, it is important to note that these data represent only children and adolescents with private health insurance. Additional data are needed to assess geographic variation among young people with public health insurance.
Our results suggest that geographic variation in the prevalence rate of type 1 diabetes among young people is different from that of type 2 diabetes (2). Although genetic predisposition plays a role in both types, precipitating factors vary, with autoimmune-related factors being closely associated with type 1 diabetes and lifestyle factors associated with type 2 diabetes (2). The availability of health services, however, is critical for people with either type to prevent long-term complications.
The Patient Protection and Affordable Care Act included provisions to enable people with pre-existing conditions to secure health insurance, which has important implications for those with diabetes (7). The most frequent barriers to health care among young people with type 1 diabetes are cost, communication problems, and obtaining needed information (8). Insurance alone does not eliminate all such barriers but should curtail some, such as cost, although interruptions in insurance remain a concern (9). The frequency of such interruptions varies by state and is associated with 5-fold increases in emergency department visits and hospitalizations (9).
The variation in state-specific prevalence rates of type 1 diabetes is mirrored by state-level variability in services. Not all states mandate that insurers cover diabetes treatment and supplies (10). Alabama, Idaho, North Dakota, and Ohio do not have such mandates. Missouri also does not have a mandate across all insurance policies but requires that insurers offer at least one policy that covers treatment of diabetes (10). Laws relevant to emergency access to insulin also differ; 10 states now allow pharmacists to dispense insulin with an expired prescription in emergency situations. Therefore, one actionable consequence of our study would be to improve state laws and consider federal legislation so that patients with type 1 diabetes are provided the services necessary for optimal health — regardless of the state in which they live.
This study was funded by the National Institutes of Health (grant no. UL1TR000433) to the Michigan Institute for Clinical and Health Research and by the Jaeb Center for Health Research. The funders had no role in the design of the study; in the collection, analysis, and interpretation of data; or in writing the article. No copyrighted surveys, instruments, or tools were used. The authors have no conflicts of interest.
Correspondence: Mary A. M. Rogers, PhD, Research Associate Professor, Department of Internal Medicine, University of Michigan, Bldg 16, Rm 422W North Campus Research Complex, 2800 Plymouth Rd, Ann Arbor, MI 48109. Telephone: 734-647-8851. Email: [email protected]
Author Affiliations: 1Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. 2Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan. 3Department of Geography, Bowling Green State University, Bowling Green, Ohio.
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a Estimated number of people aged 19 or younger with type 1 diabetes and private health insurance in 2015.
November is National Diabetes Month, but for the more than a million children and adults in the U.S. living with Type 1 diabetes, every day and night is a constant reminder of a physically and emotionally tedious disorder that requires constant monitoring.
“I wear an insulin pump, a continuous glucose monitor, do several finger-sticks a day, count carbohydrates,” said Bridget Kelly, a mother of two who was diagnosed in her 20s and now in her 40s. “Type 1 diabetes is like a second job that you can’t quit.”
People with Type 1 diabetes must work to keep their blood sugar in a normal range. High blood sugar over a long period of time can lead to devastating complications.
In the short term, blood sugars that are too high or too low can be deadly.
Kerri Sparling, from the blog SixUntilMe.com, also is a mother of two and was diagnosed in second grade. No one else in her family has Type 1 diabetes, and she remembers her parents being very upset with the diagnosis.
They tried to explain a chronic illness to her, to which she said, “So I’m gonna have it until Christmas?!”
Her parents gently replied, “No, honey — all the Christmases.”
Type 1 diabetes can strike people at any age and in any condition. Once called “juvenile diabetes,” we now know people can be diagnosed as children or adults.
Symptoms often include extreme thirst, frequent urination and sudden weight loss, leading to a medical visit during which a person is given a blood test — the only way to identify Type 1 diabetes. For those at risk, their blood sugar is dangerously high.
Type 1 diabetes is an autoimmune condition in which a person’s immune system attacks the insulin-producing cells of the pancreas, and it can no longer make insulin. Insulin is essential for life because it delivers glucose, aka blood sugar, which all cells in the body need to function.
There may be instant relief after diagnosis, knowing that there is a name for what is happening and that there are monitoring systems — and that insulin that will be available for daily treatment. But for a person with Type 1 diabetes, life is never the same.
“After my diagnosis, I was ready to do whatever was necessary to take care of this disorder, but it’s unimaginable the amount of work that is required to keep your blood sugar within a safe range when your pancreas stops making its own insulin,” Kelly said.
This is different from the more common Type 2 diabetes, most often seen in adults with obesity, high blood pressure and high cholesterol. Both types are believed to have a genetic component, and both are linked to the pancreas.
In Type 2 diabetes, however, the pancreas still makes some insulin and it can be controlled with oral medication, exercise and diet.
There is currently no way to prevent Type 1 diabetes, typically referred to as T1DM, and there is no cure.
ABC News’ Medical Unit has previously reported on the technology available now to make managing diabetes easier and the solutions on the horizon.
For now, it’s a very difficult disorder to manage, surrounded by second-guessing by the individual and the well-meaning people around them who may offer dietary advice without understanding Type 1 diabetes.
“I choose when I eat my carbohydrates carefully,” Kelly said. “So if I want to have pizza or chocolate cake I can. … but I need to know how many carbohydrates are in that food and take the necessary insulin through my pump, so my blood sugar doesn’t skyrocket. And I can’t take too much insulin or my blood sugar will plummet and I can go into a coma and worse.”
“I’m also considering variables like whether I’ll be exercising soon or sleeping soon and what my current blood sugar is,” Kelly added. “I have to think of all those things before I eat and make insulin dosing decisions. So it’s not helpful if other people are commenting on my meal choices.”
New daily life
Every day, a person with T1DM needs to make many decisions: They need to check their blood sugar levels with a finger-stick test regularly, especially before they eat; inject themselves with insulin, as no pills are available to treat T1DM, or use an insulin pump device; and actively think about what they’re eating — how many carbohydrates every meal or snack contains.
If they’re sick, more active than usual, gained or lost weight, they need to adjust the insulin doses; these variables are difficult to manage.
And finally, they need to watch out for dangerous signs of blood sugar being too low or too high. They may begin to learn to care for their own body better than any health care professional can.
And they need to do this every hour, of every day, of every year. There is no quitting or putting diabetes on hold.
Carl Armato, CEO of Novant Health, recently published “A Future With Hope.” He was diagnosed with T1DM as a toddler. In the book, he shares important lessons about his 50 years of experience.
“The disease is the disease, but it’s how people deal with diabetes and adapt to it that is critical to the quality of life they have — more importantly, to whether they even have a life to live,” he said.
He admits it’s difficult to manage, but advises from his experience that it’s more than possible to have a successful and fulfilling life.
“Diabetes is a marathon, not a sprint,” Armato said. “Stuff happens. You lose. You fail. Then you have to get back up and fight.”
Kelly, the mother of two diagnosed in her 20s, works with her endocrinologist, certified diabetes nurse educator and, at times, a specialized nutritionist.
She looks at dealing with the disorder as “going into battle.”
“I always have my diabetes devices with me. I always need to think, ‘If I have a hypoglycemia, how am I going to get fast acting sugar to raise it?'” she said. “I keep Gatorade by my bedside and glucose tablets in my purse” to help regulate blood sugar.
A Day in the life
Doctors who treat people with T1DM are endocrinologists. They can prescribe insulin and talk to a person with diabetes about their health, and check blood tests that measure their average blood sugar level over the past three months to see how well they are controlling their blood sugar.
Kelly said: “For me, the diabetes online community has been so important. Emotionally and practically, it helps so much to share information and experiences with other people with Type 1 diabetes.”
“This is a lot to deal with, and most people in my life have very little understanding of what I’m really doing to take care of myself,” she added. “Well-meaning people want to suggest ‘alternative’ treatments involving cinnamon or a special herb, and I have to say, ‘Thanks, but I’ll always need insulin.'”
“It’s good to connect with other PWDs who really get it,” she added, referring to persons with diabetes.
One of the first people to share experiences online was Kerri Sparling, who said that when she started blogging she was one of four or five T1 bloggers she knew about.
Today, she regularly speaks on panels at diabetes conferences.
“I started Six Until Me in May of 2005 because I was tired of Googling ‘diabetes’ and coming up with little more than a list of complications and frightening stories,” she said. “Where were all the people who were living with this disease, like I have been since I was a little girl? Was I the only person with diabetes out there who felt alone?”
She shares her daily experiences online in a very transparent way under titles like, “Love Poem for my Stupid Pancreas,” “World’s Okayest Diabetic” and “Um, can you eat that? A Halloween Poem.”
She’s written a book called “Balancing Diabetes” but points out she isn’t a medical professional and joked, “I can’t even drive a stick.”
But her openness about her experience is invaluable to a large community of people living with Type 1 diabetes who gather online in Facebook groups, at conferences and monthly meet-ups in their own community to avoid the isolation.
“For much of my life, I was the only diabetic I knew,” Sparling said. “Thankfully, that’s not the case anymore.”
“When you’re diagnosed so young, every life event has included diabetes,” she continued. “I went to prom with diabetes. I got my license with diabetes. I graduated high school with diabetes. I had a special pocket sewn into my wedding dress for my insulin pump.”
In her day-to-day life, she thinks about diabetes every few minutes. From the moment she opens her eyes in the morning until she closes her eyes at night, there are hundreds of small decisions she needs to make to keep herself safe.
There is a “variable to everything that you do — how to get dressed, how far is the drive,” she said. “It all becomes automatic after a few decades.”
If people with Type 1 diabetes don’t use newer technologies, like an insulin pump or a continuous glucose monitor, they may need to inject themselves with insulin four to eight times a day and check finger-sticks at least six to eight times a day.
Sometimes, they need to check more. They must always be aware of how their body feels when blood sugar level is too high or too low. If it’s too high, some people describe feeling anxious, a stomachache, very thirsty or not themselves. If it’s too low, which can be very dangerous, they may feel a headache, tremors, heart palpitations, confused, slur speech or even be unresponsive.
“We tiptoe that line all the time, between I’m sick and I’m fine,” she said.
But she doesn’t let that stop her from living her life.
“You can do everything everyone else can do, except make insulin,” Sparling said.
Speaking of insulin, diabetes is one of the most expensive chronic conditions — insulin prices has tripled in the past 15 years.
From 2001 to 2015, the price of Novolog, a commonly used insulin, went from $100 per vial to $336 per vial in the United States. People have been known to ration their insulin, which can be deadly for someone with T1DM.
There are generic versions, or alternative types of insulin, as well as patient-assistance programs, which can help to decrease the cost of insulin. The Endocrine Society and other physician and patient advocacy groups are calling on the government to pursue initiatives on insulin affordability.
In the meantime, people with diabetes are their own best advocates.
What about these things I read online about pumps and sensors, and the ‘artificial pancreas?’ Is that a cure?
Technology in diabetes is evolving at the fastest pace in history and working to improve the lives of people with T1DM. There are insulin pumps that can automatically decrease the amount of insulin you get if your blood sugar numbers are too low or heading low.
There are continuous glucose monitors, or CGMs, which sense your blood sugar levels every five minutes without requiring a finger-stick prick.
And now, there are systems whereby the CGM can communicate with the insulin pump in a “hybrid closed-loop system.” At Boston University and various start-ups across the country, there’s ongoing research to build a “closed-loop system,” or artificial pancreas, that does not require any human input.
We are so close, and yet so far. Even the most advanced systems on the market now still require human input. If the blood sugar is too low or too high, the sensors or pumps will beep, and ask for a confirmatory finger-stick test. People still need to input the amount of food they’re going to eat, or make adjustments if they’re going to exercise or not eat for a long period of time.
Machines can experience technical errors or malfunction, however; tubing may kink or get clogged, the sensor or pump can fall off or the battery may run out.
You can’t turn your brain “off” no matter how good the technology is.
Sparling, the blogger, said she has “hope for a cure,” but “I have to live today.”
There are many famous and successful athletes and professionals with T1DM who never let their disease define their careers. Mountain climber Will Cross climbed Mount Everest, professional football player Mark Andrews and Supreme Court Justice Sonia Sotomayor, to name a few, continue to achieve their dreams while living with T1DM.
My loved one was just diagnosed with T1DM. What can I do to help?
“What anyone with diabetes soon learns is that you can’t do this alone,” said Armato, the CEO of Novant Health. “A good steady support system … is like the breath of life.”
Here are some key tips for family and friends of people with T1DM:
— Understand this is a disease that requires nearly 24/7 attention. Have empathy. Be positive, not critical and judgmental.
— Learn about T1DM from trustworthy sources instead of passing on things you’ve heard.
— Recognize the signs and symptoms of low blood sugar.
— Know where your loved one keeps their glucometer, insulin supplies and glucose tabs.
— Know the phone number of your loved one’s doctors.
“You can do the absolute best,” Sparling said, “and things can still happen.”
There are some good, reliable online resources and meetings for people with T1DM and their family and friends.
Armato and Sparling emphasized the importance of having support.
Here are some trusted organizations for whose living with Type 1 diabetes:
— American Diabetes Association
— JDRF (Juvenile Diabetes Research Foundation)
— College Diabetes Network
— Children With Diabetes
Dr. Tiffany Yeh is currently an endocrinology fellow at New York-Presbyterian Weill Cornell Medical Center and a member of the ABC News Medical Unit. Eric M. Strauss is the managing editor of the ABC News Medical Unit and married to Bridget Kelly. He welcomes your comments on Twitter: @ericmstrauss
Because type 1 diabetes can start quickly and the symptoms can be severe, people who have just been diagnosed may need to stay in the hospital.
If you have just been diagnosed with type 1 diabetes, you may need to have a checkup each week until you have good control over your blood sugar. Your doctor will review the results of your home blood sugar monitoring and urine testing. Your doctor will also look at your diary of meals, snacks, and insulin injections. It may take a few weeks to match the insulin doses to your meal and activity schedules.
As your diabetes becomes more stable, you will have fewer follow-up visits. Visiting your doctor is very important so you can monitor any long-term problems from diabetes.
Your doctor will likely ask you to meet with a dietitian, clinical pharmacist, and diabetes nurse educator. These providers will also help you manage your diabetes.
But, you are the most important person in managing your diabetes. You should know the basic steps of diabetes management, including:
- How to recognize and treat low blood sugar (hypoglycemia)
- How to recognize and treat high blood sugar (hyperglycemia)
- How to plan meals, including carbohydrate (carb) counting
- How to give insulin
- How to check blood glucose and urine ketones
- How to adjust insulin and food when you exercise
- How to handle sick days
- Where to buy diabetes supplies and how to store them
Insulin lowers blood sugar by allowing it to leave the bloodstream and enter cells. Everyone with type 1 diabetes must take insulin every day.
Most commonly, insulin is injected under the skin using a syringe, insulin pen, or insulin pump. Another form of insulin is the inhaled type. Insulin cannot be taken by mouth because the acid in the stomach destroys insulin.
Insulin types differ in how fast they start to work and how long they last. Your doctor will choose the best type of insulin for you and will tell you at what time of day to use it. Some types of insulin may be mixed together in an injection to get the best blood glucose control. Other types of insulin should never be mixed.
Most people with type 1 diabetes need to take two kinds of insulin. Basal insulin is long-lasting and controls how much sugar your own body makes when you are not eating. Meal-time (nutritional) insulin is rapid acting and is taken with every meal. It lasts only long enough to help move the sugar absorbed from a meal into muscle and fat cells for storage.
Your doctor or diabetes educator will teach you how to give insulin injections. At first, a child’s injections may be given by a parent or another adult. By age 14, most children can give themselves their own injections.
Inhaled insulin comes as a powder that is breathed in (inhaled). It is rapid acting and used just before each meal. Your doctor can tell you if this type of insulin is right for you.
People with diabetes need to know how to adjust the amount of insulin they are taking:
- When they exercise
- When they are sick
- When they will be eating more or less food and calories
- When they are traveling
HEALTHY EATING AND EXERCISE
By testing your blood sugar level, you can learn which foods and activities raise or lower your blood sugar level the most. This helps you adjust your insulin doses to specific meals or activities to prevent blood sugar from becoming too high or too low.
The American Diabetes Association and the Academy of Nutrition and Dietetics have information for planning healthy, balanced meals. It also helps to talk to a registered dietitian or nutrition counselor.
Regular exercise helps control the amount of sugar in the blood. It also helps burn extra calories and fat to reach and maintain a healthy weight.
Talk to your doctor before starting any exercise program. People with type 1 diabetes must take special steps before, during, and after physical activity or exercise.
MANAGING YOUR BLOOD SUGAR
Checking your blood sugar level yourself and writing down the results tells you how well you are managing your diabetes. Talk to your doctor and diabetes educator about how often to check.
To check your blood sugar level, you use a device called a glucose meter. Usually, you prick your finger with a small needle, called a lancet, to get a tiny drop of blood. You place the blood on a test strip and put the strip into the meter. The meter gives you a reading that tells you the level of your blood sugar.
Continuous glucose monitors measure your blood sugar level from fluid under your skin. These monitors are used mostly by people who are on insulin pumps to control their diabetes. Some monitors do not require a finger prick.
Keep a record of your blood sugar for yourself and your health care team. These numbers will help if you have problems managing your diabetes. You and your doctor should set a target goal for your blood sugar level at different times during the day. You should also plan what to do when your blood sugar is too low or high.
Talk to your doctor about your target for the A1C test. This lab test shows your average blood sugar level over the past 3 months. It shows how well you are controlling your diabetes. For most people with type 1 diabetes, the A1C target should be 7% or lower.
Low blood sugar is called hypoglycemia. A blood sugar level below 70 mg/dL (3.9 mmol/L) is too low and can harm you. A blood sugar level below 54 mg/dL (3.0 mmol/L) is cause for immediate action. Keeping good control of your blood sugar can help prevent low blood sugar. Talk to your doctor if you’re not sure about the causes and symptoms of low blood sugar.
People with diabetes are more likely than those without diabetes to have foot problems. Diabetes damages the nerves. This can make your feet less able to feel pressure, pain, heat, or cold. You may not notice a foot injury until you have severe damage to the skin and tissue below, or you get a severe infection.
Diabetes can also damage blood vessels. Small sores or breaks in the skin may become deeper skin sores (ulcers). The affected limb may need to be amputated if these skin ulcers do not heal, or become larger, deeper, or infected.
To prevent problems with your feet:
- Stop smoking, if you smoke.
- Improve control of your blood sugar.
- Get a foot exam at least twice a year from your doctor, and learn whether you have nerve damage.
- Ask your doctor to check your feet for problems such as a bunion or hammertoe. These need to be treated to prevent skin breakdown and ulcers.
- Check and care for your feet every day. This is very important when you already have nerve or blood vessel damage or foot problems.
- Treat minor infections, such as athlete’s foot, right away.
- Good nail care is important. If your nails are very thick and hard, you should have your nails trimmed by a podiatrist or other provider who knows you have diabetes.
- Use moisturizing lotion on dry skin.
- Make sure you wear the right kind of shoes. Ask your doctor what kind is right for you.
Your doctor may prescribe medicines or other treatments to reduce your chances of developing common complications of diabetes, including:
- Eye disease
- Kidney disease
- Peripheral nerve damage
- Heart disease and stroke
With type 1 diabetes, you are also at risk of developing conditions such as hearing loss, gum disease, bone disease, or yeast infections (in women). Keeping your blood sugar under good control can help prevent these conditions.
Talk with your health care team about other things you can do to lower your chances of developing diabetes complications.
Living with diabetes can be stressful. You may feel overwhelmed by everything you need to do to manage your diabetes. But taking care of your emotional health is just as important as your physical health.
Ways to relieve stress include:
- Listening to relaxing music
- Meditating to take your mind off your worries
- Deep breathing to help relieve physical tension
- Doing yoga, taichi, or progressive relaxation
Feeling sad or down (depressed) or anxious sometimes is normal. But if you have these feelings often and they’re getting in the way of managing your diabetes, talk with your health care team. They can find ways to help you feel better.