Running head: TYPE 1 DIABETES

TYPE 1 DIABETES

by

Sonia Donaires

Applied Research Project Paper Submitted in Partial Fulfillment Of the Requirements

For the Degree of Master in Public Health MPH 500

Concordia University Nebraska

Dr. Rebeca Toland

August 14, 2014

1

TYPE 1 DIABETES 2

Abstract

This is a studies of T1D from the point of view of the Domains of Public Health: epidemiology

and biostatistics, biomedical basis, environmental factors, social and behavioral factors, and

policy. In terms of epidemiology, T1D is a disease that affects children, teenagers, and young

adults. The prevalence is particularly in whites children more than others with an incidence of

26.6/100,000 in US, and affecting million around the world. According to the biomedical basis,

T1D is categorized as a chronic disease that destroys B-cells that impede the production of

insulin in the pancreas; as a result of this the blood glucose levels increase which can cause

serious harm to the body. In addition of the genetic, environmental factors may contribute to the

disease, such as the prenatal influence, seasonal effects, viruses, possible reaction to cow’s milk,

and vitamin D deficiencies in early childhood. Social and behavioral factors are based on

research from two psychological models of health behaviors: The Health Believe Model and

Ecological Model. These models determine if the person is likely to change behavior when faced

with a health threat. The application of these models by patients with T1D involves a progressive

step of acceptance of the disease: to follow a daily treatment and to provide psychological

support to assume responsibility of the disease and to take control over patients’ life.

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Epidemiology of Type 1 Diabetes

Today, Type 1 Diabetes (T1D) is an autoimmune disorder affecting millions of children

around the world, and is increasing at rates that cannot be explained. In this study I will discuss

the risk factors and the distributions of T1D and I will review the epidemiologic studies and

reports by public health agencies such as the WHO and its Multinational Project for Childhood

Diabetes, know as the DIAMOND Project, EURODIAB, and the SEARCH for Diabetes in

Youth (SEARCH).

Studies conducted between 1990-1994 by the WHO revealed the incidence of T1D

among 75.1 million children in 50 countries was 19,164 cases. CDC reports a low of 0.1/100,000

per year in China and South America to a high of 36.5/100,000 in Finland and 36.8/100,000 per

year in Sardinia, Finland, Sweden, Norway, Portugal, the UK, Canada, and New Zealand.

Approximately half of the European population reported higher incidence rates 5-10/100,000 per

year. (Karvonen, 2000)

An ethnicity study by SEARCH showed that T1D was most prevalent among Non-

Hispanic whites at 2.0/1,000 with an incidence of 23.6/100,000 because of smoking, and a diet

high in saturated fats. Among African American youth the prevalence of T1D was 0.57/1,000 for

youth ages 0–9 years and 2.04/1,000 for youth 10–19 years. The incidence of T1D for 0–9 year

olds and 10–19 year olds during 2002–05 was 15.7/100,000, of the African American youth that

attended the research visit with T1D, 50% of those older than 15 were either overweight or

obese.

The incidence of T1D in Hispanic youth in the SEARCH study was 15.0/100,000 and

16.2/100,000 for females and males 0–14 years of age. Poor glycemic control as well as high

LDL-cholesterol and triglycerides were common and 44% of these youth with T1D were

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overweight or obese. The incidence of T1D among Asian and Pacific Islander youth was

7.4/100,000 for those 0–9 and 10–19 years olds, respectively. The Pacific Islanders were more

likely to be obese as compared to the Asian or Asian-Pacific Islanders.

The majority of Navajo youth that were identified as having diabetes were diagnosed

with T2D (66/83 in the SEARCH paper). The authors state that T1D is present in Navajos, but

that it is infrequent; they estimate that the prevalence of T1D in Navajo youth is 0.5/1,000 and

the incidence of 5/100,000 per year. The authors state that, regardless of age, Navajo youth

likely to have poor glycemic control and a high prevalence of unhealthy behaviors and depressed

mood.

There are various risk factors for the development of T1D: age – the incidence rate

increases from birth and there is a high incidence in ages of 10-14, which declines after puberty

and appears to stabilize between ages of 15-29. (Maahs, 2010); gender - females and males are

equally affected with T1D in young populations; genotype - although the majority of T1D cases

occur in individuals without a family history of the disease, T1D is strongly influenced by

genetic factors. In the United States, individuals with a first-degree relative with T1D have a 1 in

20 lifetime risk of developing T1D, compared to a 1 in 300 lifetime risk for the general

population (Redondo, 2001). Additional risk factors include those who are genetically

susceptible or have reactions to cow’s milk, breastfeeding, wheat gluten, and vitamins D and E.

T1D is increasing especially in children under 5 years of age in Europe and in the U.S.

Each year, more than 13,000 young people are diagnosed with T1D in U.S., While in Europe the

totals reach 28 million children who diagnosed with T1D. Today, the incidence rate of T1D is

increasing 0-14.

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Biostatistics for T1D

Diabetes has increased in the last decade among children and adults and today is the 7th

leading cause of death in the U.S. My research includes biostatistics data for T1D collected

between 2002- 2010.

The data collected in these research was derived from various data systems such as the

CDC, the Indian Health Service’s (IHS), National Patient Information Reporting System

(NPIRS), the U.S. Renal Data System of the National Institutes of Health (NIH), the U.S. Census

Bureau, National Health Interview Survey (NHIS), 2009 IHS data, and 2010 U.S. resident

population estimates.

The methods for estimating the percentage of people younger than 20 years with

diagnosed Type 1 or Type 2 diabetes was obtained from the 2007–2009 NHIS data. Information

on diagnosed diabetes was obtained from a knowledgeable family member under 18 years, and

was self-reported for patients 18–19 years of age. Investigations reveals that among people under

20 in the U.S. in 2010, 215,000 have T1D or T2D, which represents. 26 percent of all people in

this age group with 18.8 million people diagnosed yearly, and 7.8 million undiagnosed. (CDC)

SEARCH for Diabetes in Youth is another multicenter study funded by CDC and NIH to

examine diabetes type 1 and type 2. SEARCH findings for youth under 20 include the

following:

• During 2002–2005, 15,600 youth were newly diagnosed with T1D annually, and 3,600 youth

were newly diagnosed with T1D.

• Among youth under 10 years, the rate of new cases was 19.7 per 100,000 each year for T1D

and 0.4 per 100,000 for T2D. Among youth aged 10 years or older, the rate of new cases was

18.6 per 100,000 each year for type 1 diabetes and 8.5 per 100,000 for T2D

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• Non-Hispanic white youth had the highest rate of new cases of T1D with 24.8 per 100,000 per

year among those younger than 10 years and 22.6 per 100,000 per year among those aged 10–19

years.

• T1D was extremely rare among youth 10 and under. While still infrequent, rates were greater

among youth aged 10–19 years than in younger children, with higher rates among U.S. minority

populations than in non-Hispanic whites.

• Among non-Hispanic white 10–19 years, the rate of new cases was higher for T1D than for

T2D. For Asian/Pacific Islander and American Indian youth aged 10–19 years, the opposite was

true—the rate of new cases was greater for T2D than for T1D. Among non-Hispanic black and

Hispanic youth aged 10–19 years, the rates of new cases of T1D and T1D were similar. (CDC)

Results from these studies indicate that the incidence of T1D is increasing in ages 0-10

year and is decreasing in ages 11-20. Studies also show that T2D is increasing from 11-20 years.

These data is used to analyze the incidence and prevalence of the disease, identify the risk factors

for T1D, and to prevent, control, and implement programs of prevention. But, according to the

research, there is no known way to prevent T1D. Several clinical trials for preventing T1D are

currently in progress or are being planned. To survive, people with T1D must have insulin

delivered by injection or a pump. Risk factors for T1D may be autoimmune, genetic, or

environmental.

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Biomedical Basis of Type 1 Diabetes

T1D is a metabolic disease that commonly affects children. The two most common forms of

diabetes are Type 1 and Type 2; and have very different etiologies and different clinical

presentation. In this study, I will show how the body reacts in the absence of pancreatic B-cell,

compare T1D with T2D, and describe the biological and molecular characteristics of T1D.

After a person eats food that contains carbohydrates, a healthy body breaks down the

chemicals in the small intestine to single sugar molecules. The cells that are resting in the

intestine absorb the glucose which passes into the bloodstream; when it reaches the pancreas, the

pancreatic B-cells inside detect the rising glucose level and release insulin into to the

bloodstream and keep glucose levels in a healthy range. Most cells in the body have receptors on

the surface that attract to the circulating insulin. Insulin acts like a key that open up the doors of

the cells so that the circulating glucose can get inside the cell. The cells can use the glucose to

produce energy that the body needs to function properly.

T1D is a polygenic T-cell dependent autoimmune disease characterized by the selective

destruction of the B-cells of the islets of Langerhans; it is susceptible to individuals that have

inherent defects that increase the risk of a pathogenic response rather than protective immune

response. When the body is affected for Type 1 diabetes, the pancreas does not produce insulin; a

hormone the body needs to maintain proper blood sugar levels. In Type 1 diabetes the pancreatic

B-cells lose the ability to produce insulin, resulting in high blood glucose levels and other

complications in the body. The immune system, specifically the white blood cells, mistake the

pancreatic B-cells for foreign invaders and as an autoimmune response, they secrete antibodies

(T-cells) that destroy their own B-cells. As a result, the pancreas produces little or no insulin.

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Without insulin, glucose cannot enter the cells, so the cells are starved for calories that they

should be receiving and as a consequence of this failure glucose level builds up in your

bloodstream resulting in a condition called hyperglycemia. T1D is an autoimmune response of

the body that destroys the pancreatic B-cells that are very important to producing insulin in the

body.

In comparison with T2D, the loss of pancreatic B-cells also occurs in T2D, but with a

different mechanism, and more often, in adults. T2D is typically linked to metabolic syndrome

and the presence of insulin resistance. However, a large subset of T1D patients routinely

exhibits insulin resistance contributing to the metabolic distress in islets (regions of the

pancreas).  In T2D, as weight increases the insulin resistance appears, the pancreatic B-cells

become overworked and die from high glucose levels. As the fat content in the body increases,

the B-cells die. T1D and T2D have similar consequences in terms of glycemic control and the

emergence of long-term complications. With the rising incidence of T1D and T2D, it is now

being argued that both T1D and T2D are essentially disorders of altered insulin resistance set

against the backdrop of genetic susceptibility and the inflammatory process. (Sarkar, 2012). In

type 1 diabetes (autoimmune diabetes) the loss of B-cells is often close to absolute with less than

1% of beta cells remaining in patients with long-term diabetes that have prolonged C peptide

production. (Buttler, 2007)

In most patients with almost no remaining B- cells, essentially all of the islets are devoid

of B- cells while islets contain cells expressing glucagon and somatostatin. Nevertheless, some

beta cells often remain as scattered single cells in the parenchyma and ducts.  In a small subset of

patients, even with long-term type 1 diabetes, significant C-peptide is present and lobules of

pancreas remain where all the islets contain beta cells and appear essentially normal in terms of

TYPE 1 DIABETES 9

expression of insulin while the rest of the pancreas is devoid of beta cells in islets. Shrinkage in

overall pancreatic mass in patients with T1D has long been noted. (Henderson) Analysis of

decreased pancreatic volume was recently combined with imaging of iron particle pancreatic

accumulation to help distinguish patients with T1D from normal controls. (Gaglia, 2011)

According to Witebsky, the definition and classification of autoimmune disease has been

difficult to establish. Definition of a disease as an autoimmune state depends on detectable

circulating or cell-bound antibodies reactive with an auto-antigen, identification of the auto-

antigen, presence of mononuclear cell inflammation in the target tissue, and ability to transfer

disease with lymphoid cells or with serum. In Type 1 diabetes, there is still uncertainty regarding

the nature of the auto-antigens. Taken together, these observations indicate that B-cell

destruction in T1D cannot yet be definitively classified as an autoimmune disease, but certainly

as an immune-medicated disease. (Eisebarth, 2004)

The increasing deficit of pancreatic B-cells is correlated with increasing the incidence of

T1D. All genetic studies point to two cells types: the T cell in the immune reaction and the

pancreatic B-cells.

TYPE 1 DIABETES 10

Environmental Factors of Type 1 Diabetes

Studies show that T1D is a genetic disease that typically appears within the first few

months or years of a child’s life. Scientists have proposed a multiple hypothesis to explain the

increase of T1D. In addition to genetic factors, environmental causes include prenatal influence,

seasonal effects, viruses, genetic susceptibility to cow’s milk and other early nutritional factors,

and vitamin D.

Prenatal risk occur if parents of siblings have T1D the child has from to 2%-6% risk of

developing the disease, when he has a higher birth weigh, or when he is born from a mother who

is old his chances increases. (Baker, 2013)

Seasonal pattern of T1D increases during late autumn, winter, and early spring.

Reports on the seasonality of T1D in adults have been mixed, but a recent report from Sweden

on more than 5800 patients ages 15–34 found higher incidence during January–March and the

lowest during May–July with no difference by gender

Viral infections can provoke autoimmune responses or interfere with beta cell function;

this may cause acute cell rupture with exposure of intracellular antigens to the immune system

causing the destruction of beta cells.

Research indicates that breastfeeding for at least three month decreases the risk of T1D.

Other studies conclude that exposure to cow’s milk-based formula before one year of age may

increase diabetes risk. (Baker, 2013)

Vitamin D is presented in skin in response to sunlight. Studies show that young people

with T1D have lower circulating levels of VD, which is correlated, with an increase of T1D. But

there are not enough studies to prove that the increase of VD can decrease T1D. (Gale, 2013)

TYPE 1 DIABETES 11

Social and Behavioral Factors

In this study, I will review the social and behavioral factors related to T1D, the

psychological models of health behavior, the health belief model, and the ecological model of

health behavior.

T1D is a chronic disease and a potentially life-threatening condition, which has a life-

long impact on those diagnosed with it and their families. T1D is an autoimmune disease that is

not extensively researched and therefore not preventable. The major concern is preventing the

disability that is inevitable when the disease is not well controlled (Schneider, p.184). The

multiple complications of T1D, if blood glucose is not controlled well, are atherosclerosis,

blindness, nerve damage, and kidney disease.

The social and behavioral factors such as family behavior and support, peer support, and

stress and emotional status of the patient heavily impact the presence of T1D. T1D has major

psychological impact on adolescents.

Family behavior and support

T1D is a chronic illness, affecting children 0 – 10 whose parents are then responsible for

controlling the blood glucose levels and following treatment advice. According to research,

adolescence is the most difficult stage to be diagnosed with T1D because the relationship

between parents and teens is often weak. A study of 58 adolescents with T1D concluded that

youths with well-controlled diabetes reported less conflict among family members and parents.

Studies have shown that a child who lives with parents and relatives who poorly control his

diabetes will exhibit negative side effects noticeable in his personality, physical well being,

schooling, and participation in activities away from home. (Carline, 2013)

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Other studies concluded that proper treatment includes targeting family communication

and implementing conflict resolution to improve adaptation to Insulin Dependent Diabetes

Mellitus (IDDM), treatment, adherence, and diabetic control. Different types of therapies have

been developed to support patients as well their families to deal with the impact of the disease

such as the efficacy of Behavioral Family Systems Therapy (BFST-D) that according the studies

has improved glycemic control.

Mental Health Problems

Adolescents with T1DM face a number of stressors and daily challenges as a result of

their chronic illness. Treatment regimes includes daily insulin injections, self-monitoring of

blood glucose, a prescribed meal plan, regular exercise, problem solving tactics to regulate blood

glucose in the school (social interaction with friends and teachers) and at home (family

members).

Stress is one of the factors that have the potential to affect metabolic control directly

through its impact on cortisol and other catabolic hormones that interfere with insulin

metabolism. It may also affect metabolic control indirectly, by completion of self-care tasks.

(Snoek, 2002) In addition, Cognitive Behavior Therapy (CBT) is effective in the treatment of

stress-related depression in T1D patients. (Carline, pgs.159-162)

Peer Support

For patients with T1D, it is difficult to make adjustments at school, because the treatment

involves a 24-hours control of blood glucose, and multiple daily prescriptions. A study through

structured interviews of friends and peers of patients with T1D concluded that high support from

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only family or friends was not necessarily associated with better adjustment, but both

components (supportive family and friends) were associated with better adjustment. (Wallander,

1989)

The Health Belief Model for Type 1 Diabetes

This model has four stages: perceived susceptibility, perceived severity, perceived

barriers to taking action and perceived benefits. These stages help modify human behaviors.

(Schneider, 2014)

Perceived Susceptibility

In this stage the individuals feel vulnerable to the threat of the disease; the symptoms

make the patients feel that they cannot control the disease. As a result, patients encounter the

diabetic emotional stress that affects brain function, and physical changes that include loss of

weight, irritability, weakness, etc… Since this is a difficult stage, children need to reflect and

think positively: “my diabetes would be worse if I did nothing about it”.

Perceived Severity

When the patients recognized the severity of the symptoms like excessive hunger,

excessive thirst, frequent urination, weight loss, fatigue, weakness, irritability, and blurry vision

they need to confront the feelings and the diagnosis to know that this is a disease of lifelong

disease and adjust to unfamiliar responses and emotions. Studies have shown that patients with

low perception of the severity had poor diabetes management, and those that had high perception

had good diabetes management. (Malik, 2009) Patients need to know the seriousness of the

negative effects on their future health and recognize that “my diabetes will cause me to be sick a

lot.”

Perceived barriers to taking action

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In this stage people with T1D must followed the treatment and understand directions to

know how to do. Treatment may require the use of insulin injections or, combination of proper

insulin replacement, insulin therapy, blood glucose monitoring, healthy diet, and getting a

regular exercise. In this stage patients arrive at the conclusion: ‘I would have to change too

many habits and follow my prescriptions even dough prescriptions interfere with my normal

daily activities’

Perceived benefits

Patients in this stage perceive the effectiveness of taking an action to prevent or minimize

the problem. (Schneider, 2014) Statistics show that there is a significant relationship between

perceived benefits and diabetes management. (Carline, 2013) Patients need to learn two

important factors that will help them to overcome their illness. The first one is self-management,

where patients understand the treatment is a process requiring them and their families to oversee

the disease. The second factor involves adhering to medical advice (Kitchler, 2012). Patients in

this stage conclude, “I believed I can control my diabetes and my medicine would make me feel

better”.

Ecological Model for Type 1 Diabetes

Intrapersonal Factors

This stage encompasses family contribution to T1D, which includes genetics, which

determine the nature of the disease, attitude of family toward the disease and interaction between

patient and family members. With adequate illness management, a child can live a fairly normal

life, participating in many of the same activities in which his peers do. However, for a child who

does not perform his illness management behaviors adequately, living with diabetes can be

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difficult because there are very serious short and long-term complications associated with poor

illness management.

Interpersonal Factors

Family, friends, and coworkers have critical impact on health-related behaviors of those

with T1D. Friends at the school can become a support for a patient with T1D. The relationship

between a child and his peers is also impacted by diabetes. A child with diabetes might be

reluctant to reveal his diagnosis to his peers or include friends in diabetic illness management

tasks out of fear of stigma. Similarly, a child with diabetes might be disinclined to complete his

diabetes care when in the company of his peers in an effort to conform to social norms,

especially when the child perceives his peers as unsupportive of the illness or illness

management tasks. Conversely, peers represent an important source of social support for a child

with a chronic illness such as diabetes. Being able to share a group identity that promotes health

and well being. Having supportive friends and those who promote healthy activities such as

athletics, increases adaptation and improves illness management behaviors (Carcone, 2010).

Institutional Factors

Teachers and school personnel play an important role in the life of a child with diabetes,

as illness management behaviors must be attended during the school day. Like the extended

family members and alternative caregivers, the degree to which teachers and school personnel

are educated and informed about the illness management behaviors required to care for the

child’s diabetes during the school day directly impacts the child and family’s adjustment

(Carcone, 2010).

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The American Diabetes Association has developed a program called National Diabetes

Education Program (NDEP) that helps students with diabetes succeed. It is a guide for school

personnel that informs them about how to keep kids with diabetes safe, identifies and describes

warning signs, and gives tips for helping students cope in the classroom.

Community Factors

Community influences and support are very important to ensure that people with T1D are

not alone and will be able to achieve the success in their treatment. One international program

that helps to implement campaigns to treat and cure T1D is Juvenal Diabetes Research

Foundation (JDRF). The organization, whose slogan is “improving lives until we find the cure”

works with researchers, industry, and governments to ensure the greatest positive impact on the

lives of people with T1D now and in the future. (Juvenal Diabetes Research Foundation)

Public Policy

Policy and parliamentarians regulate and limit research funding for the disease, and

reduce, and ensure that regulations and limitations impact behaviors of people with T1D.

Government regulations ensure research funding for T1D, reduce bureaucracy that hinders T1D

research, and improve the delivery of T1D research findings. One example of this type of

regulation occurred in Northern, Ireland in 2008, when the Department of Education and the

Department of Health, Social Services and Public Safety published a guide entitled “Supporting

Pupils with Medications Needs” which stated that parents are responsible for properly

medicating their children. Funding was subsequently provided to education and library boards

for training key administrators on how to meet student medical need, including those with

diabetes. (JDRF)

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Conclusion

T1D is a research based in epidemiology, biostatistics, medical and social and behavioral

factors. Based in epidemiology and biostatistics, T1D is a chronic disease affecting 28 million

children in Europe ages 0 to14 yearly, while in U.S. more than 13,000 children are diagnosed

with T1D. T1D is currently more prevalent among white children than any other ethnicity.

Statistics show that the incidence of T1D is increasing in ages 0-10 and decreasing in ages 11-20

although researchers don’t know way. Researches conclude that there is ongoing investigation to

discover the cure and develop strategies to prevent it. Currently, the only way the patient can

survive is having insulin delivered by injection.

T1D is of biomedical interest because it is an autoimmune disease in which the pancreas

does not produce insulin; a hormone the body needs to maintained proper blood sugar levels.

Glucose levels build up in the bloodstream resulting in hyperglycemia and severe disabilities if it

is not well controlled by the patient.

There are several arguments about the environmental factors that might produce T1D

since this disease appears the first few months or year of life, interaction with the environment

seems most likely to have begun before or shortly after birth. Because the disease appears early

in life, environmental factors may include exposure to viruses, seasonal effects, low levels of

VD, susceptibilities to cow’s milk and other early nutritional deficits

Social and behavioral problems arise when the patient cannot control the blood glucose

levels and follow the treatment advice. T1D is a disease, which has a life-long impact on those

diagnosed with it and their families. In addition to maintaining a self-care regiment, family and

peers support is very important in these cases. The two psychological model presented in this

research are the Health Belief Model in which the patients go through stages of perceived

TYPE 1 DIABETES 18

susceptibility, perceived severity, perceived barrios. These stages are critical that patients accept

their condition and take control over it. Finally, the Ecological Model works to change

unhealthy patient behaviors and those within his social environment. This model involves 5

strategically stages to change people behavior in collaboration with the local, and state

regulations: Intrapersonal factors, interpersonal factors, institutional factors, community factors,

and public policy.

TYPE 1 DIABETES 19

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