Type 1 Diabetes on the rise – a reminder of the “4T’s”

While our role in primary care diabetes management usually centres on people living with type 2 diabetes, we are all likely to see a handful of people presenting with new onset type 1 diabetes during our careers.  Being aware of the possibility of a new diagnosis of type 1 in anyone presenting unwell is an essential part of reducing the risk of significant DKA and poor outcomes at presentation. 

The highest incidence of Type 1 diabetes is between the ages of 10 and 14, however as we see from national diabetes audit data in England and Wales, 1 in 5 people are actually diagnosed after the age of 40. 

Several years ago, Diabetes UK started the very successful 4T’s campaign to promote awareness of type 1 diabetes. The 4Ts: tiredness, thirst, toilet and thinner are a nice way of remembering the common presenting features, although these can be easily missed with people presenting in different ways.  Checking a capillary blood glucose is an important part of the work-up of an unwell person if the diagnosis is unclear. 

Over the last decade or so, there has been a gradual rise in the annual incidence of type 1 diabetes in European countries of around 3-4%.  A fascinating new systematic review and meta-analysis has been published in JAMA looking at whether the incidence of type 1 diabetes in children and adolescents has increased post pandemic and whether this has been sustained  The paper looked at 17 studies of over 38000 children and adolescents across multiple countries including the UK, and reported an increased incidence rate during year one of the pandemic (March 2020-2021) of 14%, and a larger increase of 27% during the second year (March 2021-2022), compared with pre pandemic figures.  This increase is significantly above the expected increase which we have already seen in European countries and the sustained increase in year 2 suggests mechanisms beyond the initial catch up of care.

The possible reasons behind this rise are not fully understood.  There has been a previous link identified between Covid-19 infection and new-onset type 2 diabetes, with infection contributing to dysregulation of glucose metabolism and direct viral damage to beta cells in the pancreas, impairing their ability to produce insulin and likely pushing people already at risk into overt diabetes.  However, there is no clear underlying mechanism explaining an association with Covid-19 infection and subsequent increased risk of autoimmune type 1 diabetes.  Possible indirect effects of the pandemic are discussed in the paper, however the lack of exposure of children to viral illness during lockdown would in theory actually protect them from the development of  type 1 diabetes because of a reduction of the suggested trigger of recurrent infections in auto immune disease.  Essentially, the reason for this increasing incidence remains unknown and it will be important to monitor to see if this increase is maintained over subsequent years. 

This study is both fascinating and concerning.  For us, a good reminder of the 4T’s of type 1 diabetes and remembering to “think glucose”.  Although this study if about type 1 diabetes in children, remember that we can see new type 1 at any age.  If you think this may be type 1 diabetes, far better to assume this until proven otherwise. Great free resources, including posters for the waiting room at the Diabetes UK Website.

We will be covering safely diagnosing the right type of diabetes, as well as many other primary care diabetes related topics in our Diabetes Course on 28^th September with myself and Consultant Diabetes Nurse colleague Su Down – do come along and join us.