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[IP] Which are you: Type I vs. Type II--Interesting Article!

I found this at  www.diabetesnet.com  and thought it was interesting.  It's a
little lengthy, but is interesting.

Roxanne Villanueva RD, LD
Cleveland, Ohio
IDDM X 18 years, Pumping since 1/4/1995.
Remember...Diabetics are naturally sweet!
e-mail:    email @ redacted
Really Know Your Diabetes Type?
Were You Correctly Diagnosed?
by Ruth Roberts, M.A.
Copyright ) 1998, Diabetes Services, Inc.

When you were diagnosed, you were probably told you had either Type 1 or Type
2 diabetes. Clearcut and tidy. Since diabetes occurs in two types, you have
to fit into one of them. Many people do fit clearly into one of these
categories, but not everyone. For those who clearly fit a type at diagnosis,
some may find the clear lines begin to smudge over time. Are there really
only two types? Are you really the type you were told you were? Could you
even have more than one type of diabetes? And is your original diagnosis
still correct after all these years?
Misdiagnosis or unclear diagnosis of diabetes can create problems in
treatment. Misunderstanding causes and changes in the disease as you age can
also lead to mistreatment. A clear understanding of diabetes is essential.
A Short History Of Types
Described and treated since ancient times, diabetes has certain tendencies
that have long been recognized. Before the discovery of insulin, people found
to have sugar in their urine under the age of 20 often died, while those over
the age of 40 usually lived for many years with this condition. Beginning in
the mid 1920's, those who got diabetes when young (juvenile onset) were put
on insulin, and those who got it when older (adult onset) often weren't.
However, the mechanisms behind this distinction were unknown. The only marker
that differentiated the two types was the presence in the urine of moderate
or large levels of ketones when blood sugars were high. If significant
ketones were present, the person could not make enough insulin, needed
injected insulin to control the blood sugar, and was called
Then in the early '80's a breakthrough in understanding childhood onset
diabetes was made. It became clear that this early onset form was actually an
autoimmune disease in which the body destroyed its own beta cells. The
antibodies which the immune system put out during this attack distinguished
it from adult onset diabetes. For the first time diabetes had a clear causal
marker that differentiated the two types.
Definitions became clearer. Type 1, called IDDM (insulin-dependent diabetes
mellitus), now was recognized as an autoimmune disease that often appeared in
childhood or adolescence. Near the final phases of the attack, the person
requires injected insulin because the body stops producing its own supply. At
the time of diagnosis, the person often has excessive thirst and urination,
has lost a lot of weight and their blood sugar is extremely high. The person
is normal weight or thin when Type 1 diabetes starts and may stay relatively
trim through life. Type 1 occurs in about 10% of all people who have
diabetes. Treatment for this type revolves around adjusting the required
insulin injections to match diet and exercise.
Type 2 or NIDDM (non insulin-dependent diabetes mellitus), on the other hand,
was described as occurring in a person over 40 who is often overweight and
sedentary, and has a family history of the same type of diabetes. At the time
of diagnosis, there may be no symptoms, or the person may have mild symptoms,
such as blurred vision or more than normal thirst and urination. The person
continues to make their own insulin, but their insulin production is not
sufficient to keep their blood sugars normal. Treatment for Type 2 diabetes
revolves around varied combinations of diet, exercise, medications, or
Note that the use of insulin does not make someone "insulin-dependent" or
Type 1! Some 30 to 40% of Type 2's use insulin, but even when insulin is
used, this type of diabetes continues to be non-insulin dependent diabetes
mellitus or NIDDM, because death will not occur if insulin is discontinued.
Some 90% of people with diabetes are considered to have Type 2.
Then, in the early '90's the definition of Type 2 was further clarified to
distinguish those with and without Syndrome X. Syndrome X is strongly
associated with insulin resistance. This syndrome is associated with high
overall cholesterol (over 200), high triglycerides (also over 200) and low
HDL (under 40 mg/dl), high blood pressure, and gout. Those with an apple
figure who carry excess weight predominantly in their abdomen are at the
highest risk to develop Syndrome X. The cholesterol and blood pressure
problems associated with Syndrome X trigger accelerated cardiovascular
disease leading to heart attack, stroke and kidney disease.
Syndrome X is a larger category than just diabetes, and includes all those
who have resistance to insulin. Some 25% of Americans fall into this high
risk category, although only about 30% of these will ultimately develop Type
2 diabetes at some time in their lives. One end result of insulin resistance
is Type 2 diabetes, which occurs when the body can no longer produce enough
insulin to overcome the resistance and keep up with the body's increased need
for insulin. Another is high blood pressure which can be triggered by the
insulin resistance found in Syndrome X.
But not all Type 2's actually have insulin resistance and Syndrome X. As
evidence of this, a study done in Bruneck, Italy, published in <A
HREF="http://www.diabetes.org/diabetes/">Diabetes</A> in
October, 1998, found that 84% of the people therein the study who have Type 2
diabetes have insulin resistance, while 16% do not. What are these 16%
When "Type 2" occurs without insulin resistance, it is often referred to as
Type 1.5 or Type 2-s (for insulin sensitive) or Type 2-d (for insulin
deficient). Type 1.5 occurs in adults who usually are lean or normal weight.
These people have normal insulin sensitivity but, similar to a mild form of
Type 1, their insulin production is deficient. When their blood sugars are
controlled, they usually do not have the high risk for cholesterol, blood
pressure, or cardiac and vascular problems typically found in true Type 2
diabetes. This type of diabetes shares characteristics of both Type 1 and
Type 2. Of all the people with diabetes, roughly 10% will have classic Type
1, 75% will have Type 2 (insulin resistant), and another 15% will have Type
In their book, Diabetes, Type 2 and What To Do (revised October, 1998),
Virginia Valentine, June Biermann and Barbara Toohey relate that in their
1993 edition of the book, they described June who developed diabetes in her
sixties as a lean Type 2-d.  She was originally similar to the many people in
the 16% group in the Italian study above. But now they define June as a Type
1 who got diabetes later in life. They feel this description more closely
follows the American Diabetes Association's revised system where Type 1s are
insulin deficient and Type 2s as basically insulin resistant as published in
<A HREF="http://www.diabetes.org/diabetes/">
Diabetes Care</A>, January 1998. I prefer to keep the third category, Type
since, as at the time of June's original diagnosis, this group represents a
sizeable portion (about 16%) of those who have diabetes but are neither
ketosis-prone nor insulin-resistant.
Other forms of insulin resistant diabetes can also be seen in gestational
diabetes, polycystic ovary disease, acanthosis nigricans, and maturity-onset
diabetes of the young or MODY. Insulin resistant diabetes can also be
unmasked by medications like prednisone. In rare cases, nonresistant forms of
diabetes may also be seen following trauma to the pancreas or pancreas
surgery. This last form is insulin dependent because no insulin is produced
once the pancreas is removed or severely damaged.
Most people with diabetes have Type 1, Type 1.5 or Type 2. As more is known
about the causes of diabetes and more treatments are developed, more types or
sub types are certain to be defined.
Why Is Knowing Your Type Important?
Properly understanding your type of diabetes lets you know you have been
correctly diagnosed, but more importantly, it assures you that you will
receive correct treatment. For example, a person diagnosed with Type 1
diabetes needs insulin right away. They may have had the destruction of their
beta cells going on for a while without symptoms. In fact, not until about
90% of their beta cells are destroyed do they typically begin to have
symptoms. If the person does not clearly fit the model for Type 1, they may
be mistakenly placed on oral agents even though little insulin production
capability remains.
If they are lucky, an oral agent might stimulate the few active beta cells to
produce more insulin for a short time, and the blood sugar may be controlled
during the "honeymoon" phase this way. An oral agent will eventually fail and
injected insulin will be needed. If they are not so fortunate, the oral agent
will not work and the person will continue to be very sick until insulin is
started. If Type 1 is recognized right away through an antibody test, using
insulin immediately might protect the remaining beta cells and enable them to
produce insulin for a longer period of time. Blood sugar control is easier
when beta cells continue working as long as they are not overworking.
Reducing insulin production is believed by researchers to quiet the immune
system's attack on the beta cells.
Knowing your diabetes type can also give you a better understanding of the
changes that may occur to you as you age and your disease progresses. For
example, if you have had insulin-resistant diabetes for several years that
has become harder to control on a sulfonylurea medication and your C-peptide
level is now low, insulin may now be required. But if your C-peptide is
normal, adding another oral agent and paying closer attention to your food
and exercise choices may be all that's needed.
Dr. David Bell, a clinician and researcher in Birmingham, Alabama, wanted to
see if he could take a group of people with Type 2 diabetes who were already
on insulin and eliminate insulin use using a combination of oral medications.
He first tested C-peptide levels and chose only those who had normal levels.
Of the 130 people with adequate C-peptide levels in his 1997 study, 100 were
able to discontinue insulin use altogether and control their diabetes on
various doses of glyburide and metformin. He found that their overall
control, measured by a HbA1c level, was better on these two oral medications
than it had been on two doses of insulin a day. Other people in the study
were able to improve their hemoglobin levels by using glyburide, metformin
and one dose of insulin at dinner or nighttime. Researchers have determined
that the Type 2 patients who are most likely to control their blood sugars on
combination oral agents alone are those least overweight (BMI of 30 or less),
with shortest duration of insulin use, and C-peptide levels normal or only
slightly low.
Who is most likely to be misdiagnosed?
Many people with Type 2 diabetes are not diagnosed at all. This rampant
problem means some 8 million Americans don't know they have this disease.
Symptoms are usually minimal or nonexistent, sometimes for years. An elevated
blood sugar is only picked up when the person goes in for a routine physical
exam or visits the doctor for another problem, like a cold or a flu.
Among people who are diagnosed with diabetes, misdiagnosis as to type does
occur. This happens most often when the person does not have the body type or
age expected for traditional Type 1 or Type 2 diabetes.
For example, a person who is 38 and slender has mildly elevated blood sugars.
Is this person Type 1 or Type 2? He is older and his blood sugar may not be
as high as a typical Type 1, but he is too thin for a true Type 2. Perhaps he
has Type 1.5 with diminished insulin production but no insulin resistance.
Or consider a child of 14 who is 40 pounds overweight and has high blood
sugars. Does this child have Type 1, Type 2, or MODY (a different type of
diabetes genetically predetermined)? Due to overeating, poor nutrition habits
and a sedentary lifestyle, more and more children are now developing Type 2
at an early age. In fact, Dr. Gerald Bernstein, president of the American
Diabetes Association, says one-fourth of new cases in people under age 20 are
now Type 2. In the Journal of the AMA, November, 1998,   researchers are
recommendaing that diabetes screening be considered for people as young as 25
as a way to prevent the complications that years of high blood sugars can
What about the person who is 50 years old, has high blood sugars, and is 15
pounds overweight, but her body is pear shaped? Is she Type 1 or Type 2? She
could be an older-than-usual Type 1 or she could be a Type 2 with a strong
family background of diabetes, so that a modest weight gain is all that's
needed for diabetes. This is especially true if body fat is high and
deposited interperitoneally (in the gut).
People often don't fit into clear profiles. When the profile doesn't match
the person, understanding what causes their diabetes and how it should be
treated is often missing.
Does your type ever change?
Blurring of the lines between Type 1 and Type 2 diabetes is becoming
increasingly common. Due to aging or the progress of the disease, people with
one type of diabetes tend to take on characteristics of the other major type.
As a result, people with diabetes may have characteristics of both types. If
Type 1's exercise less and gain weight around the middle, as many people do
when they age, they may be not only insulin deficient but also insulin
resistant. They can develop the same cardiac risks associated with Syndrome X
and require medications to lower cholesterol and blood pressure. They require
more insulin to control their blood sugars, and certain medications typically
used in Type 2 diabetes, such as Glucophage or Rezulin, may be helpful in
controlling blood sugars.
On the other hand, as Type 2 diabetes progresses, especially if it is not
well-controlled and the pancreas is placed under additional stress, insulin
production may diminish to a point where it can no longer keep up with need.
A sulfonylurea may no longer be able to stimulate the beta cells to produce
enough insulin. Medications in addition to sulfonylurea, such as Rezulin,
Precose or Prandin, may be needed. As the production falls further, injected
insulin will be required to keep blood sugars from rising. Some people with
Type 2 eventually become totally dependent on insulin, and can go into
ketoacidosis if insulin should be stopped.
How Can You Really Know Your Type?
When a person does not fit into a clear profile, a diagnosis of Type 1, Type
1.5, or Type 2 is not obvious. A variety of lab tests and clinical signs help
to provide the critical information needed to more closely determine which
type of diabetes the person has.
* Ketones: Ketones are a byproduct produced when the body uses large amounts
of fat as fuel, which occurs if carbohydrate is unavailable as fuel due to a
lack of insulin. When a urine or blood test shows large amounts of ketones,
that person definitely has Type 1 or insulin dependent diabetes. (One rare
exception is young, black males who can have ketones at diagnosis but regain
insulin production.) If insulin is injected before the ketone test is
administered, the opportunity to find large ketones may have passed. The
urine can easily be tested for ketones at home with Ketostix or Ketodiastix
anytime the blood sugar levels are high.
* Antibodies:  Type 1 diabetes is an autoimmune disease, so 80 to 90% of the
time when Type 1 exists, the person is producing antibodies characteristic of
Type 1, such as the islet cell antibodies and GAD 64 antibodies. The blood
can be tested to see if any of these antibodies are present. If antibodies
specific to Type 1 are detected, the person already has or is likely to
develop Type 1 diabetes. These are the tests currently used in the DPT-1
trial to test relatives of those with Type 1 diabe
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