Need help navigating life with diabetes? You can always Ask D'Mine! Welcome again to our weekly Q&A column, hosted by veteran type 1, diabetes author and educator Wil Dubois. This week, Wil tackles that universal question of "who has it worse?" when it comes to diabetes. We never like to compare conditions, but this question does keep popping up, and as usual, Wil has done his homework. So, read on!
Amy, type 1 from Wisconsin, asks: What are the findings on which 'brand' of diabetes -- type 1 or type 2 -- has more complications, or has serious complications more frequently? Is there any research out there that monitored complications for each type separately? I have looked and found nothing...but you are the master; if it is out there, I am sure you can get your hands on it!
Wil@Ask D'Mine answers: You're right that good research is hard to come by on this subject, and passions about it run very high. Nothing seems to get type 1s and type 2s at each others' throats more quickly than the "who has it worse" question.
Now, all other things being equal, sugar in the blood stream is equally toxic for T1s and T2s. We know it can trash your eyes, kidneys, nerve endings, and pretty much everything else in your body. And in either type 1 or type 2, if you can normalize your blood sugar, you are largely immune from these toxic effects (yes, I know that this is easier said than done). So, in theory, the two types of diabetes should be on equal footing.
But they are not. More on that in a minute. But first I want to talk a bit more about who has it worse.
Being type 1 myself, and working with a fair number of other type 1s, and a whole lot more type 2s for many years now, I think I'm qualified to state which is "worse." At the risk of being flamed alive—a common fate for columnists—I'd have to vote for T2 being the nastier variety. Hold on, now! Hear me out. And then let's look at what little scientific evidence we have, and see if it backs me up or not.
I know all the arguments for why type 1 is "worse." DKA can kill you now. A hypo can kill you now. It's unrelenting in its management responsibilities, etcetera, etcetera, etcetera. But those are all fear and effort related -- really more lifestyle issues than actual biological risk factors. They are real in that they impact our lives, I'm not discounting that. But for whatever reason, type 2 seems to come with a greater range of comorbidities that collectively become a greater challenge to manage, and seem to lead to worse outcomes.
Type 2s suffer greater levels of obesity, hypertension, hyperlipidemia, depression, and assorted inflammation than we type 1s do. In fact, new evidence suggests type 2 is actually an inflammatory disease, rather than simply insulin resistance syndrome as previously thought. If this proves true, it may explain type 2 diabetes' wider-ranging effects on its victims' bodies.
But you asked me to identify "findings" and research, not to just give an opinion. And you were specifically interested in complications, not management difficulty—although there is likely a connection between the two.
What can science really tell us? Well, it's complicated, of course. But here we go...
When it comes to sheer mortality, type 2 is the big killer. Annually it fells more than 3,060,000 people world-wide (the equivalent of euthanizing the entire population of the state of Iowa every year), while type 1 takes out roughly 340,000 of us. Of course, you have to remember that we type 1s are a minority population in the diabetes universe. Where on Earth did I get those numbers? From the World Health Organization's Diabetes fact sheet. But we need to look at more than just the total number of fatalities to see which diabetes is more dangerous. We also need to look to lifespans, it's widely published that we type 1s have much shorter lifespans than type 2s.
But do we?
Type 2s, according to research by Diabetes UK, can expect a decade reduction in life expectancy over "sugar normals." The same report states that type 1s "traditionally" had a 20-year reduction in lifespan, but that this may have lengthened with modern improvements in diabetes care (this assumes changes in government policy and health insurance doesn't wipeout these newly recognized gains).
Why is the lifespan gap closing for type 1s yet stable for type 2s? I think it comes down to the medical qualifications of the docs who treat us. Most type 1s in the developed world are under the care of specialists, and often have access to a team: endos, eye docs, nutritionists, educators, and more. Most type 2s are under the care of a single primary care doc. Nothing against primary care folks, but they just don't have the time and resources that the specialty practices do.
But wait. It's not that simple either.
Where you get your diabetes matters to how bad your complications become as well, regardless of type. Both where in the world you live, and where you are on your country's socioeconomic ladder greatly affects your diabetes outcomes. Diabetes is a social disease—but that's a subject for another day.
Of course: if you don't have access to medications, you will do worse. If you are too poor to see a doctor, you will do worse. If your doc doesn't know what he is doing, you will do worse. If you don't ever have the opportunity to see an educator, how can you learn how to take care of yourself? But those grim relationships between environment and outcomes don't shine a light on the underlying biology of the two primary flavors of diabetes.
But this does: Kids who get type 2 have more complicated complications than kids of the same age with type 1—even when the type 2 kids have had diabetes for a shorter period of time. How much more complicated, and how much shorter time span? A classic study showed that type 2 kids, after having diabetes a mere 1.3 years on average, had more than double the rates of microalbuminuria and hypertension than type 1 kids who'd been members of the club more than five times longer. For those of you who forgot, microalbuminuria is the canary in the coal mine when it comes to kidney failure. That study showed similar rates of neuropathy between the two types, and the only complication that was more common in type 1 kids was eye damage.
So, at least in youth, type 2 is clearly more aggressive in the short run.
More recently, a new study that looked at long-term outcomes (defined as 25 years) between type 1 and type 2 youth who got diabetes at the same age concluded with a sentence so scientifically chilling that I have to quote it, "Young-onset type 2 diabetes has greater mortality and lethality when compared to type 1 diabetes in similar ages of onset."
Something unique may be happening to youth. Maybe mixing diabetes with puberty supersizes the type 2. This is one of the few areas where I could find something close to a head-to-head comparison between the two flavors, and it is very clear that the type 2 is the more wicked of the pair: Both in the short and long runs.
We don't yet have studies comparing outcomes between adult dx'd type 1s and type 2s, or if we do, I wasn't able to find them. Still, given that complications happen faster in type 2s than types 1s of the same age, even though the type 1 kids had diabetes longer; and given that we see more type 2s dying compared to type 1s who got diabetes at the same age, I think we can say the complications (I'm sure you will agree that death is the ultimate complication) are worse for type 2s than for type 1s.
So there's the evidence, as we have it. High blood sugar is toxic, no matter how you get it. The poorer you are, the more likely it is that you won't have the resources and access needed to control it. Both types are difficult to control. Looking to studies of young people seems to be the best way to remove the many layers of social, political, economic, and lifestyle issues that can confuse the data. Unless youth confers some additionally wicked factor to type 2 that doesn't happen in adults (a possibility), it's pretty clear that type 2 is the more complicating disease: it generates complications more rapidly than type 1, and it shortens lifespans more.
But really, the bottom line is that either type sucks, and we can't discount the emotional, psychological, and financial strains of living with diabetes. What's the worst type of diabetes?
I think the worst type of diabetes is the type you have.
Whatever type that is.
This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.