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 and diabetes author Wil Dubois.

Today Wil's addressing a very basic question that is sometimes more complex than you might think, about identifying different types of diabetes. 

{Got your own questions? Email us at AskDMine@diabetesmine.com }

 

Deb, mystery type from Florida, writes:I was diagnosed as prediabetic at age 50. I was able to control it for years with diet, exercise, and weight loss. Around age 55, my numbers went up due to a traumatic incident, I was considered type 2, and I was put on oral meds. After receiving steroid shots several years later, more orals were added. At age 61, basal insulin was added. Around age 63, my blood sugar was out of control so I was given a continuous glucose monitor for two weeks and blood tests were ordered. From the test results, it was determined that I had antibodies and was reclassified as a type 1. I have never heard of this before. I have been on multiple daily injections ever since. I am so confused. Am I a type 1 or a type 2 or something else altogether?

 

Wil@Ask D’Mine answers: You would think that the question, “Doctor, what type of diabetes do I have?” would be an easy one to answer, but as you’ve experienced, that isn’t always the case. What makes it difficult for docs to know what flavor of diabetes they’re staring at? Well, it’s actually a lot more confusing than you’d think…

Let’s start with “classic” type 1 diabetes diagnosis: A kid shows up half-conscious (or worse) in the ER with crazy-high blood sugar. The mother reports the kid hasn’t felt well for a few weeks. Been peeing a lot. Losing weight. Sleeping all the time. This is an easy diagnosis. Every doc in the country can recognize it, and still today, most cases of type 1 diabetes are diagnosed only after the patient goes into something called Diabetic Ketoacidosis (DKA).

Now let’s look at “classic” type 2 diabetes diagnosis: The doc has been watching a slow-motion metabolic train wreck for years. He’s been lecturing his middle-aged patient to lose weight. Eat better. Get some exercise. The patient’s blood sugar edges up with each annual physical. Finally, it crests the dam. The doc starts an oral pill. And another one the next year. And a third the year after that. When, 5 or 10 years down the road, the pills won’t work anymore, basal insulin is added. Then fast-acting insulin. Again, this is an easy diagnosis, and again, every doc in the country can recognize this flavor of diabetes. 

But then, sometimes, docs found baffling outliers. Type 2s who were diagnosed decades younger than most, who then spiraled out of control quickly. Pills worked for them at first, but proved ineffective in mere months. Basal had to be added quickly, but it wasn’t enough, either. What the heck was going on? Was it some strain of super-sized, super-accelerated type 2? Or… could they be slow-motion type 1s? But they were adults! Everyone knew that type 1 only hit kids, right? After all, it wasn’t that long ago it was called Juvenile Diabetes!

As these mystery diabetics seemed to have elements of both type 1 and type 2, for a time the label "type 1.5" was kicked around. Upon more study, it was recognized that the mystery middle diabetes was an autoimmune condition, and the name Latent Autoimmune Diabetes in Adults, or LADA, was staked out for it. It’s basically adult onset type 1, but for reasons that aren’t clear, the onset time increases with the age of the patient. It moves more slowly than it does in kids. Blood sugars creep up. Initial treatment with pills succeeds, but then fails as the immune response kills off more and more of the insulin-producing beta cells in the pancreas.

But then, as if things weren’t confusing enough, America had an obesity crisis that reached all the way back to the crib, and adolescents began developing type 2 diabetes. Suddenly, or so it seemed, docs now had old people developing young people’s diabetes, young people developing old people’s diabetes, and people in the middle who didn’t seem to fit either mold.

How on earth could a doctor sort out who has what kind of diabetes?

New blood tests came to the rescue. Type 1 and LADA are autoimmune diseases. Type 2 is not. And autoimmune diseases leave their tracks in the form of antibodies than can be tested. There are now a handful of different antibody tests that are used to ferret out type 1/LADA diabetes when docs aren’t sure what kind they are dealing with, and for the most part, the results are unambiguous. If the tests say you are type 1, then you are type 1, no doubt about it. 

So you, my dear, are type 1. Welcome to the family. 

I know what you’re thinking: But isn’t 13 years a rather long onset period for LADA? Yes, it is. Current LADA definitions hold a six-month insulin independent period post-diabetes diagnosis as the standard. A year or two would not be unheard of, but 13 years? Well, that’s much more like what you’d expect from the progression of type 2 diabetes, which, like all other types, eventually ends with total insulin dependence.

But you’ve got antibodies. And even though your age was right for a type 2 needing insulin, it all happened too fast once it hit. So what to make of all of that?

Personally, I think you have more than one kind of diabetes. I think you were developing type 2 diabetes in the “normal” manner in your 50s. Then, sometime in your sixties, LADA came to call. I guess that gives you Polybetes. Don’t google that. I just made it up. But it’s a great word to describe someone who has more than one kind of diabetes.

The fact of the matter is that type 1 and type 2 are separate conditions, and as such, there’s no reason why you can’t have both. It’s like having measles and mumps at the same time. Rare, granted. A pain in the ass, granted. But still entirely possible. 

Realistically, what does this mean for you? Well, as a type 1, you’re stuck with multiple daily injections, or an insulin pump, until the cure—which you should read as “for the rest of your life.” And as a type 2 as well, insulin won’t work as effectively for you as it does for the rest of us, due to increased insulin resistance. You’ll need larger doses, and more aggressive insulin-to-carb ratios and correction factors, to control your blood sugar.

Now, as we all end up at the same place (needing daily insulin), does the "type" of diabetes we have even matter? Personally, I think so, for two reasons: First, knowing the type guides the treatment. If you’re recognized as having LADA early on, pills can be dumped by the wayside and insulin can be optimized, avoiding a period of poor control.

But perhaps more importantly, we humans have a strong sense of tribal affinity. We need to know where we fit into the universe. Knowing our type tells us where we fit into the larger picture of diabetes.

 

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. Bottom Line: You still need the guidance and care of a licensed medical professional.