I have seen a lot of posts here about how there are different kinds of Type 2 and that it's not really fully understood, basically anyone who is not Type 1 or one of the rarer forms of diabetes like MODY is Type 2. And this is why some Type 2s can use diet and exercise for a long time while others need insulin after a little while, why some are overweight and some are skinny, why some find control relatively easy and others find it difficult.
Which makes total sense to me. And also got me thinking, are there also different kind of Type 1?
On another diabetes forum I am on there is a post about whether testing 8-10x per day is too much. Some people replied saying that they have great control only testing 4-5x per day. Some replied saying they need to test 8-10x per day to get good control. Some (like me) replied that even testing that much we have trouble obtaining great control.
So I was thinking, is it ALL just environmental factors like what you eat, exercise, daily schedule, and so on? I know I myself have simplified a lot of these (eating low carbohydrate, exercising daily, keeping schedule consistent) and haven't seen any improvement at all in my control. But I know there are others who don't do half that stuff and yet maintain good control.
So, could I actually have a different kind of Type 1 diabetes than the person who is able to stay in range 90% of the time and have an A1c of 5.7%? Different levels of insulin production, autoimmune attack, other hormones or areas that might be involved/associated with Type 1?
What do you think? I don't know much about the hard core science of Type 1 so maybe I am stating something that is already obvious or has already been disproven. But if there are lots of different kinds of Type 2 and MODY and such, doesn't it make sense there could also be different kinds of Type 1 and have different end results?
I think there is some truth to that. I just read a interesting article last night about Joslin medal winners. How they are wondering what the common factor is that so many of these people reaching the 50 year mark are relatively complication free.
There are different kinds of people so there's likely to be different kinds of T1, T2, Alzheimer's, ALS and any other ghastly disorder one might come up with.
Interesting! Have they ruled out that the 50-year medalists just had tighter control than everyone else for some reason? I don't think I know anyone who has had diabetes for 50 years in person. I know a few who have had it for 45 years, but all of them have complications.
I am diagnosed as a secondary Type 1. To me it is the same as a T1, I take insulin 4 times a day and Pills 2 times a day. They call it secondary because my main problem is my pancreas (Due to having severe Pancreatitus). My Endo says my Pancreas will never operate normal again but I pray that it will some day.
I've always viewed Diabetes as a spectrum disorder for lack of better words. There are primarily two issues (spectrums) at hand that each and every Diabetic has to deal with to one extreme or the other. Regardless of Type, the two issues at hand are insulin production (one either produces enough or not) and sensitivity/resistance, which are just opposite ends of the second spectrum.
Type 1's clearly have production issues although I suspect the degree of deficiency can vary from one individual to the next making management easier for some and harder for others. Type 1's also deal with sensitivity/resistance issues as well . . ie, varying I:C ratios with some even going on to develop the severity of insulin resistance issues of a Type 2.
Type 2's production issues may be a little murkier. Clearly there are production issues as the pancreas is limited in how much insulin it can produce . . . seriously . . . if only the pancreas would make enough, isn't this a production issue? However, this is why diet, exercise and drugs associated with T2 can be so effective. Lower the resistance and the pancreas is now capable of sustaining homeostasis, or increase production if needed to overcome resistance . . . or do both.
However, even among those T2's there are those in which the drugs just don't cut it so exogenous insulin is required. Some take serious amounts of insulin and some like me don't. I get by on a TDD of 45-50u.
At one point my doctor asked me what type I thought I was. I told him I clearly wasn't your stereo typical T1 and not exactly a typical T2 either. He suggested that some people are hard to type and not to spend to much effor to figure it out, what's really important is getting a handle on management.
Yes I found it very interesting to. Unfortunately this article doesn't really go into a lot of detail at how well these people have been under control or much information like that. I imagine they have had good control...but when you think over the course of 50 years, control could have only been SO good 50 years ago. I find it strange too, how some people can seem to not be in as good of control and remain relatively free of complications, while others seem more prone to complications regardless of how well they control. I certainly think good control is key, but it kind of makes you wonder if there isn't also I dont know other factors as well, our genetic make-up, etc that doesn't also have a hand in the control we keep and the complications we may or may not develop.
My personal thought is, I think it has something to do with the longer you can remain complication free, the less chance you have of developing certain problems.
A lot of health problems have peak ages where incident is higher to develop, but that chance decreases after a certain age. Might have something to do with this too.
Well, the definition of Type 1 is auto-immune destruction of the beta cells, so in that sense, there is only one kind of Type 1. But there are a lot of other variables that come into play that make each person with Type 1 different from the others. As someone else said, insulin resistance occurs on a spectrum; it's not an either/or proposition. If you are more insulin resistant, you can make larger errors of insulin dosage, and not see such wide swings of BGs. And insulin production varies, too -- some Type 1's make detectable amounts of insulin -- maybe enough to make control easier, while others make none at all. Thirdly, each person's gut, adipose tissue and brain hormones are different, and some people apportion more of their glucose to the energy bucket, and some more to the fat bucket, and that will make a difference in blood sugars, too, because the energy people will have better glucose transporters in their cells, and burn glucose much more efficiently. And then there must be genetic or environmental factors that determine why some people get complications and others don't. It's NOT just glucose, but how the cells in the body respond to high glucose. If they don't glycate easily, maybe those people won't get complications.
So the ultimate answer is, yes, people with Type 1 DO vary a lot, and no one treatment or diet or routine fits all.
It is certainly true that blood sugar control is not just all about insulin. In non-diabetics, glucagon plays an important role counterbalancing insulin in maintaining good blood sugar control. But beyond these there are clearly other factors which affect blood sugar control, and they are not little things. These are things which can just mess you up big time. For instance, sodium is known to play a critical role in glucose uptake and hence sodium deficiency can impair the efficiency of insulin. I guess it would be safe to say that this is probably true for most of the electrolytes, I have seen mention of potassium, magnesium and zinc all implicated in the overall metabolic processes. So basically, if you are having trouble with your electrolytes, then that can further mess things up. And these problems may or may not be related to your T1.
And other autoimmune conditions occur together with T1. In fact there is a name for it, PolyGlandular Autoimmune Syndrome. PGA links T1 with other autoimmune conditions (in a cluster of conditions) like Addisons disease, thyroid conditions, myasthenia gravis, celiac, pernacious anemia and other disorders. Many of these can make blood sugar control difficult. PGA is thought to be genetically linked to specific HLA haplotypes. PGA often occurs when you are in your 30s and 40s.
And as to your question about MODY. It is entirely possible to have both T1 and MODY. Most would consider them independent problems. But most forms of MODY are characterized by good insulin sensitivity and you would expect that you would actually respond well to insulin. In the case of MODY-3, you have a reduced natural insulin response at high blood sugar levels, but their blood sugar responds well to external insulin (amost too well). You still struggle. You probably don't have MODY.
I don't mean to scare you. But there are lots of things that could be happening. And your latest problems may simply be some other form of health problem which has thrown your body out of whack. It may well turn out to be totally unrelated to your diabetes.
Yes, there are different kinds of type 1s. I know that one thing the Joslin medalist study was looking at was whether the people who have made it 50+ years without complications have some sort of residual insulin production and, with that small amount of insulin production, have been able to maintain tighter control than some other type 1s, thus resulting in their longevity. Presence of residual insulin production may be seen in some individuals with type 1s and not others because of differing kinds of the condition.
Type 1 diabetes actually has several different subtypes - type 1A is the classic form of the condition (autoimmune). Type 1B is an idiopathic form of type 1 that can be transient or permanent. Then there are the various genetic mutations that result in MODY (frequently children who actually have MODY are diagnosed as having type 1). There's also LADA and then I think a few other specific genetic mutations that result in type 1. Finally, people can develop type 1 diabetes because of specific injuries or illnesses that affect the pancreas.
There is so much that is not known about type 1 diabetes; for example, when the beta cells in the pancreas are destroyed by the immune system, it's not just insulin production that is lost. Many type 1s also lose the ability to produce amylin, leptin, and c-peptide (a molecular precursor to insulin). Little is known about the role these hormones play in the development of complications. It could explain why there are some type 1s who, despite having excellent A1Cs, still go on to develop complications. And why some type 1s who have had horrible A1Cs don't develop any complications. And why some type 1s are able to easily maintain control while others cannot. It's quite plausible that there are even different kinds of autoimmune attacks on the pancreas, some of which result in more complete beta cell destruction than others.
Bottom line: there is still SO MUCH we don't know about type 1 diabetes.
No, that's not true. There is type 1A and type 1B diabetes. People with Type 1B diabetes have impaired insulin production but do not have the antibodies seen in type 1A diabetics. (see http://www.nejm.org/doi/full/10.1056/nejm200002033420501).
Strictly speaking, "type 1" diabetes refers to lack of insulin production (thus making a person dependent on exogenous insulin). But the causes for that lack of insulin production can vary. Someone who has his/her pancreas removed because of a tumor, for example, will be classified as a type 1 diabetic because they do not make insulin. However, they will not have antibodies.
Treatment has come a long way in just the past few years. Research seems to say that D is diffferent in everyone. I just do what the Endo says and keep the A1C's down in the normal range (whatever that means). For me 6.0-6.4 makes my Endo and me satiisfied. So much we don't know. Yet. To be continued...........
Wow, had no idea you could have MODY plus Type 1. I did know you can have Type 1 plus Type 2, though. I've also heard of people who thought they had Type 1 for years and then find out as an adult they really have MODY.
I think with the problems I've been having lately I just want some cause, no matter how horrible (I mean, better to know and deal with it than not). My blood sugars were actually decent yesterday and hopefully today as well. Amazing how much better that alone makes me feel!
Type 1b is just the way that some researchers characterize the diabetes that occurs primarily in blacks, but sometimes in Asians and Native Americans, in which they present in DKA, but are able to go off insulin when they get back in control. Halle Berry has that type of diabetes. Other terms for it are Ketosis-Prone Type 2, and Flatbush Diabetes. MIchael Barker has very good information on it on his webpage. Because of the lack of consistency in describing it, I didn't include it in my definition of Type 1. It's really a totally different disease from classic Type 1.
In addition, lack of insulin production is NOT the characteristic feature of Type 1's, or else all Type 2's who lose insulin function would turn into Type 1's. People with surgically induced diabetes are considered "other".
But I agree, diabetes terminology is confusing and incomplete. I don't think they have described all the types of diabetes that are out there, and wouldn't be surprised if they change terminology yet again some time in the future.
I have been considering that the degree of endogenous insulin production may have quite a bit to do with a T1s overall control. I have been toying with this idea for a bit and would be interested to do a study on T1s. Here goes some of the initial ideas:
If a T1 still produces some endogenous insulin, then they would likely require a lower TDD and be able to maintain better control without as much work. Or rather: the lower your TDD (per body weight) the more endogenous insulin you make (everything else equal). More endogenous insulin production could equate to lower A1Cs, less extreme hypos/hypers, less work (finger sticks) to maintain control, more BGs in target range, etc.
This may also be true for I:C ratios. The lower a T1s I:C ratio (average) means that their residual beta cells (endogenous insulin) are more capable of keeping post paradinals down leading to better control. Is there any merit to these ideas? Jen, if you are on the low-end of endogenous insulin production, then this may help explain why controling your T1 has been more difficult?
Hi Jen: I am sorry that you are having problems achieving the control that you want to achieve. I always say that perfect control is just not achievable with our present technology.
I think it is easier to discuss autoimmune diabetes rather than Type 1 diabetes, since idiopathic T1 is quite different. In the autoimmune diabetes category, I personally believe that it is the amount of endogenous insulin production that makes the huge difference in control. People who are newly diagnosed and in their honeymoon have a lot easier time than post-honeymoon. And many diagnosed with Type 1 autoimmune diabetes as adults retain some remnant insulin production, which makes control easier (in the DCCT, all of the trial subjects who were diagnosed with T1 as adults had measurable c-peptide, indicating insulin production, according to DCCT researcher Bernie Zinman MD). Then, as a number of people suggest, some people with autoimmune diabetes develop insulin resistance, which would also make control more difficult. And I am sure there are other factors.
Bottom line, kudos to you for doing all you can for yourself, and it is not your fault that your control is (sometimes) not what you want!
Hi Capin101. It all stays complicated. Diagnosed in 1993, I apparently still make some insulin from approx. noon/1:00 PM until approx. 3:00 PM. I have to arrange my basal around it. My 5 units of Levemir at 9:30 PM covers the dawn phenomenon; then at approx. 8:00 AM, I take 1 1/2 units of Levemir; at about 2:30/3:00 PM another 1 1/2. As a result I'm always checking my watch for the time since mistakes throws my blood sugar way, way off. I hope that in the long run the insulin I produce is making me healthier! (I'm without a doubt LADA/Type 1.)
