Bring on the Conspiracy Theorists? JAMA Article, Lack of Scientific Rigor, and Type 1 Diabetes Misdiagnosis

In the Summer of 2012, articles started appearing saying that thin people with Type 2 diabetes had a higher mortality rate than overweight/obese people with Type 2 diabetes. The media had a field day with this. The sensationalistic headlines (“When It’s Good to be Fat” in SmartPlanet and “'Obesity Paradox': Why Being Thin with Diabetes Is a Dangerous Combo” in Time) were based on Association of weight status with mortality in adults with incident diabetes (JAMA. 2012 Aug 8;308(6):581-90), which was conducted and published by research scientists who didn’t do the most basic first step of medical science: make sure the study subjects actually have the disease you are studying. Dr. Mercedes Carnethon and colleagues analyzed data from five clinical trials to compare mortality rates among subjects who were normal weight with subjects who were overweight/obese at the time of incident adult-onset diabetes. In this case, hidden far down in the article the JAMA article authors stated, “we are unable to determine whether participants who were normal weight at the time of diabetes incidence in our study have LADA.” In other words, the researchers did not exclude people with latent autoimmune diabetes in adults (LADA), which is slow onset Type 1 autoimmune diabetes, from a study on people with Type 2 diabetes. Very telling, in the JAMA article, 11.2% of the people with “Type 2” diabetes were normal weight (BMI less than 25), and studies published worldwide since 1977 indicate that ~10% of people given the label “Type 2 diabetes” are autoantibody positive, have been incorrectly diagnosed, and in fact have Type 1 autoimmune diabetes. Those 10% have a lower average BMI than the true Type 2s.

Dr. Mercedes Carnethon, the lead researcher in the JAMA study, was quoted in the New York Times saying that “sizable numbers of normal weight people develop Type 2 diabetes” and that Type 2 diabetes patients of normal weight are twice as likely to die as those who are overweight or obese. I would say her quote might be corrected to, “sizeable numbers of normal weight people are misdiagnosed as having Type 2 diabetes when they actually have Type 1 diabetes, and those misdiagnosed individuals will die early due to mistreatment and improper medical care.”

When people with Type 1 diabetes are misdiagnosed as having Type 2 diabetes and given Type 2 treatments (usually starting with a sulfonylurea and/or metformin), they are undertreated and denied life-saving exogenous insulin (insulin is the only appropriate therapy for Type 1 diabetes), which leads to rapid onset of complications with the possibility of early death. So of course the “thin Type 2s” had a higher mortality rate—they had Type 1 diabetes, were denied insulin, and died early.

Following this JAMA study and its aftermath, Anne Peters MD (endocrinologist to Gary Hall Jr, who was diagnosed with Type 1 diabetes at age 24, participated in three Olympics and won 10 Olympic medals in swimming) responded to the Carnethon JAMA article with this Medscape video/article in which she discusses how she treats lean adults with new-onset diabetes. Dr. Peters says, “We know that autoimmune type 1 diabetes -- some people also call this latent autoimmune diabetes of the adult (LADA) -- can occur at any age. My oldest patient with new-onset type 1 diabetes was in her 90s. She was 92 or 93 years old and she presented with pretty florid new-onset diabetes. But I have seen adult-onset type 1 diabetes in patients of any age, from their 20s, 30s, or 40s, and the way to measure this is to look for the presence of [autoantibodies]. Not everybody who has adult-onset type 1 diabetes will have a measureable antibody. Some won't but might appear to me to behave so much like a patient with type 1 diabetes that I will still call it adult-onset type 1 diabetes. The reason that it is so important to differentiate between the types of diabetes is that although initially these patients may respond to oral agents because they still have some residual insulin secretion, they are going to progress much more quickly to needing insulin (usually either a multiple daily insulin regimen or an insulin pump) and they will begin to look more and more like a patient with type 1 diabetes.”

So is it a conspiracy? I would say no, but it is certainly neglecting the most rudimentary rules of science. The lack of scientific rigor has extreme consequences for people with diabetes, including early death. Finally, underlying the goofy and absurd headlines “When It Is Good to be Fat” is a truly tragic situation. People’s lives are shortened as a result of probable misdiagnosis, when if they were simply given exogenous insulin they could live long and hopefully happy and productive lives. Not have their lives cut short because of medical malpractice. First do no harm.


The presence of autoantibodies can be used to distinguish between autoimmune diabetes (Type 1a diabetes) and Type 2 diabetes or other non-autoimmune diabetes (for example, monogenic diabetes (aka MODY)). Autoantibodies are not present in Type 2 diabetes; if autoantibodies are present, the person has Type 1a diabetes (according to the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, “Although the specific etiologies of [Type 2] diabetes are not known, autoimmune destruction of beta cells does not occur.”) The full suite of autoantibodies include GAD, ICA, IA-2, IAA, and ZnT8.

Dear Melitta you may recall my story and how simple it was for me in 1983 at age 42 plus and diagnosed requiring meds ask GP 6 weeks later to put me on insulin ...numbers had not go down much and visited the Lab weekly ...he listened , tests were not available ..I am here to tell the story ..being pro active paid !off

Hi Nel: You are indeed lucky! And of course your persistence paid off. You are also an inspiration in the way you live your life. Thanks!

I know that my pancreas is going caput, but I had the knowledge to argue my case with my Endo that I was LADA before my bg was showing up on the radar. I knew I had a Celiac gene, no Celiac disease. Awareness and getting the word out helped. I'm in good shape after four years plus. In my experience, no one besides my Endo had even heard of LADA. I had to explain to every single doctor. I am very vocal about getting tested. Thank you and others for making people take notice.
Still no insulin, but I exercise like a mad woman and eat very low carb.

Dear Melitta:
Thank you 4 your continued advocacy. Th world needs smart, gutsy patients willing to stand up to the Medical Industrial complex which, sadly, no longer thinks, analyzes, tests it’s hypotheses and conclusions rigorously. You may remember me as “April.” Diagnosed a few years ago first as a thin Pre-diabetic. My father and his sister, also slender, were diagnosed with IDDM, presumed to be Type 1 bc of rapid progression to exogenous insulin injections. Diet and exercise did nothing for me except that with walking 3 mi per day and eliminating virtually all carbs I was losing a pound every other day (and getting scared because I wasn’t very chunky to begin with). My Endo who Dx’d DM tried Onglyza, I tolerated it fine. It h
Just didn’t help. Prandin shot me into hypo territory on 1/2 the smallest dose. I tried long acting insulin - Levemir and it eS HUGELY helpful - but I was getting greedy. I wanted to be able to eat a piece of pie on Thanksgiving Damnitall!!!

Sorry, I did not mean to post that. The bottom line is that I am outrageously Sensitive to Insulin. What does this mean. Well, the assumption is that people who develop diabetes over the age of 40-45 are obese, inactive, do not take care of themselves or their family members

I would like to prove them wrong.

Found this very informative. I have never been to a endo and have the problem of weight loss. I cant seem to put weight on an am loosing more and more. I will be able to see an endo in 6 weeks and then will be able to find out what I have. I have been able to maintain pretty good control but have to run a lot. Do between 8 -12 km per day. Eat very little carbs.

Grace I am 52. Have run over a 100 marathons. Done a heap of ultra's including muti day desert races( racing the Planet) and super fit. Hey was DX January. So you want proof, you have it. D has nothing to do with weight, fitness or lifestyle. If you want to add a few cycle races and triathlons into the mix you welcome. So if their theory is right why the heck am I a diabetic

Melitta I must echo Grace; thank you for your continue, determined research and advocacy for me and the rest of the mis-dx multitude. I am still horrified at the assumption of T2DM in adults by medical professionals simply based on age, and due to lack of education. It seeems such a simple fix: if oral meds don't afford control, first look at the patient, and second be knowledgeable enough to offer antibody testing!

We know that our members are a self-selected group, Most of the population don't know enough to question the 'experts'; I certainly wouldn't have had I not had resources like TuD available. The information here truly saved my life.

I'll be passing the atricle and your blog on to the medical professionals I encounter.

Part of the fundamental problem is that T2 is not an actual diagnsis. It does not exist as a separate condition. We have "diabetes," which can be diagnosed based on blood sugar abnormalities. T1 can be diagnosed with antibodies and c-peptide. MODY can be diagnosed with genetic testing. But if you don't have a specific diagnosis (like T1 or MODY), you are given the diagnosis of exclusion of "T2 diabetes." Technically, we shouldn't even call it T2, we should call it "diabetes," we just don't know the specific diagnosis. And whether many people with "diabetes" (T2) are actually T1, LADA, MODY or some untold number of different specific forms of diabetes is unknown. Clearly if we don't test, we won't know. But even if we do all the tests, we still may not know. These days, my endo now says I have "Ideopathic T1." Whatever that means. I have no specific diagnosis, so I have what everyone calls T2, but I also know that really I just have "diabetes" and no clue about what my specific diagnosis actually is.

Thanks for all the comments. Brian, I couldn't agree more. If doctors first simply diagnosed people as having diabetes, then did some investigation/testing, we'd all be better off. And my apologies to all, I know that Type 1 can be diagnosed in people "not at fighting weight." But the JAMA article was specifically about mortality in lean people with "Type 2."

Dear Melitta,

Thanks so much for sharing this!

It's painful, in this day and age, to see such sloppy research masquerading as science! Thank you so much for your efforts to stand up for better efforts! You help so many people!

I know I'm Type 1, but this is a great reminder about how many people aren't diagnosed correctly and how important it is to help where we can.

Thank you again, and best wishes,


Interesting that Dr. Peters said that not everyone who has adult-onset T1 diabetes has a measurable antibody. Which means that doctors need to be more aware of their patients' needs and not simply spend months following a protocol, only to find out that none of the orals works, and insulin is what is needed, and then follow a gradual insulin protocol. Wastes time and causes unnecessary misery.

Brian, idiopathic simply means without any known cause. If you function like a T1, then you need to be treated as such, just to keep you out of trouble medically. So they don't eyeball you and decide they can omit your insulin. Or have some idiot nurse tell you you can't have insulin for your meal because you tested at 94. Etc.

Melitta, I'm always grateful for your advocacy, even if the dipsticks wouldn't answer you. It's not like you don't know your scientific method!

I am very grateful that my primary doc referred me to an endo when my T2 diagnosis didn’t make sense. I was active, already eating low carb and on target w my weight. Did have antibodies and am on MDI tx. So thankful. Thanks also for shark more about LADA. My endo tells me “type 1 is type 1”.


Melitta, Being new to this site I found your blog very interesting. I was miss diagnosed as T2 2 years ago and only after taking ownership and being my own advocate found an endocrinologist who actually tested my blood for antibodies instead of keep pushing more pills at me that didn't work. Thanks for helping to shed more light!