Double Diabetes

Type 1 and LADA
1

DOUBLE DIABETES

There were no diabetes "types" when I was diagnosed in 1945. All people diagnosed with diabetes were treated with insulin taken from pigs and cows. That crude form of insulin gave me back my health. In the years 1936-1939 it was discovered that there were two types of diabetes, but it was not until 1959 that the labels Type 1 and Type 2 were attached. Oral drugs for Type 2 diabetics were introduced in the years 1955-1956.

Now, in current times, we are seeing more and more people with characteristics of both type 1 and type 2 diabetes. These individuals have "double diabetes". This occurs when:

1. A person with type 1 diabetes becomes overweight and develops the basic feature of type 2 diabetes – insulin resistance (IR). Typically, the type 1 diabetic would then use a type 2 medication to help control the IR. Insulin would still be necessary as well.

2. A person with type 2 diabetes has one of the key features of type 1 – the presence of antibodies in the blood against the insulin producing beta cells of the pancreas causing a decrease in the body's ability to produce insulin. The decreased insulin production can then lead to the type 2 diabetic becoming insulin dependent. These individuals still use their type 2 medication for their IR.

So double diabetics may have initially been either type 1, or type 2. Once they have become double diabetics they have IR, they are using insulin, and they are using a medicine (usually metformin) for their IR. I have several type 1 friends, and type 2 friends, who are double diabetics. Some of my type 2 friends are using a pump and a CGM.

In the 1990s I stopped using animal insulins, and began using synthetic insulins. I began gaining weight, even though I was following a much healthier diet, and eating fewer carbs. The only thing that had changed was my insulin. I have read many reports that say the synthetic insulins cause our cells to store fat. Maybe that was the reason for my weight gain, but I did not know that information until much later. I had never been more than five pounds above my ideal weight (185) until the 1990s. By the year 1997 I weighed 242 pounds. That was a net gain of 57 pounds. A lower carb intake and plenty of exercise did not seem to help at that time.

Finally, in 1998, I was diagnosed with insulin resistance. I had several relatives with Type 2 diabetes, and it seems likely I had the Type 2 gene. The gene and the weight gain are likely the explanation for my insulin resistance. In the early 2000s I reduced my daily carb intake, increased my amount of exercise, and lost 24 pounds. I initially used avandia for my IR, but started using metformin starting in early 2011. Using metformin for one year was very good for me. That medication has helped many diabetics lose weight. I lost an additional 29 pounds, and was then only four pounds above my ideal weight. Despite the weight loss, I still had IR. Metformin, eating an average of 140-150 carbs per day, and getting lots of exercise is now keeping me in good health. My A1c's are typically in the 5.8-6.1 range, and except for some mild nerve damage, I do not have any diabetes complications. Double diabetes can be controlled, and my health is just as good now as it was before I became a double diabetic.

Do you think you may have double diabetes? If you are type 1 and have gained weight, and are using more insulin than usual, then you might want to speak to your doctor (preferably an endo) about this.

2

I believe, Richard, that if a Type 2 has antibodies than they have been misdiagnosed and are, by definition, a Type 1. I know you were diagnosed long before all this complex typing but many of us diagnosed more recently but older in life (I was 58) were misdiagnosed merely due to age. I'm not sure what year they went from calling it "Juvenile Diabetes" to "Type 1 Diabetes" but the myth still lingers. I do believe your category for Type 2's is relevant though for those who having been type 2 for many years no longer produce sufficient insulin and need to take it exogenously.

I personally don't think of it as "double diabetes" which I think is confusing but as a Type 1 who has developed insulin resistance or a Type 2 who "now needs insulin". Perhaps that is mere semantics, and I apologize if so, but having been misdiagnosed I'm a bit sensitive to keeping the types clear!

3

I don’t entirely agree with Zoe. I think a significant amount of the general population has detectable levels of antibodies and never develop any sort of diabetes, therefore why couldn’t a type 2 also have antibodies that aren’t the source of their insulin resistance. I (and my endo) tend to more and more discount the type 1 / type 2 model and view the disease as a spectrum at which there are significant numbers at both extreme ends, and some, such as myself, somewhere in the middle.

4

Sam, I agree with you and your endo. Maybe that will be recognized by the medical profession someday. A T1 with IR is still a T1, with a T2 characteristic. That does make them a T2. Double Diabetes is recognized in some diabetes health magazines and by some reliable sources. You can find them on your browser.

5

Richard, in your post above did you mean to say, "...a T1 with IR is still a T1, with a T2 characteristic. That doesnot make them a type 2?

6

I was diagnosed in 1991 and they were calling it juvenile diabetes back then, although I also remember Type 1 being used as well. I think it was the late 1990s Type 1 began being called just Type 1 and the juvenile part was phased out.

I have gained weight over the years and definitely use a lot more insulin than I used to. But I don't think I have insulin resistance. If I lost weight, I'm sure my insulin dose would go back down to what it was before I gained the weight. Losing weight is definitely a huge challenge, and something that used to frustrate me.

I think it's harder for me than for people without diabetes, but I've come to believe that if I really put sustained effort into it, I can do it. It's finding the time and willpower for sustained effort that's challenging, but it's going to become my one Big Goal once I am done my M.A. this spring.

7

I agree, Richard. Type 1 and Type 2 may as well be called by 2 separate things entirely because they are in no way related, and both of my doctors confirmed that an individual can have Type 1 diabetes, then go on later to develop Type 2 as well (or vice versa). Imagine if our immune systems hadn't attacked our pancreas at all. We could still develop Type 2 diabetes down the road. Or imagine if we had a pancreas transplant and our system didn't attack the new pancreas, but we could still go on to develop Type 2 later. Since Type 1 is defined as insulin deficiency with the source being that our immune system attacked our islet cells, and Type 2 isn't an assault by the immune system at all. True that Type 2s can then also become insulin deficient after their islet cells are exhausted, but it's an entirely different mechanism by which it happens. But yes, many individuals do indeed have "double diabetes." I just wonder in a few years with "smart insulin", the BioHub, ViaCyte, etc how if that will change things for the better for both types.

8

Zoe, it is believed by many of my type 1 friends who are T1 with IR, that we are only T1, and not also T2. The occurrence of IR is just another complication, but the T1 is not therefore a T2. It takes more than IR to make an individual a T2. The T2 will still produce some insulin, the T1 will not.

This comes from a discussion with some of my T1 friends who have IR. It is not a decision made by medical professionals. So I don't have a better answer than that at this time. I researched this on Google but did not find a definite answer.

9

I understand, Jen. It was during my years of teaching, and with less exercise, that I gained weight. My doctor diagnosed IR, but he is an internist, not an endo. Maybe an endo would not have given that diagnosis. He based his diagnosis on my weight gain, and increased insulin dosages....that and nothing more. He would probably say you have IR too, but your way of looking at it may be more correct.

10

I agree, Richard!

11

But who’s to say insulin resistance can’t trigger an autoimmune response? Who’s to say autoimmune tendencies can’t cause some insulin resistance… Who’s to say these 2 things can’t present simultaneously as part of the same condition. In reality these are all unknowns. In my mind, part of the confusion has been how much the bar has been lowered for the diagnosis of type 2 diabetes. Currently many people are diagnosed with type 2 if they are just tending to run a little higher than normal… Historically, in the early days… diagnosis was only made of “diabetes” when it was totally out of control and the patient was peeing sugar all over the place, thus there really was no real reason or potential to consider 2 different etiologies at that point in history. Diabetes was diabetes and it was rapidly fatal until the invention of insulin. There are many people, like me, for whom a perfect diagnosis of type 1 or 2 can’t really be made with any certainty. I was slightly GAD positive, but I have a normal c peptide, yet was essentially in crisis by the time diagnosed, so obviously there is insulin resistance at work to some extent as well. Frankly I don’t completely identify with either type 1 or type 2. I just consider myself a diabetic, somewhere on the spectrum. I found the book “Diabetes Rising” very interesting, he author talks a lot about the history of diabetes, as well as the current issues and research. He also has a chapter on research regarding the “accelerator theory” which looks at the link between insulin resistance and type 1… The researchers hypothesis is type 1 and 2 are really just different ends of the same spectrum and there are many points between the two of the same spectrum. Made a lot of sense to me, and I could certainly relate.

12

Richard, I agree that quite a few people with Type 1 will go on to develop IR. and some number of LADAs (which is just Type 1 at an older age) will have IR or develop IR. but I believe your Item #2 (Type 2s who are antibody positive) is not correct. “Type 2s” who are autoantibody positive are actually misdiagnosed Type 1s, an incredibly common occurrence. As the WHO and ADA definition says, autoantibodies are not present in Type 2 diabetes.

13

Thanks, Jen; I was wondering what year that happened.

14

I’m just not convinced its simple enough to define in a black and white statement like that, in reality I think there are a whole lot of shades of gray

15

Actually, several studies have proven that up to 20% of T2's have antibodies for no known reason. Though I agree that many, many T2's are misdiagnosed and are really T1's, I really doubt that number is as high as 20%.

16

Actually, 20% is precisely the number that John Walsh says are misdiagnosed Type 1's.

17

Richard - As best as I can tell, I am a LADA T1D. I was diagnosed T1D in 1984 and no antibodies were checked at the time but my D onset did not present with DKA. First indications were the classical thirst and peeing and finally blurred vision. Looking back I had diabetes symptoms, reactive hypoglycemia and slow wound healing in the year before my diagnosis.

Over the years I slowly gained weight, about 20 pounds in ten years. My insulin needs slowly crept up from 40 units/day up to 60 or 80. I finally got to a point where some correction doses didn't work at all.

Last year I went low carb, lost weight, regained BG control. and reduced total daily insulin intake to the 30-40 range. A 2012 Liposcience cholesterol panel showed good insulin sensitivity. Insulin correction doses now work in a consistent expected manner.

I believe that I am a T1D autoimmune diabetic. I further believe that as a result of over-aggresive insulin administration that I gained enough weight over time to develop insulin resistance, a classic T2 characteristic. I don't believe that I'm a double diabetic, just one whose T1D past includes episodes of IR. Interesting post.

18

I have to say, in my view double diabetes just doesn't exist. T2 diabetes is a diagnosis by exclusion. If you have autoimmune T1, you have a specific diagnosis, there is a set of tests which confirm the diagnosis and we believe we understand how it happens. But T2 isn't like that. There isn't any T2 test. If you have abnormal blood sugar regulation but don't have any specific diagnosis (like T1 or MODY), then you are given a diagnosis of T2 "by exclusion." And if you don't bother to try to exclude any other specific diagnosis (like Mellita describes), then you get a misdiagnosis of T2.

And T2 is not some singular thing about having IR. It has been described as a spectrum of as many as eight separate defects. And it is probably the case that T2 consists of a number of actual disorders which we have yet to be able to figure out, understand how they happen and actually test for. And one of the defects in T2 is insulin deficiency, exactly the defect that appears in T1. But that doesn't make T1s automagically T2 and it doesn't make T2s automagically T1.. Sure, the defects that present in both sets of patients may overlap, but because T2 is a diagnosis by exclusion, you can't properly be diagnosed with T2 if you are already T1.

Just my opinion.

19

Is there some definition or test for IR? I was discussing this w/ some other folks yesterday (Richard on FB...) and noted that some people have higher Carb/insulin ratios than others which isn't in and of itself that big of a deal, as everything always varies from person to person but mine (7.7) seemed closer to "resistant" than to "fine" although, w/ T1, the rx is generally to just take more insulin to maintain one's balance. There were a couple people chatting about it but I found it interesting that one person mentioned an 18 year old who reported 5ish CI ratios w/o Met but 15ish with Met. This, along with Richard's report and others mentioning the untility of Met w/ T1 makes me think that however different the conditions are, perhaps they are more closely related than we might think?

20

My internal medicine doctor recognized my increased insulin dosages and that it was continually increasing over a long period of time, probably a year. He diagnosed IR in 1998. There was no specific testing done, however there are tests for IR at the present time. Look at the following link:

http://www.news-medical.net/health/Insulin-Resistance-Diagnosis.aspx