Proposal to Drop Type 1 and Type 2 Classification

I think what they do is Dx type 2, and only if you don’t respond to T2 drugs do they look more closely. Unless, of course, you’re in DKA. And that could be type 1, LADA, ketosis-prone diabetes, or some as-yet unrecognized type.

One problem with running a lot of tests right off is that it would run up costs, and people with diabetes would be reviled even more than they are now.

One trip to the ER offsets the cost of many tests. Most of the tests are far less expensive than the test to confirm other serious or chronic conditions, often starting with less-confirming evidence than many people with just-diagnosed diabetes exhibit. I’d rather test, test, test.

I hear these complaints about cost, but I consider that to be totally unfounded. I just looked back, my insurance rate for the antibody tests is about $20 each and the c-peptide is $21. I recently had a genetic tests done (for another condition) for $60. These tests are either already entirely affordable or could be made very affordable if done competitively at scale.

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I agree. But when the public doesn’t understand difference between what is currently called Type 1 and Type 2, they’re unlikely to understand that early Dx and treatment is cheaper than letting things progress until your feet fall off.

Some tests are relatively cheap, but others, like the MODY tests, are not.

You are correct at this time the MODY tests are like $5,000. But AthenaDiagnostics holds a complete monopoly on MODY tests in the US. The minute doctors start to routinely order the test the price will drop by a factor of 10-100x as competition sets in. This is exactly what has happened with other genetic tests which are now offered by QuestDiagnositics and Labcorp. The actual “cost” of the MODY tests charged by places like Exeter is more like $100.

As you know, Brian, about 10% of people diagnosed with “Type 2” diabetes are autoantibody positive, have Type 1a diabetes, and have been misdiagnosed. Missing 1 in 10 doesn’t seem accurate to me, and obviously if all people with slowly-progressive Type 1 diabetes are included in the Type 1 stats, as they should be, Type 2 is not 95% of all cases of diabetes.

I understand your theory I realize that studies show that Type 2s and non-diabetics test positive for antibodies but they are not considered T1 by the medical field. Even if we accept that all these people are T1 my point is that the “wave the hands” diagnosis is very, very accurate and will continue to be the norm. Unless we demand more specificity in diagnosis this is unlikely to change. And the way to demand more specificity is to do as Schwarz suggests and not lump all of T2 into one big dumping ground of “diabetes of unknown cause.”

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Even if classifications were dropped I still hear people saying “you must have the bad kind” which is no different than what happens now. People see an insulin pump and know I’m on insulin so I must have the bad kind.

Furthermore, in the maternal fetal medicine office today getting an NST and the nurse asks me if I’m diet controlled. I had to tell her twice I’m type 1 and on a pump. Different than most of her diabetic patients that are diet controlled or on pills.

I say keep the classifications because the majority of the time type 1 and 2 are approached differently.

I think the issue with the disease classifications is that T2 is a quilt of different conditions which are not entirely understood. “From the Triumvirate to the Ominous Octet” goes into more detail than I can totally understand, being biochemically oblivious. I do find it somewhat reasonable to link the diseases as their end games, in the absence of control*, can be very similar. Clinical analysis and classification of T2 variants would greatly improve the level of care T2 patients might receive. I’m not sure a new name is a good idea, because 1) the endgame and 2) the fact that it’s one of the oldest diseases recognized by humanity. T1 and T2 should stick together as long as we can, even if T2 ends up T2a, T2b…T2s, etc.

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[quote=“Brian_BSC, post:1, topic:50659, full:true”]
I’ve long felt that the classification of diabetes into T1 and T2 is just messed up.

I just don’t have “feelings” about stuff like this. I have noted for decades how different the conditions are and how the diabetics (you know the ones who wear this crap around) are the first to point out the differences.

T2 is just a hodgepodge of different things and a diagnosis of T2 really means diabetes of unknown cause and the diagnosis for many is not really useful in guiding treatment.

Yep, and dropping classification will resolve this?? For reals?!?

A recent editorial article on DiabetesInControl discusses a view proposed by Dr. Stanley Schwarz to do away with the current messed up system and instead adopt a more useful model that identifies the pathways that contribute to hyperglycemia. The article by Schwarz in Diabetes Care is not available to non-subscribers but will presumable be available in three months.

There is also an interest interview of Dr. Schwarz by Steve Freed (if you listen to Dr. B’s monthly teleconferences you will recognize Steve’s voice).

What do you think of the idea of changing the diagnostic classification of diabetes?

I think it is fine so long as folks get a proper dx and treated as needed. What are you doing to pursue this endeavor? My classification meets my needs so I’m just okay with it. But being in the original tribe before the hodgepodge might be a “bad thing” now - I don’t want a new name/number/testing BS.

ps. Some additional discussion can be found in the topic " Proposed New Classification: No More Type 1 or Type 2 Diabetes."[/quote]

ps. That thread was closed by you…why are you suggesting we go there?!?

This “Proposal” is just silly and looks like another attempt to promote difference and solve nothing. Way to Go! What would you suggest for the “reclassification” to make you “feel better”? Have you done anything solid to make that happen?

@karen57 – I have a few suggestions about your comment because I think its format tends to confuse. You quote a large block of @Brian_BSC’s original post. But then you inserted your comments in bold format within his block of quoted text. I know, because I have been following this thread that these bolded comments are yours and not @Brian_BSC’s but others may not.

This topic was started by @Brian_BSC and several comments were made. In the meantime another member unintentionally started a duplicate thread on the same topic. When this second thread initiator realized this he posted a comment in his own thread and suggested that Brian lock that thread so as to drive all future comments to a single thread. Brian, as administrator, complied with this polite and unselfish request.

Brian’s suggestion for readers to look at the duplicate thread was made when he knew that two threads on the same topic were now open. Brian was acting politely toward the second and duplicate thread poster. Once the second thread was locked, Brian’s reference to it was now not timely.

I don’t like the combative tone that you have taken here based in part by your misunderstanding of the history of this thread. You may go back to the locked thread and review if you’re interested.

I apologize for my dive into the meta but I think it’s fueling provocation where none was intended.

Brian, you know full well that this is not “my theory.” Certainly a very credible source is “The Type 1 Diabetes Sourcebook” (ADA/JDRF 2013), in which Michael Haller MD states, “Adults with LADA [latent autoimmune diabetes in adults or slowly progressive Type 1 diabetes] may represent 10% of those adults incorrectly diagnosed with Type 2 diabetes. Clinicians treating adults must be aware of the need to screen for LADA, particularly in their patients with relatively low BMI.” And regarding your statement that those autoantibody-positive people are not considered Type 1 by the medical field? If your statement is true, then why do the (medical field) editors of “The Type 1 Diabetes Sourcebook” say, “We consider all patients with evidence of autoimmunity to have Type 1 diabetes?” And the (medical field) Expert Committee on the Diagnosis and Classification of DM says that the etiology of Type 2 is unknown, but “autoimmune destruction of beta-cells does not occur.” Brian, the subject that you used for this thread was “Proposal to Drop Type 1 and Type 2 Classification.” Not “Working to Get Better Classifications and Care for People with Type 2.” Autoimmune diabetes shouldn’t be part of that discussion, IMO.

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So why are those doctors’ (who wrote the book you cite) professional opinions so much more valid than the vast vast majority of doctors who are not diagnosing strictly based on this protocol, which to me seems tremendously overly simplistic? Is the assumption just that everyone who doesn’t agree is flat wrong or poorly educated? That’s a legitimate question, and I know it’s a subject you are very passionate and well read on the subject so I hope you’d take the time to reply?

Melitta, I understand what you are saying I just have a different view. This is really all besides the point, none of the proposal suggests dropping antibody testing. It appears that a number of people have very disparate views of the consequences of this proposed change in classification. I argue that this change will increase the rate of testing for antibodies and insulin deficiency in all people with abnormal blood sugars. This is because doctors will have to do real work to diagnose, they can’t just “assume” everyone is T2.

I haven’t quite watched the whole video however I’m not sure I disagree with his assertion that there needs to be additional classifications for perhaps both T1 and T2. I think the issue may become getting this past the insurance industry which “needs” the classifications to evaluate coverage. If we were all out of pocket, it would be simple to just go out and shop for pumps, CGMs and oral meds to manage the melange of conditions we might encounter. I hope that at the end of the video, he comes up with a clever strategy to leverage this but I only have about 2:30 left…

Fair enough but we also have to realize that it isn’t just insurance. The FDA approves drugs for the “types” of diabetes. There are a fair number of drugs approved for T2 that have been found useful in addressing the same defects in T1. The FDA would have to adopt such a classification as well and when drugs are approved to treat a certain defect that would presumably flow down to insurance coverage. I actually don’t think Schwarz or others have necessarily thought about the downstream issues, they are just considering the scientific aspects of classification.

It’s very academic and interesting and very much in line with the many experiences people have shared of YDMMV situations but the money issue will be a very tough hurdle for Doctor Schwartz. I perceive him to be very active but I’m not sure that taking on FDA classifications or feuding with insurers is part of his long-term plan. Which is unfortunate.

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I do no agree with this. Type I and Type II are fine with me. Adding all these other names for Diabetes will further confuse the general public in my opinion. I do like some of these ideas though like how it would help to identify and treat the cause of the Diabetes but I don’t think it is necessary to change the classifications for that.

I haven’t posted here for ages, but I read Schwartz’s paper and I’ve heard DiFronzo speak. I think that there is a central scientific factor here that has been ignored in this discussion.

It is the fact that you can’t biopsy islets, so inferences about what a particular patient’s beta cells are doing are extremely unreliable. Moreover, you can’t biopsy or directly monitor in a physiologically or medically meaningful way any of the ‘alliterative allies’, whether it be the terrible trio, the ominous octet (DiFronzo). the egregious eleven (Schwartz), or (in the future) the ‘twirpy twenty three.’ Even if you could monitor them, you’d need a quantitative model of how they interact in order to understand the effects of theraputic interventions.

In the absence of the above, a reclassification scheme is meaningless, and the allterative classification scheme is just an updated version of old medical theories where all diseases were imbalances of the ‘four humors’, Schwartz appears to want to get patients off of insulin. which I think is motivated by the fact that he doesn’t trust patients to regulate their own BG with insulin. That may or may not be a general problem, but certainly not with many posters here.

I think that the central change needed is to educate physicians that the cause of type 2 is UNKNOWN. From my observations (from the inside) of the biomedical reserach community, I am pessimistic that this well happen soon. Keep in mind the example of stomach ulcers. Whem I was a child, every physician KNEW that they were caused by ‘lifestyle decisions’–stress, spicy food, etc. It is now known that they are a consequence of H. pylori infection. The analogy to diabetes (and other so-called 'diseases of civilization) are clear.

In the absence of scientific breakthroughs, this fundamental lack of knowledge means that the best that can be done is that physicians try a variety of treatments according to the response and individual characteristics of each patient. The key point is that there are a certain set of classes of diabetes where the etiology is known–autoimmune (T1), single gene mutations (MODY), and others. This is why Mellita is correct to campaign for every newly diagnosed person to tested for antibodies. The cause of type 2 diabetes is NOT KNOWN. Moreover, Brian is correct to say that type 2 is ‘type X’ or ‘type other’–it is a mix of different conditions.

–zzyzx
No auto antibodies, otherwise indisguinishable from T1 except (maybe??) less susceptible to hypoglycemia .

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