Types of Diabetes (The worst kind of Diabetes part 2)

Types of Diabetes

(the worst kind of Diabetes part 2)

This past week I posted a blog that got way more attention than I had ever bargained for. What I posted was about an overheard conversation in the doctor’s office between two people who were a bit uneducated about the types and causes of diabetes. This post elicited responses that were for the most part valid and even insightful. However, one line of the post mentioned a phrase that caught some people’s spirit and they commented on it. Here is the line verbatim from the post “the Worst Kind of Diabetes”:

“The wife said he needed to call the doctor when they left and find out because it made a big difference. “You know she said you do not want that killer diabetes”. He said no he did not think he had the “killer” kind because the doctor said “lose some weight and I will be cured”(Phillips, 2014). The entire post can be read in the blog section of the web site and of course most of you reading this today read the entire post, so I am not telling you anything you do not know.

I was disheartened however by some posts that turned the discussion of my blog into a discussion of which kind of diabetes was worse. No single blog I have done has elicited either the number o the type responses this one elicited. Along the way I asked people twice to not turn the discussion into a debate about who has it worse. Despite that request, a few responders continued that line of discussion and without the intervention of some kind commentators it may still be continuing. I hope not.

At any rate I want to say that I though the most profound statement in the discussion came from Lloyd who said “The worst kind of diabetes is the kind you ignore” (Mann, 2014). For me at least that was the truest and most insightful statement in the post. While the statement seems self-evident it does reveal a basic truth. The truth is that diabetes is a dangerous and awful disease. It does not matter the type.

I think what is missing is a basic understanding that there are more than two types of diabetes. In 2004 The American Diabetes Association (ADA) released a position paper outlying the various types of Diabetes ("Diagnosis and Classification of Diabetes Mellitus,"). With one addition these are the identified types of diabetes:

Type 1: This was identified in 2004 as exhibiting the destruction of Beta Cells in the pancreas because of genetic abnormality. In 2004 the ADA estimated that this represents 5% to 10% of diabetics ("Diagnosis and Classification of Diabetes Mellitus," 2004). It is also the general category that most of the remaining similar, but very different types of diabetes are included. The paper says specifically that Type 1’s exhibit this kind of immune reaction

“Markers of the immune destruction of the β-cell include islet cell autoantibodies, autoantibodies to insulin, autoantibodies to glutamic acid decarboxylase (GAD65), and autoantibodies to the tyrosine phosphatases IA-2 and IA-2β. One and usually more of these autoantibodies are present in 85–90% of individuals when fasting hyperglycemia is initially detected. Also, the disease has strong HLA associations, with linkage to the DQA and DQB genes, and it is influenced by the DRB genes. These HLA-DR/DQ alleles can be either predisposing or protective” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Type 1.5 (LADA): This type of diabetes was hinted at, but not specifically identified in the 2004 classification system. LADA (Latent autoimmune diabetes of adults) is characterized by typical type 1 genetic causes, but later in life. Sometimes well into a person’s 90’s. In fact some LADA's are misidentified as Type 2 Diabetics. The term is a bit slippery but in 2004 the ADA classification system the opening was given for a diagnosis of LADA when the report sated the following:

“Immune-mediated diabetes commonly occurs in childhood and adolescence, but it can occur at any age, even in the 8th and 9th decades of life” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

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I suggest everyone read it if you are seriously interested in the topic.

Type 2: This is the most common diagnosis in 2004 the ADA estimated that between 90% and 95% of all Diabetics fell into this category ("Diagnosis and Classification of Diabetes Mellitus," 2004). This category is typically identified as:

“Ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

From there the types of diabetes grow more diverse but now less complicated. Here is how the2004 report identified the various types:

Gestational diabetes mellitus (GDM): “GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The definition applies regardless of whether insulin or only diet modification is used for treatment” ("Diagnosis and Classification of Diabetes Mellitus," 2004). In many cases this type of diabetes morphs into a typical type 1 or type 2 diagnosis. However in 2004 the ADA specifically said that any GDM that lasts beyond pregnancy is still identified as GDM ("Diagnosis and Classification of Diabetes Mellitus," 2004). By this definition it is debatable if my mother had Type 1 Diabetes or extended GDM for the remainder of her life. In her case mom developed untreated GDM and a few years later was diagnosed as a type 1. None the less mom lived live as a Type 1, and don’t tell her (she passed in 1986), but she might have been a GDM. If I said that to her face, she might hit me (duck).

Genetic defects in insulin action: “There are unusual causes of diabetes that result from genetically determined abnormalities of insulin action. The metabolic abnormalities associated with mutations of the insulin receptor may range from hyperinsulinemia and modest hyperglycemia to severe diabetes. Some individuals with these mutations may have acanthosis nigricans. Women may be virilized and have enlarged, cystic ovaries” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Diseases of the exocrine pancreas: “Any process that diffusely injures the pancreas can cause diabetes. Acquired processes include pancreatitis, trauma, infection, pancreatectomy, and pancreatic carcinoma” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Endocrinopathies: “Several hormones (e.g., growth hormone, cortisol, glucagon, epinephrine) antagonize insulin action. Excess amounts of these hormones (e.g., acromegaly, Cushing’s syndrome, glucagonoma, pheochromocytoma, respectively) can cause diabetes” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Drug- or chemical-induced diabetes: “Many drugs can impair insulin secretion. These drugs may not cause diabetes by themselves, but they may precipitate diabetes in individuals with insulin resistance. In such cases, the classification is unclear because the sequence or relative importance of β-cell dysfunction and insulin resistance is unknown” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Infections: “Certain viruses have been associated with β-cell destruction. Diabetes occurs in patients with congenital rubella, although most of these patients have HLA and immune markers characteristic of type 1 diabetes. In addition, coxsackievirus B, cytomegalovirus, adenovirus, and mumps have been implicated in inducing certain cases of the disease ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Uncommon forms of immune-mediated diabetes: “In this category, there are two known conditions, and others are likely to occur. The stiff-man syndrome is an autoimmune disorder of the central nervous system characterized by stiffness of the axial muscles with painful spasms. Patients usually have high titers of the GAD autoantibodies, and approximately one-third will develop diabetes” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

Other genetic syndromes sometimes associated with diabetes: “Many genetic syndromes are accompanied by an increased incidence of diabetes mellitus. These include the chromosomal abnormalities of Down’s syndrome, Klinefelter’s syndrome, and Turner’s syndrome. Wolfram’s syndrome is an autosomal recessive disorder characterized by insulin-deficient diabetes and the absence of β-cells at autopsy” ("Diagnosis and Classification of Diabetes Mellitus," 2004).

As you can see there are more than two types of Diabetes. It is true that diabetes is primarily identified with two labels type 1 and 2. But we have a big tent disease. These other classifications cloud the issues. Now the main point, as upset as I got over this business of who has it worse, at least include the full range of causes. Is it worse for a Type 1 or a person who has diabetes as a result of an infection? Is it worse to have Type 2 or a person with genetic syndrome caused diabetes? The comparisons could go on and on. Here is the thing this discussion is inane. As you can see which is worse? I agree with Lloyd, and it is the only possible answer. The worst kind is the kind of diabetes is the kind that is not taken care of. But if you must argue, and I hope you don’t, at least consider all the various types, not just the two main types. Discounting the other kinds, does a disservice to both the disease (it is in my opinion one outcome with several different causes) and the people who have it. Namely us.


Diagnosis and Classification of Diabetes Mellitus. (2004). Diabetes Care, 27(suppl 1), s5-s10. doi: 10.2337/diacare.27.2007.S5

Mann, Lloyd. (2014). The Worst Kind of Diabetes. Retrieved March 6, 2014, from http://www.tudiabetes.org/profiles/blogs/the-worst-kind-of-diabetes

Phillips, Lawrence. (2014). The Worst Kind of Diabetes. Retrieved March 6, 2014, from http://www.tudiabetes.org/profiles/blogs/the-worst-kind-of-diabetes



really great article, rick.

Brilliant. Absolutely, positively brilliant. The last four sentences should be carved in stone in letters ten feet tall.

Great post Rick. I am new to diabetes and have a unique viewpoint because as of now my doctor thinks I may be LADA but I don’t have the antibodies so he really isn’t sure what to do with me. I had 2 other endos throw up their hands and say they didn’t know either. So despite post prandials that routinely go over 200 if I eat moderate carbs, and plenty of symptoms, I have struggled to get any kind of treatment or support from doctors. Maybe I’m a thin 2, a LADA, or possibly even a MODY, whatever! I would just like my health and quality of life to matter based on MY symptoms, MY history, and MY BG, not on what “Type” I am or how I compare to the typical T1D or T2D. Lloyd is right, “The worst kind of diabetes is the kind you ignore”. Diabetic complications like blindness and gangrene don’t care what type you are, we all need to do our best to control our blood sugar and educate and support one another.

IMHO, no matter WHAT your type is, you are not getting the treatment you need. (The treatment you need is the treatment that WORKS, which you clearly don't have.)

Your medical team needs to "come to Jesus" and help you get your blood sugar down where it belongs. Maybe that means insulin or maybe it means something else. But whatever it is, you need it and you're apparently not getting it. It's fine to play the diagnostic game but what matters is gaining control. "Eyes on the prize", so to speak -- the trees may be individually fascinating, but if they take attention from the forest then someone is not seeing what they need to see. And deal with.

A dear friend of mine had an endo who advocated the "ten second rule". "If you can work out the cause of what's happening within ten seconds, great! Otherwise FIX it and move on." Sounds like exactly the kind of thinking your medical team is not doing.

Yes, once you have diabetes of whatever kind or flavour, it is the worst kind and out to kill you one way or another.

Wonderful blog Rick. I think many of us struggle with really hating having diabetes. And in our minds, our own diabetes is the absolute worst, no matter what kind. Having to discuss whose condition is worse can amplify and distort our own feelings about our condition. So in celebration, I post Monty-Python, "it's just a flesh wound." At least I don't have a flesh wound.

Brain I thought I would post something that folks could indeed fight about with facts, if fighting is the choice. As you can tell by my post I am anything but a yellow bastard!! hahahahaha

Thanks, as usual, Rick. For years, I have worked hard trying to bring folks to this site--travelling half-way across the country on Amtrak with a purseful of TuD postcards, arranging local meetups, etc. Posts like this, as well as all the supremely supportive emotionally-charged posts are why.

The only time I have ever been flamed online was over at an ADA forum when I made what I thought was a totally innocuous post that said: I have found eating fewer carbs gives me better control. I never suggested anyone else try it.

Sorry--the point is: we have the greatest admin/moderators on the DOC web. This is a safe place. So your post that stirred up discussion was a good thing..

Blessings and xx000...Judith in Portland

Good discussion and reminder that there are so many out there needing more education and awareness.
Lloyds (?) comment is simple, short and facts: the ignored one, is the worst kind.