Tuesday, December 16, 2008

diabetes but what type?

What is the cause of type 2 diabetes? We all can answer that by rote much as we can recite TV ads for cereals from the 1960's. "being fat and/or gaining weight and bad eating habits".

Well, then, what causes type 1 diabetes? "that's when your immune system or something else destroys cells in your pancreas".

Where things seem to get confusing is how they distinguish between two. I used to think it was something like "if your father had diabetes or your mother or your grandmother, it's type 2 because type 1 is obviously not hereditary". Or maybe if you walk into the doctor and have a blood sugar reading of 1000, at the first reading, you might have type 1. Or if you are a kid, of course, it's type 1 because kids don't get type 2 (that's why it's called "adult onset diabetes" dummy - didn't you know that from the 1950's?... ok I'm being sarcastic here... I admit it. My bad)

But a recent Discovery Health CME was extremely confusing. A young ballerina (15 years old) came in with a blood sugar reading of 400. Now _that_ seems to suggest she has a partially functioning pancreas, doesn't it, especially since her mother also has diabetes also...which suggests a genetic factor, very typical of type 2 diabetes or insulin resistance, right?

But it appears that because both the mother and daughter are very slim and eat healthy etc (well supposedly - many slim people actually do NOT eat healthy - they just "get away" with eating poorly), and the girl is a kid (15 years old) it must be type 1 diabetes, decides the doctor and puts this kid on 7 shots of insulin a day (and 8 pricks).

Later, you see the kid with some friends, one of whom asks "but you look so good, how come you have diabetes?"

"no no no no no no no!" exclaims the young girl, "I don't have that kind of diabetes that fat people get!" (she wrinkles her nose in disgust as she utters the words "fat people".) "I have type 1 diabetes!" Listening to this, I cringed.

And I wonder. Did they ever try her on metformin? Did it ever occur to her medical providers that insulin resistance which is a gene, can occur in a slim person also? Is it worth it to these people to not "brand" them as "fat" or "formerly fat"? Obviously if metformin worked, wouldn't that be a whole lot better quality of life for the young girl to take a couple of pills a day than to take 7 shots of insulin throughout the day and test her sugar "umpteen" times? Also, metformin is a better treatment - she's essentially being treated the same way they treated diabetics in the '50's and '60's.

I have a friend who is slim. But his mother was extremely overweight. So he noticed the usual signs of diabetes - thirsty, and so forth. He went to the doctor and because of his age and girth, got diagnosed with type I diabetes (and his mother by the way, had diabetes type 2). Was on insulin for several years until some smart doctor decided to try metformin and now, he only takes one insulin shot a day and pills which is a whole lot nicer.

My question to medical providers - are you really in tune with the fact that a slim person can have type 2 diabetes because it's essentially a genetic disorder? Even if they are not fat (because fat is largely genetic as well)? Or are you putting young kids through a horrible medical regimen just to assure their parents and/or them that they do not have the "fat person" kind of diabetes?

Fat phobia hurts everyone - even slim people. And that is why we _all_ have to fight it.

If you come in with a blood sugar level of less than 800, even if you are a kid or slim, ask your medical provider to try metformin (the pills) first. Because 33 percent of type 2 diabetics are slim - never were fat in their lives - and those are the ones we know about. How many more type 2 diabetics who were misdiagnosed because they were young and/or slim are there around?


Claire said...

Wow. Medical misinformation up the wazoo.

*plenty* of type 1 diabetics diagnosed as children are diagnosed (and are very, very sick) with blood sugars under 800. I was, at 12 (blood sugar: 486. Days before imminent coma: 1). In fact, at diagnosis, many type 1 diabetics have pancreases that haven't been totally disabled by the immune system yet, and so some functionality remains, though it disappears over the next several months (this is called the "honeymoon period", because the disease is particularly easy to manage. It inevitably goes away, however). Giving a type 1 diabetic metformin when she's dying of diabetic ketoacidosis and days from a coma is beyond dangerous. Insulin won't hurt a type 2 diabetic, at least, but *not* giving it to a type 1 can be lethal. Better safe than sorry.

Beyond that, A) it *is* the case that *most* slim, very sick, newly diagnosed diabetic adolescents under the age of 16 presenting with signs of DKA *are* Type 1 B) they don't know what causes type 1, and there are many families where there seems to be some sort of genetic component, and C) there are tests for antibodies that can distinguish between the two. But frankly, it's hugely irresponsible to suggest that someone with a blood glucose reading below a certain arbitrary number shouldn't take shots because they might have the other kind - shots are better than a coma, and if there's really doubt, it can be sorted out once the danger has passed.

*end rant*

vesta44 said...

According to a couple of diabetes lists I belong to, there are more than 2 types of diabetes. There's also LADA and MODY (latent autoimmune diabetes and maturity onset diabetes of the young). LADA & MODY are probably subsets of type 2 diabetes, but they are treated in slightly different ways and diagnosing them is difficult, since not a lot of doctors know about them or believe they exist.

SueW said...

Claire, you are just re-iterating what we've heard from the medical providers - I'm questioning it. That's all. I never said it was hard and fast info. Just a question and I am entitled. I guess I should have explained more about "insulin resistance". That's old info to me but I forget that many people are a bit confused about what it is, exactly.

You don't know it's "misinformation" so your "rant" seems a bit inappropriate and since you have a personal investment in your hope that you were NOT misdiagnosed, you are not exactly an "unbiased" source.

But yes, insulin CAN hurt a type II with a functional pancreas. First of all, if they are "insulin resistant", they need MORE insulin and second, it can cause more damage to a functional pancreas.

They have only quite recently been testing for INSULIN resistance and even at that, many providers DO NOT bother which I think is WRONG because if a person is insulin resistant, yes, they will do well on Metformin and no, they may not need shots for years. Or if they need shots, with metformin, they need far LESS insulin (something I'm sure Aventis and others who finance these CME's would not like i.e. people buying LESS insulin and yes, it IS all about bucks - the bottom line.)

You are quoting the state of the science, decades ago and that can be more misinformatory than my musings which I carefully IDENTIFIED AS musings or wonderings and not as "medical information". But asking more questions is always a good idea these days.

And you have confused the point by talking about acidosis etc which is NOT true of someone with a BSL of 400.

My point and I stand behind it, is that ALL people NOT coming in, in a coma or near coma, REGARDLESS OF AGE OR GIRTH, and ESPECIALLY if they have it in the family, should be tested for insulin resistance BEFORE diagnosis... because they may be misdiagnosing many people and especially kids who would MUCH rather take pills (and would be helped more by that) than shots. I hope this clarifies.

* end of MY rant *


Harpy said...

I definitely think they should test for insulin resistance AND antibodies when someone comes in with high blood sugar/diabetes symptoms. People who already have another autoimmune condition (like Hashimoto's, Celiac, etc) are at risk of autoimmune-caused diabetes, even if they're older; and, while rare, type 2 diabetes can happen in young people. It just makes sense for a patient to know which kind they have! Related to what I just said, people who have type 1 (autoimmune) diabetes are likewise at risk of other autoimmune conditions, whereas there are different risks for type 2.

Ashley said...

I have polycystic ovarian syndrome with insulin resistance, and I can attest that a) it is extremely easy to test your fasting insulin level at the same time you do your fasting blood sugar. That's how they did mine, and b)metformin has fixed me wonderfully.

I thankfully have no signs of diabetes other than being a fatty (which insulin resistance causes) though they were definitely pushing the Type 2 diabetes angle until I came in with gorgeous blood sugar numbers.

Claire said...

Hi Sue-

I really didn't mean to get into a snippy comment war, so I'm sorry if I got a bit...touchy. It's all in the interest of healthy debate.

:-P Personal investment or no, I *was* in DKA at 486. I don't remember the pH of my blood, but it was dramatic. Delaying treatment for my (very evident) condition would have been very, very dangerous. Maybe it's based on old medical information, but let me tell you, I was incredibly ill. In my recollection (and granted, I was 12), my diagnosis was based on the result of blood and urine tests and had nothing to do with my weight, which only came up because, as many newly diagnosed type 1 diabetics, I was eating an enormous amount of food and dropping an enormous amount of weight (classic symptom, and all that).

I don't dispute that plenty of people with Type 2 diabetes are slim. That's true. That *doesn't* mean, however, that plenty of slim children with diabetes have type 2. I worry about "musings" that say "if your blood sugar is under 800 it can't be type 1, especially if your pancreas is still functioning", because it is manifestly not the case that your blood sugar needs to be above an arbitrary level before you're a Type 1 diabetic and in desperate need of insulin. Mine wasn't, and I was hella sick. Granted, this is anecdotal, but I don't think I know *any* type 1 diabetics who were diagnosed over 800.

I think it was the random number that set me off. Of course, there are people who are borderline, who should be checked for resistance. But not everyone knows the difference, and so picking a number like that and saying "there's no way you can be type 1 with blood sugar below X" is...dangerous, really. (...not to mention untrue, as I think I can quite well attest. I mean, I guess I have a personal interest in not having been misdiagnosed, but A) if I was...uh, no harm done, I guess I'll figure it out eventually, and be better off for it. Would be kind of cool, actually. Bring on the pills! and B) I wasn't. Trust me. Take me off my pump for 12 hours. You can meet me in the ICU tomorrow.) That's the part that upset me. I worry about very sick children being delayed in their necessary treatment because their parents are mixed up on the two types of diabetes.

So please, share your doubts. I'm all in favor of getting everyone the treatment most suited to their condition. I trust the medical community about as far as I can throw them. But please don't quasi-authoritatively spout random-ass numbers without research to back it.


SueW said...

Claire, I don't doubt that you are type 1 if you say so. And I didn't quote any "random numbers" and I just asked questions. But I've seen many questionable people diagnosed when they have it in the family as type 1 without testing for insulin resistance, a test which STILL is NOT AT ALL, common in the diagnosis of diabetes. One cannot generalize "to everyone" from their specific case as you are trying to do. I just think we SHOULD ask these questions and if in doubt, these young folk SHOULD be tested for insulin resistance.