Overlap type 1 and type 2?

[pegasus]

Has anyone heard of this? My dr believes I am *both* type 1 and type 2 (diagnosed type 1 40 years ago). I'm clearly type 1, and the type 2, he infers because of my family history--dad, type 2 at 65, brother type 2 (needing insulin now) 28 yrs ago. Which would mean I am both insulin sensitive and insulin resistant. My insulin sensitivity is clear--I use very little; he believes my insulin resistance is suppressed by my thinness (despite the belly I see in mirror :T my BMI is good) and my exercise activity (I'm a good tho sporadic swimmer and bicycle rider).

He says about 10% of diabetics fall in this category.

I googled it and found at that there's an theory being explored that says that rather than type 1 and type 2 being basically separate but with same symptoms, they are on a continuum.

Would appreciate hearing from others about this.

[morrisma]

I could see this as a possibility.
Type 1 is auto-immune. Type 2 is poor insulin production/sensitivity.

You could have an auto-immune response going on and an insulin usage problem as well. Nasty but possible.
Mike

[Emm]

Yeh I've heard of it it before - there's some argument about whether it's actually T1 and T2, or just that some T1s get insulin resistant over time.

Basically it's just a name - I mean, if we're already diabetic and handling our blood sugars then I'm not sure it matters how it's diagnosed.

If you're still using such small amounts of insulin, what makes you/ your doctor think you have the double whammy?

[pegasus]

Because of the family history. And I have some (small) coronary artery cholesterol buildup which he somehow associates more w/type 2. There may be other reasons; I can't remember just now.

I guess it just matters to me to know fully what I'm dealing with. If I am somewhat insulin resistant, as well as insulin sensitive, it might explain some management issues. I don't know that for sure--I've just switched to the pump, so I'm trying to handle that, and with the level of finetuning involved, some of the insulin resistance might become more evident.

[BlueSky]

I am confused here. I can't see how you can be both insulin resistant and insulin sensitive at the same time. If you had insulin resistance, you would have to use large amounts of insulin to control your blood sugar levels. But you use very small amounts of insulin. So you can't be insulin resistant.

I have also seen articles suggesting that T1 and T2 are manifestations of the same thing, but they really don't make sense. T1 and T2 are clinically completely different conditions and only have a symptom in common - inability to control blood glucose levels. T1 is a disease of insulin production failure, while T2 is a disease of insulin resistance. Sure, it is possible to suffer from both of them at the same time. It is often referred to as "Double Diabetes". But large amounts of insulin have to be injected to overcome the insulin resistance and satisfy insulin requirements.

It doesn't sound like you have any insulin resistance at this stage. But, especially based on your family history, you may well start experiencing it over time. When this happens, you will have to increase your insulin dosage. A T2 family background is not required for this to happen. Increasing insulin levels, because of increasing insulin resistance, is part of the aging process. It just happens much more quickly in some people than it does with others.

[pegasus]

Thanks for the info.

I'm confused, tho, Blue Sky. First you say that it's not possible to be both, but then you name something called "Double Diabetes," which sure sounds like both. I think what my doc was saying was that, instead of needing large amts of insulin to deal w/resistance, my lifestyle, weight, etc., is supressing the resistance symptoms.

Please tell me more about double diabetes, or give me links/article titles to look for.

Thanks.

[BlueSky]

I was saying that you can't be insulin sensitive and insulin resistant at the same time. They are like opposite sides of the same coin. Someone with double-diabetes is insulin resistant. They have to inject lots of insulin and are definitely not insulin sensitive.

The doctor seems to be suggesting that the same thing as is wrong with family members is also a problem for you (insulin resistance), except that there are no symptoms. It is some how lying dormant, getting ready to pounce ;) . To me, that is a bit of a stretch. Like most illnesses, insulin resistance is defined by its symptoms. If there are no symptoms, there is no disease.

Here is an article about double diabetes Type 1 Diabetics Can Get 'Double Diabetes' From Insulin Resistance, Says University Of Pittsburgh (http://www.sciencedaily.com/releases/2003/04/030425071101.htm). Here is another one 'Double Diabetes' a New Threat | LiveScience (http://www.livescience.com/healthday/534999.html)

[Geoff]

Hi all I thought this may be of interest to this discussion, it is taken from a new book on type 1 diabetes "Type 1 Diabetes in Adults" 2008

"Soon after the demonstration of ICAs in type 1 diabetes, in a study by Irvine et al. itwas
stated that∼11% of patientswith type 2 diabetes were also positive for ICAs (17); compared
to ICA− type 2 diabetic patients, this ICA+ subset of type 2 diabetic patients tended to fail
sulfonylurea therapy and needed insulin treatment earlier (17). Subsequently, several other
investigators have also identified a similar subset of phenotypic type 2 diabetic patients
who are positive for the antibodies commonly found in type 1 diabetes; this subset has been
variously termed—latent autoimmune diabetes in adults (LADA), type 1.5 diabetes, slowly
progressive IDDM, latent type 1 diabetes, youth-onset diabetes of maturity, latent-onset
type 1 diabetes, “double” diabetes, and antibody-positive non–insulin-dependent diabetes
(14,18–20). Although the different names have caused some confusion, the finding of this
subset of phenotypic type 2 diabetic patients by many different investigators rather than
just one or two groups confirms their existence as an important subset of diabetes."

[pegasus]

Thank you. I'll look for the book; I'll need a dictionary to read through that carefully ;)

[pegasus]

And thanks also, Blue Sky--I'll check the articles also.

[lottadata]

Hi folks,

I missed this thread, but I would like to weigh in as it is really important.

Doctors have been going on for years about how Type 2 is caused by insulin resistance. But that isn't what they are finding now that they are looking at the genes associated with Type 2. Just last week an article about MODY and genetic diabetes that went out on the AP news wire featured a quote from a doctor at MIT saying that surprisingly, all the Type 2 genes they've found so far affect NOT insulin sensitivity but insulin secretion.

When your blood sugar goes way up, you become insulin resistant. High blood sugars do that. And you gain weight in the early stages of blood sugar dysregulation which will increase the insulin resistance. But your blood sugar doesn't go out of control in the first place unless it started out marginal and that may not happen unless you have some kind of initial secretory defect.

So it is much more complex than the oversimplified picture doctors learned in school years ago.

I am very insulin sensitive. Two units of Lantus are too much for me. I covered a big chunk of pastry today with 3 units of Novolog and was at 98 90 minutes later.

But even so, if I stop taking metformin my insulin need goes up 33% even if that means only 1 more unit, proportionally, it's a lot. And even more important, without metformin even if my blood sugars are rock solid normal, I'll gain weight like crazy and that weight will be on my abdomen. So in a weird way, I am IR and insulin sensitive at the same time.

I think it will turn out that there are a lot more insulin sensitive type 2s out there than doctors ever realized, now that doctors are no longer waiting until a person is about to go blind and lose their toes to give them insulin.

Had I not been put on insulin, I would have gone to my grave believing I was, as I was told, "A typical type 2."

[Emm]

Thank you Lottadata! That's been my theory about type 2 for years... but I'm no scientist or doctor and can't prove a thing!

Do you have a link to any info about this? I'd love to read more.

[BlueSky]

.... When your blood sugar goes way up, you become insulin resistant. High blood sugars do that. And you gain weight in the early stages of blood sugar dysregulation which will increase the insulin resistance. But your blood sugar doesn't go out of control in the first place unless it started out marginal and that may not happen unless you have some kind of initial secretory defect.....
I agree that high blood sugar increases insulin resistance - I have experienced it many times. But T2 insulin resistance is quite different. Large amounts of insulin are needed to keep blood glucose down. This insulin resistance has nothing to do with high blood sugar. There are high insulin levels when blood glucose is near normal. It is not uncommon for a T2 with only slightly elevated fasting blood glucose to have a fasting insuli level of 90+. Normal is about 10. That means the beta cells are producing 9 times as much insulin as would normally be required to maintain normal blood glucose. The beta cells are producing plenty of insulin. It just isn't being used as well as it should be.

While the causes of it are not well understood, insulin resistance is a very real phenomenon. The jury is still out on just what causes the decline in beta cell function. When blood sugar starts rising in a T2, up to 40% of beta cells have already been lost. Traditionally, this was thought to be caused by "beta cell burnout" - the overuse of beta cells to counter insulin resistance. But it seems that this may not be the case.

Having said all that, it still doesn't make sense fo a T2 to be insuli sensitive. If after being put on insulin a supposedly T2 diabetic is found to be insulin sensitive, they were probably never T2 in the first place.

Thats my take on it, anyway ;) .

[lottadata]

Em,

I have several articles on my web site, which refer to the research backing up what I posted.

Blue sky,

What you wrote is partially but not entirely true. My endo claims that it is not possible to determine the extent of IR from C-peptide or fasting insulin tests. The very high insulin levels you cite happen early on for some Type 2s, but by the time most show up in a doctor's office they have lost 50-80% of their beta cell mass and hence their insulin production is much lower.

It is possible for many people diagnosed as Type 2s to have widely varying amoutns of insulin sensitivity, because in many ways "Type 2" is a "garbage can" diagnosis. If someone isn't Type 1--i.e. has no autoimmune markeres, they get diagnosed as Type 2. But the diagnosis covers hundreds of different genetic flaws and underlying causes and varying degrees of beta cell dysfunction.

There's a pancreas autopsy study I link to on my site where they found that the rate of beta cell death was much higher in lean Type 2s, for example. And NIH statistics say that about 20% of "Type 2s" are normal weight.

I know quite a few normal weight Type 2s, whose IR varies hugely. Some are eating very low carb and stilll need a lot of insulin to get normal numbers. Some eat can 30-40 grams per meal and get completely normal numbers. I know a couple other officially type 2 people who use insulin doses similar to the tiny ones I use who respond strongly to them. Some people get dramatic blood sugar drops in response to Byetta, others see their bgs go up.

And while there are those who can restore normal numbers by losing a lot of weight as IR seems to be their main problem. they do seem to be in a minority, and probably were in the very early stages of deterioration at diagnosis. Bernstein reports only knowing one, a male. I have encountered a few online, all male.

Because the underlying dysfunctions can be so different, the effective treatments differ too. That's pretty much the message of the book I've just published: that people diagnosed with Type 2 have to carefully observe their blood sugar responses to food and meds to determine what the nature of their individual case might be, and use what they learn to choose the most effective treatments for them, which aren't going to be the same as for someone else diagnosed as Type 2.

With the more drugs coming on line for Type 2, this is becoming much clearer. Only 25% of Type 2s have a strong response to Byetta, and even fewer have a dramatic response, but for those who do, it is a wondeful drug. For others, they might as well be injecting water. But it is possible from past history to get a good idea who might be in the responder column.

[BlueSky]

... What you wrote is partially but not entirely true. My endo claims that it is not possible to determine the extent of IR from C-peptide or fasting insulin tests. The very high insulin levels you cite happen early on for some Type 2s, but by the time most show up in a doctor's office they have lost 50-80% of their beta cell mass and hence their insulin production is much lower. .....
Possibly I need to rephrase that then. In someone with insulin resistance, large amounts of insulin are required to maintain normal blood glucose levels. This defines the Type 2 classification. In the absence of this attribute, someone really shouldn't be diagnosed as T2. Being sensitive to insulin and having Type 2 diabetes is a contradiction in terms.

Having said that, I agree that there is a lot of misdiagnosis going on. If it doesn't look like T1, it gets diagnosed as T2. The result is that there are a lot of anomalies in the so-called T2 basket. There needs to be a definitive test for insulin resistance, and maybe they need a third classification - "idiopathic diabetes" ;)

[matingara]

It is possible for many people diagnosed as Type 2s to have widely varying amoutns of insulin sensitivity, because in many ways "Type 2" is a "garbage can" diagnosis. If someone isn't Type 1--i.e. has no autoimmune markeres, they get diagnosed as Type 2. But the diagnosis covers hundreds of different genetic flaws and underlying causes and varying degrees of beta cell dysfunction.

There's a pancreas autopsy study I link to on my site where they found that the rate of beta cell death was much higher in lean Type 2s, for example. And NIH statistics say that about 20% of "Type 2s" are normal weight.

I know quite a few normal weight Type 2s, whose IR varies hugely. Some are eating very low carb and stilll need a lot of insulin to get normal numbers. Some eat can 30-40 grams per meal and get completely normal numbers. I know a couple other officially type 2 people who use insulin doses similar to the tiny ones I use who respond strongly to them. Some people get dramatic blood sugar drops in response to Byetta, others see their bgs go up.

Great to see you here lottadata!!! your expert opinions and website are probably the best diabetes info in the world.

I am a normal weight person and have been diagnosed as Type 2. (July 2007).

I am pretty sure I am insulin deficient. i eat pretty low carb and what little insulin i make keeps my BGLs close to normal.

Therefore, I am sure that (like you) if i used insulin to cover meals i would need just tiny amounts.

My GP has said that he will put me on insulin if i want. my concern at the moment is that i might go low even with a tiny amount of insulin.

i mean, i have been waking with a fasting BGL of between 72-90.

have you experienced lows due to injected insulin?

i also need to figure out if i am Type 2 (probably not), LADA or MODY. Any idea what i should ask next?

-- Joel.

[lottadata]

Joel,

Thanks for the kind words!

You already are using insulin--Diamicron is causing insulin secretion all the time no matter what your blood sugars might be. So if you aren't hypoing on the tiny dose of diamicron, you probably would do fine on tiny doses of injected insulin. I'd recommend starting with 1/2 unit and working up.

That said, Diamicron is the sulf that isn't available in the U.S. and it is the one recommended for MODY by Dr. Hattersley at exactly the dose you are taking.

The sulfs available in the US may pack more wallop which makes them miserable to use for MODY. I have huge respect for Dr. H, and it is possible that if you are feelling good on the Diamicron it is the right treatment and very tiny doses of short acting meal time insulin might be all you need to give you more dietary freedom.

Your numbers are coming down so dramatically with your current regimen, it's probably a good one. I was just this week trying to find out how I could get some Diamicron to test myself. Doesn't look possible.

Re lows, though, my situation is a bit different than normal, because I have a very counterregulatory response that pushes my blood sugar up. Even with a bit of Lantus and meal time insulin with a failry low carb intake my fasting bg is rarely under 95. I've put years into trying to get it lower and occasionally it will dip, but then it comes right back up. I live with it.

[clauna]

HI!
this is my first post, so I apologise for my english(second languaje) HI ALL! Hi Pegasus!
I started 5 years ago with A1c 18! I was never overwieght, first in the family. I am on lantus (11u) and max metformin, very high antibodies, but my endocr said I am type 2, I still don't understand the combination of insuline resistance and antibodies, is the resistance because the inicial hyperglucemia?? too much of a chance of having together 1&2 at the same time!

[clauna]

I forgot I am on encreasing amounts of fast insuline also!

[BlueSky]

... very high antibodies, but my endocr said I am type 2, I still don't understand the combination of insuline resistance and antibodies, ...
If there are lots of antibodies, you are type1. What makes you think you are insulin resistant? How much rapid acting are you using?

[clauna]

Hi bue sky
my antibodies seem pretty high...but at the same time if I forget to take the metformin my glucemia skyrockets.
I started with 2-4 u fast insulin premeals. I was told I am finishing my "honey moon" :(

[Emm]

Everything you've said suggests type 1 to me (most likely LADA?). 2-4u suggests NO insulin resistance at all.

[clauna]

you think I don't have resistance even the evident need for metformin?
I also thought I have D1 given the antibodies...
thanks!

[clauna]

How do you define diabetes 1.5? :o

[Emm]

Basically, 1.5 (LADA) is adult onset of type 1 diabetes which comes on a lot slower. Type one generally hits with some speed... a person can be perfectly happy one day and then heading for hospital the next. LADA (Latent Auto-immune Diabetes in Adults) Can take months to kick in - even years.

In the end though, it's still type 1 - still auto-immune diabetes, and still needs insulin.

Metformin can lower your insulin needs - I took it myself for a while as it was meant to help me lose weight. Unfortunately it didn't have that side effect for me but it did lower my insulin dosage a little.

I should add that the term 'type 1.5' is not an official name - and to some people it seems to have a different definition. So when I'm talking about adult slow onset type 1 I generally call it LADA and avoid the 1.5 thing so as to avoid some confusion!

[clauna]

yeap...LADA/1.5 sounds like me.

when in a meal situation, do you excuse yourself and go to the bathroom to inject insulin?(without pump) isn't too disruptive?
I suppose there isn't any other way, isn't it?

[Emm]

I would never inject in a bathroom!
I inject before I eat, or right there at the table. It's easy to be discreet.