Questioning The Classification of Types of Diabetes
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Summary: This newspaper article questions the classification of Type 1 Diabetes into two distinct conditions based on age of diagnosis, highlighting conflicting family cases. It critiques the complexity of diabetes classifications, suggesting potential over-categorization akin to misidentifying plant species. Emotional and historical variables in research are considered, challenging the validity of findings based on snapshots of pancreatic function.
In today’s newspaper, I found an article suggesting that Type 1 Diabetes is in fact two separate conditions. The referenced study in the journal Diabetologia found a marked difference between those diagnosed before the age of seven and those diagnosed over the age of thirteen.
The people in the group diagnosed before the age of seven were found to have poor insulin production and a stronger attack by their immune system on their pancreatic beta cells. This group were named the ‘Type 1 diabetes endotype 1’ (T1DE1) group.
The people in the group diagnosed after the age of thirteen were found to have fewer immune cells in their pancreas, thus suggesting a weaker attack from their immune system. They also appeared to have more ability to make insulin from properly functioning insulin beta cells. These individuals were thus classified in the ‘Type 1 diabetes endotype 2’ (T1DE2) group.
The T1DE2 group were of notable interest because of their insulin cells. They had not been destroyed, like in the T1DE1 group, and thus suggest that they are instead dormant. Future research could potentially look into methods for kickstarting these cells into life.
People diagnosed between the ages of 7 and 12 were a mix of those exhibiting T1DE1 and T1DE2. This group was not so predictable in their endotype but they did fall neatly into one or other category.
The researchers from the University of Exeter therefore concluded that, for future research into Type 1 Diabetes, it is now pertinent to apply different therapeutic treatments for the two different conditions. In other words, healing Type 1 Diabetes may need to take different approaches, depending on the age at diagnosis.
HOWEVER…
I am struggling to feel at ease with this piece of research.
Firstly, I am thinking about the cases of Type 1 Diabetes in my family. I was diagnosed with Type 1 Diabetes at 18 months of age. My sister was diagnosed at the age of 9. My aunt was diagnosed when she was nineteen. So are we truly a miraculous family that just so happens to have examples of both T1ED1 (myself) and T1ED2 (my aunt) and the interim group of ages 7-12 (my sister) in one family?? That doesn’t feel right to me.
Secondly, the researchers in this article compare the two groups of diabetics they identified (T1ED1 and T1ED2) with a Scandinavian study from 2018, where the research identified five categories of Type 1 Diabetes, based on variables such as age at onset, body mass index, blood sugar levels, insulin production and insulin sensitivity.
One of these five categories correlated with one of the endotypes in this study. Therefore, the researchers concluded that maybe there are six different types of Type 1 Diabetes, once their additional endotype category is included!
Now, I don’t know about you but it just seems to me like something is amiss here. The classification system for defining diabetes over the years has become more and more convoluted. In the good old days, there was simply juvenile-onset diabetes. But, when the researchers realised that you didn’t necessarily have to be young to get this type of diabetes, they renamed it Type 1 Diabetes (as opposed to Type 2 Diabetes).
Then, those two distinct categories became less clear-cut with the addition of Type 1.5 Diabetes (really?? is that the best you could come up with??). This type of diabetes, otherwise known as LADA, shares the autoimmune attack component of Type 1 but has the more slow onset of Type 2 Diabetes.
This latest piece of research suggests that we may be looking at a list of subtypes of diabetes that now looks something like this:
- Type 1 Endotype 1 Diabetes
- Type 1 Endotype 2 Diabetes
- Perhaps another four types of diabetes identified by the Scandinavian study mentioned above
- Type 1.5 (LADA) Diabetes
- Type 2 Diabetes
- MODY Diabetes (of which there are currently 11 different subtypes… and counting!)
My intuition is screaming at me as I look at this list… Nineteen different types of diabetes?? Really???? I’m thinking of confounding variables. What if the researchers are looking at this wrongly? Let me given an analogy…
I’m an explorer. I have decided to go to a new land and document my findings for people to learn about. On the first day I am there, I notice this plant. It has two green leaves and a green stalk. The flower is slightly odd… It is bud-shaped and probably not more than three centimetres long. I wonder how it can become pollinated since it does not seem to be showing any pollen. The wonders of new plants, I surmise! I take a photograph, sketch a picture of it, and name this ‘Plant One’.
The next day, I explore a different part of the land. This time, I come across a new plant. Again, it has green leaves and a green stalk. But this plant has a beautiful yellow flower! It is attracting many bees and insects, it has stamen from which they are collecting pollen. Again, I take a photograph, sketch a picture of it, and name this ‘Plant Two’.
When I return to my home, I tell the people about the two new plants that I have seen. I show them the pictures. One person turns to me and says that I have just taken two photographs of the same kind of plant, but at different times in their development… One is a bud, the other is a fully blooming flower. I tell him he is being ridiculous. I saw both plants. They were completely different!
What if this is happening in diabetes research? This particular piece of research, which I can use as an example for my argument here, used pancreatic cross-sections from diabetics who died in the 1950s plus also blood samples taken from people alive today. Both of those measurements take a snapshot in time of what that particular person’s body is doing, what their health is like and therefore also what their pancreatic function is like in that moment of time only!!
Emotions, Emotions, Emotions!!
As I outlined in my article on ‘The Neuroscience of Diabetes’, insulin is a neuropeptide. It is a molecule of emotion. Has anyone in these studies been controlling for the emotional conditions in their research participants’ bodies? In this study, I can confirm that they haven’t. The researchers would not have known what the emotional response was for the pancreatic cross-sections for people who died in the 1950s!! So this study already exhibits a large confounding variable when considering this variable alone. I’m sure there must be more too, when you think outside of the narrow scientific box.
I’m also really intrigued that this article is still using the model of Eisenbarth model of diabetes. As I discussed in my post ‘What Is Type 1 Diabetes?‘, there is now accumulating evidence to indicate that there is no beta-cell burnout with Type 1 Diabetes. So, having this study delineate the two endotypes T1ED1 and T1ED2 through the amount of pancreatic beta-cell burnout seems a false categorisation.
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Natalie is a blogger with Type 1 Diabetes. Natalie's special gifts are questioning the status quo and being a rebel. She is using these gifts to question medical 'knowledge' and find a true cure for Type 1 Diabetes.
