Can you have both type 1 and type 2 diabetes?

[Uafl112]

Hi,

I am a peasant undergrad student, but I had a thought recently regarding diabetes. If a person has type 1 diabetes and he/she takes enough synthetic insulin to cope with their sugar/fat intake, would it be possible for this person to eat enough to become obese and maybe even develop an insulin resistance, leading to type 2 diabetes?

I bring this question here because the internet isnt really providing me any answers about the mechanism. The doctors and medical students I know are saying either 1) its impossible (without any supporting information) or 2) they simply dont know.

Forgive me if this question is irrelevant to this forum, but the debate has really inspired me to get the right answer. Does anyone have the answer?

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[rokshana]

the short answer is yes..in layman's terms, have both...

its important to understand what is meant by type 1 and type 2...type 1 is an autoimmune disease in which the beta cells in the pancreas are destroyed and the person is no longer able to produce insulin and is dependent on exogenous insulin for their needs...resistance is not generally an issue...

type 2 is more about resistance...these people usually make a great deal of insulin...and are not symptomatic until they are no longer able to overcome the resistance. insulin is an anabolic hormone so it makes it difficult to lose weight...and obesity is common in those with type 2...also there is more evidence that there is a genetic predisposition for type 2 than type 1.

so can you have a person who has type 1 with a family history of type 2 develop insulin resistance? sure...its interesting that in these pts metformin can be helpful.

 

[Uafl112]

the short answer is yes..in layman's terms, have both...

its important to understand what is meant by type 1 and type 2...type 1 is an autoimmune disease in which the beta cells in the pancreas are destroyed and the person is no longer able to produce insulin and is dependent on exogenous insulin for their needs...resistance is not generally an issue...

type 2 is more about resistance...these people usually make a great deal of insulin...and are not symptomatic until they are no longer able to overcome the resistance. insulin is an anabolic hormone so it makes it difficult to lose weight...and obesity is common in those with type 2...also there is more evidence that there is a genetic predisposition for type 2 than type 1.

so can you have a person who has type 1 with a family history of type 2 develop insulin resistance? sure...its interesting that in these pts metformin can be helpful.

Thank you so much for the answer! Also, am I wrong to say that these types of patients are rare?

 

[rokshana]

Thank you so much for the answer! Also, am I wrong to say that these types of patients are rare?

rare wouldn't be quite right, type 1 represents only 5-10% of diabetes in general so that in and of itself is not common per se...and when a person has the dx of DM1, many time the increased need for insulin may be more about resistance than the DM1...but not really noted by PCPs that are taking care of DM1 pts. They just end up increasing the insulin doses when maybe insulin sensitizers like metformin could help decrease the amount of insulin needed.

this article can give you some info and the references in it can be helpful

http://care.diabetesjournals.org/content/30/3/707.full

 

[Uafl112]

thank you so much!

 

[DrAwesomo]

Wrong way to ask the question. Once your insulin requirement is so high in DM2 it essentially acts like DM1, although in DM1 patients are more sensitive to insulin (conversely, more prone to DKA as well).

 

[rokshana]

Wrong way to ask the question. Once your insulin requirement is so high in DM2 it essentially acts like DM1, although in DM1 patients are more sensitive to insulin (conversely, more prone to DKA as well).

no, the OP asked the question correctly...and your 1st statement is incorrect...DM2 is about resistance...they actually make a great deal of insulin and have normal to high c-peptide level for quite sometime and while at some point they may not make insulin, they still have a resistance issue...

most DM1 (i.e. true autoimmune DM1) will not have a resistance issue...its the fact that they have autoimmune destruction of the beta cells and they simply cannot make insulin...however you can have someone with DM1 who can have have a resistance issue...that is not related to the autoimmune issue...

and there there is LADA, MODY, Type 1.5, Flatbush diabetes that add to the confusion.

 

[Mad Jack]

Yes, you can have both. That's the short answer.

 

[Liontale]

I thought the question is wrong.
But the replies show the value of this question.
Most people like me think, how a person have both T1 and T2 after I read a webmd post.
Lion Tale

 

[Nyatar]

Hello, I do think that it's rather difficult to have that type of patient in the real life. Type 1 diabetes, as we know, is because of an absolute deficit of insulin due to an autoimmune-mediated destruction of the pancreatic beta cells. In this condition, managing the optimal levels of glycemia is very challenging because of the strict intake control and tight insulin dosing, so in practice we see patients who aren't adherent to treatment and goes constantly on KDA because of the insulin deficit, or patients who don't achieve the correct insulin dose and goes on hypoglycemia. Considering that most of these patients get the diagnostic from infancy, the lifestyles that they have is very different from the patient who has type 2 diabetes. They have a long time of unhealthy habits that can precisely do because of the normal function of their pancreas, and the obesity that comes along (in the majority of cases) that lifestyle always come with an insulin resistance (read about leptins and the endocrinology of adipocytes). So in practice, type 1 diabetic patients would have a lot more hard way to get obese AND have insulin resistance without having to go to the ED every time they decompensate than going to achieve a tighter glycemic control.
PD: English is not my primary language, so I'm sorry for the grammar mistakes

 

[rokshana]

Hello, I do think that it's rather difficult to have that type of patient in the real life. Type 1 diabetes, as we know, is because of an absolute deficit of insulin due to an autoimmune-mediated destruction of the pancreatic beta cells. In this condition, managing the optimal levels of glycemia is very challenging because of the strict intake control and tight insulin dosing, so in practice we see patients who aren't adherent to treatment and goes constantly on KDA because of the insulin deficit, or patients who don't achieve the correct insulin dose and goes on hypoglycemia. Considering that most of these patients get the diagnostic from infancy, the lifestyles that they have is very different from the patient who has type 2 diabetes. They have a long time of unhealthy habits that can precisely do because of the normal function of their pancreas, and the obesity that comes along (in the majority of cases) that lifestyle always come with an insulin resistance (read about leptins and the endocrinology of adipocytes). So in practice, type 1 diabetic patients would have a lot more hard way to get obese AND have insulin resistance without having to go to the ED every time they decompensate than going to achieve a tighter glycemic control.
PD: English is not my primary language, so I'm sorry for the grammar mistakes

nor is endocrinology your forte...as an actual endocrinologist, this type of patient is not that unusual...unfortunately many other physicians utilize the stereotype of what a type 1 or 2 patient is supposed look like or when they should be diagnosed (as you have) to "make" a diagnosis...and when they are difficult to control, they blame the patient.

 

[Nyatar]

nor is endocrinology your forte...as an actual endocrinologist, this type of patient is not that unusual...unfortunately many other physicians utilize the stereotype of what a type 1 or 2 patient is supposed look like or when they should be diagnosed (as you have) to "make" a diagnosis...and when they are difficult to control, they blame the patient.

As the way I see it, nor teaching is your forte haha. I live in a developing country, where is difficult to achieve glycemic control not because of the patients (I never said that, so you just assumed a lot of things lol) if they aren't adherent or can't adjust the correct dose it's because a LOT of factors that are present in the developing countries; lack of specialists, lack of education, lack of resources to make a more accurate diagnosis (so the most are T1 or T2 but trying to make a MODY or LADA diagnosis takes more resources that in our practice doesn't exist very often), etc. Also, the phenotype of type 1 with metabolic syndrome comes with a more effective and intensive glycemic control with the cost of hypoglycemia and the anabolic metabolism promoted by insulin, so it's logic that in this kind of setup it will be rarer to see that type of patient, but it will be more common as we progress in our health policies.

 

[rokshana]

As the way I see it, nor teaching is your forte haha. I live in a developing country, where is difficult to achieve glycemic control not because of the patients (I never said that, so you just assumed a lot of things lol) if they aren't adherent or can't adjust the correct dose it's because a LOT of factors that are present in the developing countries; lack of specialists, lack of education, lack of resources to make a more accurate diagnosis (so the most are T1 or T2 but trying to make a MODY or LADA diagnosis takes more resources that in our practice doesn't exist very often), etc. Also, the phenotype of type 1 with metabolic syndrome comes with a more effective and intensive glycemic control with the cost of hypoglycemia and the anabolic metabolism promoted by insulin, so it's logic that in this kind of setup it will be rarer to see that type of patient, but it will be more common as we progress in our health policies.

so your lack of resources to make a correct diagnosis means that the condition doesn't really exist? in looking at your few posts, you seem to be chockfull of bad advice.

most diagnoses can be made with knowing how to take a good history...most of the time the patient will be able to give you enough information to make that diagnosis. Labs are to confirm your diagnosis, not make it for you.

 

[Nyatar]

so your lack of resources to make a correct diagnosis means that the condition doesn't really exist? in looking at your few posts, you seem to be chockfull of bad advice.

most diagnoses can be made with knowing how to take a good history...most of the time the patient will be able to give you enough information to make that diagnosis. Labs are to confirm your diagnosis, not make it for you.

Well, I already said your problem with teaching. If you are going to answer then take your time to discuss and not only criticise making 0 contributions. I will not judge you because I don't know you but is evident to me that you don't make any effort to understand, so I will stop arguing with you.

 

[rokshana]

Well, I already said your problem with teaching. If you are going to answer then take your time to discuss and not only criticise making 0 contributions. I will not judge you because I don't know you but is evident to me that you don't make any effort to understand, so I will stop arguing with you.

smh...

 

[Raryn]

Hello, I do think that it's rather difficult to have that type of patient in the real life. Type 1 diabetes, as we know, is because of an absolute deficit of insulin due to an autoimmune-mediated destruction of the pancreatic beta cells. In this condition, managing the optimal levels of glycemia is very challenging because of the strict intake control and tight insulin dosing, so in practice we see patients who aren't adherent to treatment and goes constantly on KDA because of the insulin deficit, or patients who don't achieve the correct insulin dose and goes on hypoglycemia. Considering that most of these patients get the diagnostic from infancy, the lifestyles that they have is very different from the patient who has type 2 diabetes. They have a long time of unhealthy habits that can precisely do because of the normal function of their pancreas, and the obesity that comes along (in the majority of cases) that lifestyle always come with an insulin resistance (read about leptins and the endocrinology of adipocytes). So in practice, type 1 diabetic patients would have a lot more hard way to get obese AND have insulin resistance without having to go to the ED every time they decompensate than going to achieve a tighter glycemic control.
PD: English is not my primary language, so I'm sorry for the grammar mistakes

Here's a very simple way to look at it:

Two thirds of Americans are overweight. One third of Americans are obese. The Type I diabetic patients we take care of in America are (by and large)... Americans. While most (but not all) Type I diabetics are on the leaner side at time of diagnosis, as they get older... they often become overweight. We counsel them regarding healthy lifestyle habits, but this isn't perfect (or we wouldn't be having an obesity epidemic at all).

For example, the Joslin clinic (probably the pre-eminent entity managing diabetes in the United States) has a gathering of their "50-year medalists" periodically. These are individuals who have lived with Type 1 DM for 50 or more years. Here's a picture of the 2013 gathering:

The first thing you'll notice? These are all individuals in their 50s-70s who look like... normal individuals in their 50s-70s! Some of them are slim, but more of them are overweight, and a large number are obese. If you showed me this picture and asked me what disease they all shared, I'd never guess in a million years and half my practice is treating diabetes!

These overweight individuals are still absolutely insulin dependent, but often have a component of insulin resistance as well, leading to higher dose requirements.

So maybe in your country type I diabetics are more religious on enacting the lifestyle recommendations that they get since diagnosis, and you do a better job in management than the Joslin clinic. If that's the case, congratulations, please let me know your secret so I can enact it on my patients.

 

[PlutoBoy]

smh...

Here's a very simple way to look at it:

Two thirds of Americans are overweight. One third of Americans are obese. The Type I diabetic patients we take care of in America are (by and large)... Americans. While most (but not all) Type I diabetics are on the leaner side at time of diagnosis, as they get older... they often become overweight. We counsel them regarding healthy lifestyle habits, but this isn't perfect (or we wouldn't be having an obesity epidemic at all).

For example, the Joslin clinic (probably the pre-eminent entity managing diabetes in the United States) has a gathering of their "50-year medalists" periodically. These are individuals who have lived with Type 1 DM for 50 or more years. Here's a picture of the 2013 gathering:

The first thing you'll notice? These are all individuals in their 50s-70s who look like... normal individuals in their 50s-70s! Some of them are slim, but more of them are overweight, and a large number are obese. If you showed me this picture and asked me what disease they all shared, I'd never guess in a million years and half my practice is treating diabetes!

These overweight individuals are still absolutely insulin dependent, but often have a component of insulin resistance as well, leading to higher dose requirements.

So maybe in your country type I diabetics are more religious on enacting the lifestyle recommendations that they get since diagnosis, and you do a better job in management than the Joslin clinic. If that's the case, congratulations, please let me know your secret so I can enact it on my patients.

Do you guys routinely check for antibodies in newly diagnosed diabetic adults?

 

[Raryn]

Do you guys routinely check for antibodies in newly diagnosed diabetic adults?

Depends on how they present.

Morbidly obese 55 year old who presents with incidentally noted DM? No.

30 year old who presented in DKA? Absolutely.

Basically, anyone thin, young (definitely if <30), or who has ever had an episode of DKA gets antibody screens from me. You can also argue about anyone who has a hx of other autoimmune diseases.

 

[PlutoBoy]

Depends on how they present.

Morbidly obese 55 year old who presents with incidentally noted DM? No.

30 year old who presented in DKA? Absolutely.

Basically, anyone thin, young (definitely if <30), or who has ever had an episode of DKA gets antibody screens from me. You can also argue about anyone who has a hx of other autoimmune diseases.

Thanks, boss. Consider the case of a patient that presents with concerns of high blood sugars.

Sure enough, he is a diabetic. HgBA1C 12% or so.

He is around 50+ years old, obese but not morbidly.

The patient is very symptomatic and dehydrated.

Within two to three weeks his blood sugar is around 110, on average. Treatment consists of rapid and long acting insulin + metformin.

Dude is doing great but decides to visit an endocrinologist who ordered antibodies. Results are pending.

In your opinion, is this justified? And if it is, what is the rationale?

 

[gutonc]

Dude is doing great but decides to visit an endocrinologist who ordered antibodies. Results are pending.

In your opinion, is this justified? And if it is, what is the rationale?

He owns the lab...or didn't read the chart.

 

[Raryn]

Thanks, boss. Consider the case of a patient that presents with concerns of high blood sugars.

Sure enough, he is a diabetic. HgBA1C 12% or so.

He is around 50+ years old, obese but not morbidly.

The patient is very symptomatic and dehydrated.

Within two to three weeks his blood sugar is around 110, on average. Treatment consists of rapid and long acting insulin + metformin.

Dude is doing great but decides to visit an endocrinologist who ordered antibodies. Results are pending.

In your opinion, is this justified? And if it is, what is the rationale?

Different people have different thresholds of suspicion. Based on the story presented, I wouldn't have gotten them.

 

[rokshana]

Thanks, boss. Consider the case of a patient that presents with concerns of high blood sugars.

Sure enough, he is a diabetic. HgBA1C 12% or so.

He is around 50+ years old, obese but not morbidly.

The patient is very symptomatic and dehydrated.

Within two to three weeks his blood sugar is around 110, on average. Treatment consists of rapid and long acting insulin + metformin.

Dude is doing great but decides to visit an endocrinologist who ordered antibodies. Results are pending.

In your opinion, is this justified? And if it is, what is the rationale?

there may have been something in the history that could have raised the question...and many times its because the pt is asking if they really need to stay on insulin or can they switch to oral med.