February 17, 2007
Diagnosis and Symptoms
Question from Vestavia, Alabama, USA:
I am a 29 year old female with a BMI of 18, a vegan and a runner. I’ve had a history of anorexia, for which I am now recovered, and I’ve never been overweight. About a year ago, I got sick with what the doctor thought was an inner ear infection. He gave me antibiotics and steroids and something for dizziness. In less than 24 hours, I got dramatically worse, with terrible stomach pain and throwing up for which I later entered the emergency room breathing like I was in labor. They admitted me to the hospital for pancreatitis and I was there for almost a week. They decided that it was food poisoning, although they weren’t sure. About three months ago at a routine check-up with my doctor, my random blood sugar was 292 mg/dl [16.2 mmol/L]. Apparently, he checked it because two months before that, my fasting sugar test was 130 mg/dl [7.2 mmol/L], but no one had told me. My blood pressure was low and my cholesterol was good, with very high good cholesterol. He referred me to an endocrinologist.
The endocrinologist thought I was LADA, mentioned something about a honeymoon period, and ran antibody tests as well as an OGTT. I have been checking my sugar at home and I found out my running affects my fasting level. If I don’t run, it is around 150 mg/dl [8.3 mmol/L]. If I run, it runs in the 130s mg/dl [7.2 to 7.7 mmol/L]. So, to prepare for the OGTT, I ran 10 miles at around 10 o’clock the night before, and it helped. My fasting blood sugar the next morning was 119 mg/dl [6.6 mmol/L]. I was 207 mg/dl [11.5 mmol/L] at 30 minutes, 230 mg/dl [12.8 mmol/L] at one hour, then, I got nauseous and threw up. I talked to the endocrinologist about my tests yesterday. May antibodies were negative, including the GAD. My A1c was 5.9 and he gave me the limited OGGT results. He did not seem nearly as excited about my fasting test as I was, after all it was under the magic 126 mg/dl [7.0 mmol/L]. He said I definitely had some glucose tolerance abnormalities and that he wanted to keep a close watch on my numbers. I go back to see him in five weeks. I have no family history of diabetes of any type in my family. My numbers since I’ve been checking tend to swing widely up and down, I rarely see a number below 120 mg/dl [6.7 mmol/L].
So, my questions are these:
Does this mean I’m pre-diabetic (isn’t that associated with type 2) or already diabetic?
If I remain athletic, watch my diet and now my carbohydrates for two months, how or can I arrest the process to diabetes?
Would my incident in the hospital last year temporarily impair my pancreatic function, so maybe this is transient and it will heal?
Does the negative GAD rule out LADA?
Would losing weight stop type 2? I am a little fearful of traveling that path with my history, but if it would help, I would do it.
Answer:
These are all good questions. I will respond using the corresponding number to your questions.
I would say you have pre-diabetes. At this point, it is not clear whether you are at risk for type 1 or type 2. Your history and evaluation do not satisfy any of the classifications in a classical manner. However, the glucose intolerance does not appear to be transient. It persists.
I think all you can do is live a healthy lifestyle. If this were an autoimmune form of diabetes (like LADA), the process could still eventually lead to diabetes. It is less likely type 2 diabetes. However, this may be a story that is not necessarily predictable at this point. Currently, doctors have no way to visualize functioning beta cell mass (the number of cells making insulin in the pancreas). We get this from the dynamic tests, such as the OGTT, that are performed. You have either decreased functioning beta cell mass or marked insulin resistance, or both. Did you have a C-Peptide levels obtained? This tests suggests the amount of de novo insulin secreted at the time of the OGTT. Low levels are suggestive of a type 1 picture and high levels are suggestive of a type 2 picture.
People can develop diabetes from pancreatitis. However, more than 90% of the pancreas has to be destroyed before people develop diabetes from pancreatitis. I guess there is a possibility that the combination of a predisposition to diabetes and damage from pancreatitis could cause this. However, people usually develop pancreatic exocrine deficiency (inability to make the enzymes of digestion and manifested by diarrhea) before they develop the diabetes.
No, the negative anti-GAD antibodies does not rule out LADA. You should look at it such that a positive tests is helpful. A negative test does not rule it out.
Don’t go there. What else can you do? You already have a restrictive diet. You are thin. You exercise. If your healthy lifestyle does not keep you normal, you will need medications. Please work with your doctor if you develop any inclination to have any eating disorder-type habits. This can be devastating and not in your best long-term interest.
JTL
