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June 7, 2005

Diagnosis and Symptoms

Question from Clinton, Iowa, USA:

I was diagnosed with type 2 in October 2004 after a bout with pneumonia. My fasting blood glucose was 567 mg/dl [31.5 mmol/L] and my A1c was 12.4. Recently, I saw an endocrinologist and a GAD antibody test was ran. She reported the results as "positive." My research tells me to switch from Amaryl and metformin to insulin shots, in an attempt to save beta cell function, thus having the ability to maintain better control of blood sugar levels. The doctor told me that I would eventually have a need for insulin therapy, so why not start now? And, if a cure is found for type 1, don't I stand a better chance of benefiting from it by saving beta cell function? Do I really have adult onset type 1?


The diagnosis of type 1 versus type 2 diabetes is always a point of contention as there is not an absolute definition. Clearly, it is an imperfect means of defining the disease. In general, we use a constellation of findings to support one diagnosis over another. Factors that support type 1 diabetes include thin body habitus, onset before age 30 (although this is relative), positive antibody levels (including anti-GAD), and low C-peptide levels in response to an insulin challenge (such as oral glucose or a mixed meal). Type 2 diabetes is supported by a strong family history, history of gestational diabetes, overweight or obese status, lack of antibodies, and good C-peptide response to an insulin challenge.

Your onset after an illness is a common presentation as the illness will challenge an already compensated system and bring out the high glucose values. Although it is the feeling of most people that type 1 diabetes is best treated with insulin because it replaces what is wrong from a mechanism of disease perspective, some clinicians will still treat patients with findings that leave the diagnosis of the type of diabetes in question with oral agents up until they cannot be treated further and insulin is started. Large studies are not necessarily available to provide proof as to what is the best way to treat patients. My bias would suggest that if you meet most of the criteria for type 1 diabetes, it would be better to treat with insulin. It has also been shown that the establishment of good glucose control with insulin leads to more successful recovery of surviving beta cells and may prolong their survival. However, this is a point open to debate. A healthy discussion of these points is reasonable to have with your physician.