The Ebers Papyrus, the world’s oldest known medical text, discovered in Egypt and dating back to 1550 BC, includes remedies “to eliminate urine which is too plentiful.” Ayurvedic narratives from fifth and sixth century BC India describe a condition marked by “honey urine”—so sweet it attracts ants and flies—along with extreme thirst and foul breath. Ancient Chinese scribes wrote about “wasting-thirst” disease, marked by decreases in weight and increases in thirst, hunger, and urine.
These are all apt descriptions of diabetes mellitus, although it wasn’t until the first century BC that the term diabetes (from the Greek word meaning to siphon or pass through) was first used. Mellitus (Latin for honey-sweet) was added some 600 years later.
By the fifth century AD, two distinct categories of diabetes mellitus were recognized: one that occurred in young, lean people and had a poor prognosis, and a less severe chronic condition that was more common in heavy, older people. Centuries later, these were labeled type 1 and type 2 diabetes, the classifications that are still in use today.
But it’s not that simple. Research makes it increasingly clear that, based on underlying causes and patient characteristics, there are more than two types of diabetes mellitus. Some are serious and require aggressive treatment while others are mild and can be managed with lifestyle changes—and patients do much better when these differences are recognized and treatment is personalized rather than handled with a one-size-fits-all approach.
Five Types of Diabetes
In an article published in The Lancet, researchers from Sweden and Finland analyzed data on thousands of patients with newly diagnosed diabetes. Focusing on weight (BMI), age at diagnosis, blood sugar levels (A1C), degree of insulin resistance, function of insulin-producing beta cells, and presence of GADA antibodies (indicative of autoimmune diabetes), they identified five distinct “clusters” or types of diabetes.
The first cluster (6 percent of study participants) is classic type 1 diabetes. Characterized by the presence of GADA antibodies, it is an autoimmune disease in which the immune system attacks beta cells in the pancreas, resulting in severe insulin deficiency. This type used to be called juvenile diabetes because it typically develops at a young age. But it can also come on later in life (latent autoimmune diabetes in adults/LADA), when it is often mistaken for type 2.
The other four clusters are subgroups of type 2 diabetes. Cluster 2 (18 percent of participants) is similar to type 1/cluster 1—severe insulin deficiency, relatively young age at diagnosis, not overweight—except for one significant difference. These patients have no GADA antibodies, so they do not have autoimmune diabetes but some other defect in their insulin-producing beta cells. They were the most likely to develop diabetic eye disease.
Cluster 3 (15 percent of study subjects) consists of overweight individuals who are producing adequate insulin but their cells are severely resistant to its signals, so blood sugar remains high. This group had a significantly increased risk of kidney problems and other chronic diseases.
Clusters 4 and 5 are by far the most common types of diabetes (22 and 39 percent of participants, respectively) and the most benign. Obesity is the defining characteristic of cluster 4, along with younger age and less severe insulin resistance. Cluster 5 is age related, diagnosed only in older people and marked by relatively mild insulin resistance.
One Size Doesn’t Fit All
Different types of diabetes, different treatments, right? Unfortunately, no. The researchers reported that treatment did not correspond with disease severity, underlying causes, or risk of complications, and inappropriate treatment was noted in each cluster. For example, low-risk patients in clusters 4 and 5 were treated similarly to those with far more serious disease (cluster 3).
That is precisely the problem with the current approach to diabetes. American Diabetes Association standards of care do encourage individualized A1C goals and treatments, but there’s a strong focus on medication—which one to take first, when to add other oral drugs or insulin, and why cholesterol-lowering statins and blood pressure meds should be prescribed.
Diet, exercise, and education are also emphasized in the guidelines, but given the bureaucratic constraints of modern medicine, there’s little time or incentive for educating patients and getting down to the nitty-gritty of helping them adopt lifestyle changes.
In an Ideal World...
In an ideal world, every patient with any type of diabetes would be started on a low-glycemic, nutrient-rich, whole-foods diet and an exercise program. Because adequate weight loss can literally reverse diabetes in obese patients, they would get intensive weight loss counseling, and insulin and oral medications that cause weight gain would be strictly avoided. These people would be treated instead with supplemental berberine or metformin, one of the few diabetes drugs suitable for heavy people.
For older individuals, less emphasis would be placed on strict blood sugar control, and if drugs were prescribed, they would be limited to safe, simple regimens that minimize the risk of hypoglycemia (very low blood sugar associated with confusion, dizziness, falls, hospitalization, and premature death). In fact, patients of all ages would be steered clear of most oral diabetes drugs because they increase risk of heart attack, stroke, and other cardiovascular complications.
Every patient with diabetes would be encouraged to take a potent daily multivitamin and mineral supplement plus lutein and zeaxanthin to protect the eyes, B vitamins and lipoic acid to stave off neuropathy, extra antioxidants to help preserve kidney function, and fish oil, coenzyme Q10, and vitamin D to reduce the risk of cardiovascular disease.
In addition, those at greatest risk of complications would be closely monitored for early signs and symptoms and undergo more intensive treatments.
These five types of diabetes aren’t the final word, but acknowledging individual differences, targeting treatment, and prioritizing lifestyle changes rather than piling on prescriptions is a safer, saner, more effective approach to this increasingly common condition.