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Neither 1 Nor 2

David Spero

February 3, 2010

In response to my recent blog entry asking what people wish health professionals knew about diabetes, Michael Barker commented about “ketosis-prone diabetics,” of which he is one. Thank you, Michael. Ketosis-prone diabetes, or “KPD,” as it’s called, is an important and growing problem.

The most common cause of ketosis, aside from starvation, is lack of insulin, which can lead to a condition known as diabetic ketoacidosis (DKA). The American Diabetes Association (ADA) says that DKA “is a serious condition that can lead to diabetic coma… or even death. When your cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood… High levels of ketones can poison the body. When ketone levels get too high, you can develop DKA.”

This is a good description of DKA. But they go on to say that, “Ketoacidosis… is rare in people with type 2.” This is not strictly true.

In a study of Apache Indians with Type 2, 17 people had been admitted to the hospital for DKA, some more than once. They were more likely to be male and less likely to be heavy than people with Type 2 who had never had DKA.

Another recent study evaluating 138 consecutive admissions for DKA at a large academic center observed that 21.7% had Type 2 diabetes. Almost half of the people admitted had an identifiable infection. Any person with Type 2 can get DKA in response to an overwhelming infection or other major stress. But at least half the people had no significant infections.

DKA can only happen when there is a shortage of insulin. Insulin resistance alone won’t do it, because having even small amounts of insulin in your blood keeps fat from being burned for fuel. You might get high glucose numbers, but not ketones. So why should a person with Type 2 suddenly end up with DKA?

The answer is that there are many more types than just “1” and “2”. Type 1 is a disease in which the insulin-producing pancreatic beta cells are destroyed by one’s own immune system, so insulin can’t be produced. Type 2 is a condition in which beta cells still produce insulin, but either the body’s cells are resistant to it, there is not enough to meet the body’s needs, or some combination of the two.

“Ketosis-prone” diabetes is a form of Type 2, with insulin resistance and, usually, overweight. But in KPD, insulin production may suddenly shut down for other, poorly understood reasons, making a person’s condition temporarily look like Type 1. KPD is most common in people of African descent but can be found in any population group.

There are other of diabetes types between 1 and 2. You may have heard of LADA ( latent autoimmune diabetes of adults) and MODY (maturity onset diabetes of youth). LADA is kind of a creeping Type 1 where beta cells suffer immune attack and gradually die off. MODY is a group of genetic defects causing (so far) six different types of diabetes, most of them resembling milder cases of Type 1.

Scientists in Texas have classified KPD into four different categories based on immune activity and beta cell production. Some scientists think there is a vast “gray area” between Types 1 and 2 and people fall in different places between these two poles. Collectively, all these types are sometimes referred to as “Type 1.5” or “Type 1B.”

Most people with KPD, LADA, and MODY are diagnosed and treated as Type 2. They’re “too old” for Type 1, and many doctors are unfamiliar with the other types. So you “must be” Type 2. The problem is that they may be denied insulin when it would be very helpful.

If you have KPD, you may not need insulin most of the time, but it needs careful watching. Usually, after the DKA is resolved with insulin and intravenous fluids, some insulin production resumes and you can gradually go back to managing without injecting insulin. But be careful. You may need to resume insulin at any time.

According to Guillermo Umpierrez of Emory University, a leading KPD expert, increased blood glucose may be a trigger for beta cell shutdown and DKA. So good diabetes control seems extra-important for people with KPD. Know the symptoms of approaching DKA (such as thirst, hunger, urinating a lot) and find a doctor who knows about KPD.

Hope I got most of this right. You can see much more about KPD research and experiences on Michael Barker’s blog at http://ketosisprone.blogspot.com/.



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