The diabetes community, including medical professionals, patients, and manufacturers of therapies and devices, would benefit from a reboot of thought around what we currently consider diabetes. This reboot is designed to incorporate all current types of diabetes, and address symptoms, diagnosis, labels, culture, and most importantly, treatment paths.
Let’s start with symptoms and diagnosis:
- Diabetes, as defined in this document, describes the symptoms that indicate a glucose imbalance.
- Investigative medicine can (often) determine the cause of said imbalance: determining if it’s issues of insulin production or resistance, or some combination of both.
- Given that any individual is somewhere on the continuum of insulin production and resistance issues, we should diagnose as such, in a descriptive fashion.
- To start, I suggest we describe all people with a glucose imbalance as having an insulin disorder (instead of diabetes). This type of terminology comes from hematology where all different kinds of blood conditions are labeled blood disorders. We should aspire to leverage common language from related fields to drive condition naming continuity.
- Given that insulin disorder is the higher-order description, we now need to develop a system to describe the various natures of the disorder. I suggest intersecting sliding scales to designate the relative levels of insulin production and resistance.
- The X axis represents the amount of insulin resistance, where no resistance (R0) is when all insulin is normally received by cells for energy storage, and full resistance (R10) which represents the most extreme type 2 diabetic where literally no glucose is able to be naturally stored in their cells.
- The Y axis represents the amount of insulin production, between no production (P0), which is what most type 1 diabetics experience, and P10, which represents a state where healthy beta cells produce the naturally correct amounts of insulin.
In this new diagnostic paradigm, we’ve determined that what is currently called diabetes is actually a two-dimensional insulin disorder. The new descriptive name insulin disorder unifies all the former type 1s, type 2s, LADA, MODY, gestational diabetics, and the rest of them. But treatment is dependent on the nature of the disorder. So, we must be able to explain, clearly and accurately, the nature of the disorder. Doing so will not only help patients describe their condition, but allow them to find others with a similar condition, if they so choose to, in order to create relevant communities of education and support.
I suggest that we code this two-dimensional continuum for diagnosis so that it is precise and accurate, while also providing simple shortcuts to replace the inaccurate, imperfect diabetes labels we use today.
Diagnostic Coding
P[x]/R[y] Insulin Disorder, where [x] is determined by beta cell function (from C-peptide levels) and [y] is determined by the insulin resistance factor (from the HOMA model).
Here’s how this new coding can be used to clinically describe various current diabetic disease states:
- Type 1 diabetic with no insulin resistance: P0/R0 Insulin Disorder
- Type 1 diabetic with some insulin resistance: P0/R5 Insulin Disorder
- Moderate type 2 diabetic with full-functioning beta cells: P10/R5 Insulin Disorder
- Severe type 2 diabetic with full-functioning beta cells: P10/R8 Insulin Disorder
- Severe type 2 diabetic with exhausted beta cells: P3/R8 Insulin Disorder
Using this scheme, someone with an insulin disorder would be able to track the evolution of their condition as the P and R values went up or down. There would be trends for clinicians to track over time, and patients would get a sense of condition trajectory.
This scheme can be further simplified if we abstract the 0-10 continuum with no/low/medium/high values. A few examples:
- No Production / Medium Resistance
- High Production / Low Resistance
- Medium Production / High Resistance
- etc…
While helpful for medical/diagnostic conversations, this coding system is not simple enough for everyday conversations or easy patient comprehension. We need some simple shorthand terms to simplify common communications.
Simple Shortcuts for Patient Communications
- Diabetics of all varieties have an insulin disorder
- Typical type 1 diabetics have a insulin production disorder
- Typical type 2 diabetics have a insulin resistance disorder
- Those with gestational diabetes have a gestational insulin resistance disorder
- Those with Maturity Onset Diabetes of the Young (MODY) have a genealogical insulin production disorder
- Those with secondary diabetes have a pancreatogenic insulin production disorder
- etc…
As there seem to be countless other types and sub-types of diabetes discovered on a semi-regular basis, we can use these examples as a template for all others.
The term diabetes should be retired and replaced with insulin disorder.