Need help navigating life with diabetes? You can always Ask D’Mine! Welcome again to our weekly Q&A column, hosted by veteran type 1, diabetes author and educator Wil Dubois. This week, Wil puts on his advice hat to answer some specific questions about how insulin works and what that means for those of us living with diabetes.
Joe, type 2 from Florida, writes: Hi Wil, question for you — When I was first diagnosed as a type 2, I heard bandied about that after a number of years a T2 converts or evolves into being T1. Is this even possible or real? Thanks! I enjoy reading your column.
Wil@Ask D’Mine answers: I’ll take diabetes myths for $250 please, Alex. Your question will be perfect for the all-diabetes version of Jeopardy! And the answer is resoundingly “no.” Not possible. Not real. There is no conversion. No evolution. No metamorphosis. No transformation. No transmutation. No transfiguration from one type of diabetes to another.
Once a type 2, always a type 2. Once a type 1 always a type one. That bold statement is one of science, and assumes you’ve been properly diagnosed in the first place—I myself spent a few months misdiagnosed as a “type 2.”
Here’s how it works: The two primary flavors of diabetes are different diseases that both just happen to impact the body’s blood-sugar regulation system and also just happen to share many symptoms, treatments, and gear.
Type 1 is an autoimmune disease. Our immune systems freak out, and, gobble up all the beta cells in the pancreas. You can think of it as a worst-case scenario, friendly fire incident. Well, creepier still, because if you think about it, it’s more like friendly fire cannibalism. The Border Patrol has mistaken a National Guard Unit for the enemy and has killed them all and frickin eaten them. Eewwww. Ick.
What makes this a worst-case scenario of friendly fire, rather than a garden variety case (beyond the whole cannibalism thing), is that those dead Guard troops were the logistics experts, the only ones who knew how to keep the entire military fed. With the beta cells dead, the whole body follows. Without modern medicine, type 1 is a quickly fatal disease. In kids, this beta cell destruction happens pretty damn fast. In older people, a bit more slowly. But in either case, within a year there is virtually no insulin left and we’re shootin’ up to stay above the AstroTurf.
Type 2 is a disease of insulin resistance. For reasons that elude science, type 2’s bodies forget how to use insulin. They are flooded with it, as a type 2’s pancreas not only still works, it’s an All Star player. It puts out prodigious amounts of insulin, but the body just can’t quite figure out what to do with it. It reminds me of the Alanis Morissette riff, ♫♪ “It’s like 10,000 spoons and all you need is a knife…” ♪♫
So why all the confusion over types of diabetes?
One word: Insulin. The type from the drug store, not the type from your pancreas.
We type 1s start on drug-store insulin from day one. Additionally, most all type 2s who live long enough will need to use it, too. Type 2 is a progressive chronic illness. It never goes away and gets worse over time. Eventually, it outgrows all the pills in the medicine cabinet and the advanced type 2 requires type 1-style therapy, i.e. insulin.
But just because you are using my drug doesn’t mean you have my disease. My diabetes is still caused by a haywire immune system. Yours is still caused by the fact that the cells in your muscles, fat, liver, and butt seem to have developed some sort of funky amnesia. They don’t recognize the insulin when it shows up at the cell’s door to deliver the Girl Scout Cookies they ordered a week ago.
Do type 2s assume they have become type 1s because they now need insulin? No. It’s usually the medical community itself that gets these kinds of misconceptions started. There might be many reasons why this happened, but I blame the lexicon of the past. In the beginning there was Juvenile Diabetes and Adult Onset diabetes. (Juvenile Diabetes always sounded too much like Juvenile Delinquent to me…) Then Juvenile was replaced with Insulin-Dependent Diabetes Mellitus, or IDDM to its friends; and Adult was replaced with the easy to remember Noninsulin-Dependent Diabetes Mellitus, or NIDDM. (And the name game hasn’t gotten any better since then.)
So pity the poor, harried, overworked primary care doc in his office. He’s dealing with the lady who has chest pain, the kid who stuffed a pinto bean up his nose, the man with gout, the flirtatious foxy drug rep with her low-cut blouse, and the “noncompliant” diabetic whose blood sugar is now so out of range that it’s a choice of insulin or the morgue. So yesterday, the PWD was an NIDDM. But now they’ve started taking insulin… So the doc changes the label to IDDM, because the patient now takes insulin, and logically, how can you be noninsulin-dependent if you depend on insulin? As the names changed so too, did attitudes. A lot of people might think they now have a different disease. I think too, that a lot of doctors (especially ones who did not specialize in diabetes) also believed this, and not just the ones with fake medical degrees.
I think that’s where our myth started. The type names were therapy based, not based on the pathogenesis of the disease. By stamping a prescription pad, legions of doctors gave untold numbers of people type 1 diabetes. And as Big Foot and the Lock Ness Monster can attest to, myths die hard. A great many people still believe that once they start taking insulin they have become a different kind of diabetic. Not true. A type 2 always fights insulin resistance. It can become so severe that the pancreas poops out, insulin production tanks to practically nil, but there is still no autoimmune issue going on.
To make matters more confusing, insulin-dependent type 1s can sometimes have insulin resistance, too, meaning they need more of the stuff for it to work. This makes them “look more like” type 2s.
Meanwhile, to be an actual type 1, you need cannibals in your veins.
James, type 2 from Michigan, writes: I got to wondering while out for one of my daily walks—just HOW does insulin actually get into our system? It’s NOT injected into the blood stream. It is usually injected into a variety of locations, and yet the way to measure it still comes back to testing the blood. So, in ten lines or less, in a language that a normal person can understand, could you enlighten us ‘users’? We all know you enjoy a challenge!
Wil@Ask D’Mine answers: Ten lines or less? So that’s a hair over three haikus, right? Oh boy. OK, here we go. Let’s suppose you were the victim of a horrible industrial accident. Somehow, on the assembly line, your circulatory system got caught on the moving equipment and unraveled like a snagged sweater. Every artery, vein, and capillary got sucked out of your body in one long string.
Any idea how long that string would be?
60,000 miles. No shit. Stretched out, your circulatory system could wrap around the Earth seven and a half times. That’s a lot of miles to pack into a person! My point? No matter where you go in the body, you can’t be far from the bloodstream.
You inject your insulin into the fat layer between your skin and your muscle. But fat is a living thing. It is fed by a vast network of tiny blood vessels, called capillaries. Like alpine mountain streams, these tiny blood vessels join, merge, and grow. Just as Podunk Creek eventually becomes the mighty Mississippi, the humblest capillary becomes the Aorta.
The insulin injected into fat is absorbed into these tiny streams and moved onwards. Your body is a highly networked hydraulic system. Inject some liquid anywhere in it and eventually that liquid will end up everywhere.
So there you go, not quite ten lines… but I hope I rose to your challenge!
Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.