
Diabetes is actually five separate diseases, research suggests - sjcsjc
http://www.bbc.co.uk/news/health-43246261
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Ice_cream_suit
"We did data-driven cluster analysis (k-means and hierarchical clustering) in
patients with newly diagnosed diabetes (n=8980) from the Swedish All New
Diabetics in Scania cohort. Clusters were based on six variables (glutamate
decarboxylase antibodies, age at diagnosis, BMI, HbA1c, and homoeostatic model
assessment 2 estimates of β-cell function and insulin resistance), and were
related to prospective data from patient records on development of
complications and prescription of medication. Replication was done in three
independent cohorts: the Scania Diabetes Registry (n=1466), All New Diabetics
in Uppsala (n=844), and Diabetes Registry Vaasa (n=3485). Cox regression and
logistic regression were used to compare time to medication, time to reaching
the treatment goal, and risk of diabetic complications and genetic
associations"

k-means and hierarchical clustering are notoriously prone to producing false
positive clusters.

~~~
CuriouslyC
k-means is just garbage, but hierarchical clustering can be good. The problem
with hierarchical clustering is that you can produce whatever set of clusters
you're biased towards by fiddling with the linkage function and the cut
criterion.

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Smaug123
I was surprised to learn on reading this that the Type 1 classification always
means "autoimmune disease". I was under the impression that the two type
classifications were "1: unable to produce enough insulin", and "2: producing
what ought to be normal amounts of insulin, but for some reason resistant to
it"; naively, those seemed like much more natural classes for classifying a
syndrome. Having a finer-grained analysis can't be a bad thing; for example,
the paper identifies some increased risks for the individual clusters.

~~~
manmal
AFAIK in type 1, most of the beta cells get destroyed, and it happens because
of autoimmune processes. To me this means that immune-modulating medication or
perhaps stem cell injections could help a great deal.

~~~
ohtwenty
The problem with those are that they're more complicated (even when perfected)
than current treatment. Immune modulation would require either suppressing the
entire system (or very large chunks of it) which is done with some other
diseases but generally has super high costs, as it leaves you quite
vulnerable. Or you're targetting only the handful of cells responsible (my DM
I knowledge is rusty but I'm guessing b-cells?) in which case you're on your
way to solving a bunch of different diseases.

Stem cells has a similar issue, in that once you made new beta cells your
immune system will just react to those.

Current treatment is quite alright. There's ground to be gained in earlier
prediction and treatment, and a ton (this should excite people here on HN) in
bettering the treatment method—create a proper feedback loop with
insulin/glucose readers that automatically push out insulin when needed
instead of a huge shot of it when you're guessing you'll need it.

~~~
pimeys
My doctor wants me to start thinking about a closed loop system on this year
so I don't need to wake up every night for CGM alarms. One interesting project
would be the open source pancreas, I've heard lots of good about it, of you
have the right insulin pump and CGM.

[https://openaps.org/](https://openaps.org/)

~~~
GiorgioG
Until there’s a dual (glucagon, insulin) pump released, you’ll still be waking
up to deal with those low BG alarms. You may be dealing with fewer alarms
because of the predictive suspend feature, sure.

Our 6 year old has had a Medtronic 530g which (you probably already know)
suspends basal delivery when it reaches a low threshold. I’m pretty sure it’s
saved his life a few times (at night) over the past 4 years. He’s due for a
new pump and we were hoping the Beta Bionics dusk chambered pump would be
ready by this time, but sadly it still looks to be a couple of years away. The
Medtronic 670g is likely his next pump, which will add predictive suspend and
IIRC will also auto increase his basal rates to account for highs.

OpenAPS looks interesting but for now I’m not willing to experiment with it on
our son.

~~~
pimeys
My doctor's colleague in US uses the 670G and when they met he showed her how
now every night he has a straight 6.5 mmol/l line and no wake-ups anymore. My
need for basal changes quite often and this feature would be nice.

I use xdrip which wakes me up before I got hypo or hyper. I'd prefer to have
eight hours of sleep every now and then.

~~~
GiorgioG
Yeah we use a Medtronic MySentry (basically think of a baby monitor with a
screen that displays his BG level...and relays CGM/pump alarms, loud enough to
wake the dead.)

xDrip / parakeet looks awesome, but that looks to be Dexcom-only as far as I
can tell.

Our son carries a medtronic Minimed Connect (pump<->bluetooth adapter) and an
iPhone (yeah a kindergartener with an iPhone) so it can relay his BG when he's
in school using Nightscout.

Unfortunately neither the MySentry, nor the Minimed Connect are supported with
the 670g so we're a little concerned that we won't be able to monitor him
remotely (while he's sleeping or when he's at school...the two times he's most
vulnerable.)

I'd love to switch him to a Dexcom, but there are currently no pumps that
support predictive / suspend functionality at this time (though the T:Slim X2
is getting close to getting this type of update.)

Thanks for the heads up on xDrip!

~~~
kakoni
You could use
[https://github.com/pazaan/600SeriesAndroidUploader](https://github.com/pazaan/600SeriesAndroidUploader)
with your medtronic.

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njarboe
Too bad this is just five "clusters" of characteristics that people with not-
type-I diabetes can be grouped into. No clear underlying mechanism for the
cause of each of the groups diabetes. Maybe more in the journal paper? Or now
focused studies can be done on each group to find out the root cause? I hope
so.

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mnw21cam
The quality of this article is rather poor. It's almost beyond belief that
they didn't consult with Prof. Andrew Hattersley, who is regarded as one of
the world leading experts in this.

We have known for many many years about several other types of diabetes. It is
what I research as my job.

Type 1 is caused by the autoimmune destruction of the beta cells in the
pancreas that generate insulin, and the patient becomes dependent on injected
insulin.

Type 2 is caused by a progression from the body becoming resistant to insulin
due to being overweight, the beta cells generating more insulin to compensate,
and then eventually the beta cells burning out. Along the way, treatment
progresses from diet, to tablets such as metformin, and eventually to insulin
injections. Many people think that you progress to type 1 when you become
dependent on injected insulin, but that is not the case - it is still type 2.

There is gestational diabetes, where the huge changes in the body caused by
pregnancy can trigger temporary diabetes (although sometimes it persists for a
while after pregnancy). For this reason, we tend to test the blood sugar level
of pregnant women.

Then we have MODY (Maturity Onset Diabetes of the Young), which is a form of
monogenic diabetes. There are at least 10 types, caused by single gene defects
in various genes. The treatment and prognosis depends on the gene which is
defective. For instance, if you have one of your two copies of the GCK gene
defective, then you get GCK MODY, which typically has few symptoms, but is
usually detected when a woman is pregnant and has their blood sugar levels
tested. The danger with GCK MODY is over-treatment - they do not need any
treatment at all, but doctors may try to lower the blood sugar levels by
giving insulin injections, which can be dangerous. Other forms of MODY do
require insulin.

There is also Neonatal Diabetes (NDM), which has two broad types, being
permanent and transient, and there are several different sub-types depending
on the gene defect. In this case, you are generally diagnosed with diabetes
under the age of six months, and sometimes as young as hours after birth. If
both of your copies of the GCK gene are defective, you will get permanent
neonatal diabetes, and require insulin injections for life, from birth.
However, if you have neonatal diabetes caused by defects in the ABCC8 or
KCNJ11 genes, treatment with sulfonylurea tablets is highly effective. It is
important to obtain a genetic diagnosis in order to get the correct treatment.

There are other types of diabetes other than these. It is very weird for this
article to be claiming the fact that there is more than just type 1 and type 2
to be news - it has been widely known for many years.

A lot of the recent work has been on trying to distinguish the different types
of diabetes. Neonatal diabetes is easy to distinguish, because it has a severe
early onset. It is possible to determine the genetic cause in about 80% of
patients that have this condition, and we are confident that further searches
will reveal a large proportion of the remainder. MODY is however too similar
to type 1 diabetes, so of patients sent for genetic testing for MODY, a
proportion of them will have type 1 instead, so the genetic test success rate
is lower, around 30%. Genetic risk scores for the autoimmune type 1 diabetes
response are used to try and distinguish the two, in order to try and perform
gene discovery research on as pure a MODY cohort as possible.

~~~
woodandsteel
>We have known for many many years about several other types of diabetes.

So are you saying the research project didn't contribute any new knowledge at
all? In that case, why the quotes from the experts that it did?

On the other hand, if you do think it contributed some new knowledge, you
should have said that and mentioned some specifics.

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DoreenMichele
You can add a sixth class. I have been told that Cystic Fibrosis Related
Diabetes (CFRD) is neither Type 1 nor Type 2.

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beagle3
Alzheimer’s disease is informally referred to as Type 3 diabetes because of
similarity; this informal name Is prevalent enough that when a different form
of type I was discovered (which may or may not be cluster 2 in this article)
it was called type 4

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knbknb
What about pregnancy-related diabetes? Some textbooks have it as a 3rd
independent type of diabetes.

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eganist
It seems a remarkable number of comments seem to think that people with Type
II diabetes resulting from Obesity should be compelled not to eat and should
be denied healthcare in the interim, such as this one [dead] comment:

> Why spend money on a population who has a free, safe, and natural remedy
> (eating less) available to them?

Please study food addictions¹²³⁴. Addiction is a disease⁵. Going cold turkey
may work for some, but for many, this option is infeasible with drugs. With
food, it's infeasible for everyone.

Food addiction is especially difficult to combat without medical
intervention⁶. Denying victims access to said care will only exacerbate the
problem.

¹ [https://www.webmd.com/mental-health/eating-
disorders/binge-e...](https://www.webmd.com/mental-health/eating-
disorders/binge-eating-disorder/mental-health-food-addiction#1)

²
[http://onlinelibrary.wiley.com/doi/10.1002/eat.20957/full](http://onlinelibrary.wiley.com/doi/10.1002/eat.20957/full)

³
[https://www.sciencedirect.com/science/article/pii/S019566631...](https://www.sciencedirect.com/science/article/pii/S0195666311005617)

⁴
[https://www.sciencedirect.com/science/article/pii/S019566631...](https://www.sciencedirect.com/science/article/pii/S0195666316305050)

⁵
[https://scholar.google.com/scholar?hl=en&as_sdt=0%2C47&q=add...](https://scholar.google.com/scholar?hl=en&as_sdt=0%2C47&q=addiction+disease&btnG=)

⁶
[https://www.sciencedirect.com/science/article/pii/S019566631...](https://www.sciencedirect.com/science/article/pii/S0195666312003844)

~~~
Mountain_Skies
What happens to people who refuse to submit to medical intervention?

~~~
eganist
That's up to them. I'm addressing the prospect of refusing medical
intervention to people generally, especially to those who want it.

