Diabetic Living’s website has an informational slide show about Latent Autoimmune Diabetes in Adults (LADA) ("What is LADA?" by Caitlin Thornton) that is harmful and unscientific. Some of the information is correct, but much has no scientific or medical basis. Thornton is also the author of Diabetic Living’s “Could Your Type 2 Diagnosis be Wrong?” (Fall 2010), which contains much of the same misinformation. I continue to be amazed that otherwise rational people promote substandard care for people with adult-onset Type 1 diabetes/LADA.
To Diabetic Living’s credit, they spotlight LADA and discuss the problem of misdiagnosis as Type 2 diabetes. But then they veer off into some wacky territory that is harmful to people with adult-onset Type 1 diabetes.
First, LADA is autoimmune diabetes which is Type 1 diabetes, according to the World Health Organization and the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Even DL says, “A diagnosis of type 1 later in life is sometimes called Latent-Autoimmune Diabetes in Adults (LADA).” However, more recently, diabetes researchers have discouraged the use of the term latent autoimmune diabetes in adults, because LADA is not a latent disease. A more descriptive term for all diabetes caused by immune-mediated destruction of the beta cells is autoimmune diabetes.
Here’s what Diabetic Living has to say:
DL: Misdiagnosis is not harmful.
FACT: Misdiagnosis (diagnosing a person with Type 2 diabetes when in fact they have LADA/Type 1 diabetes) is extremely harmful and can result in rapid onset of diabetic complications and even death due to diabetic ketoacidosis. I challenge the author of this statement to say those very words “misdiagnosis is not harmful” to the family of the Pennsylvania woman who was misdiagnosed as having Type 2 diabetes when she had LADA. This woman died of diabetic ketoacidosis (DKA), and her daughter said that the woman’s doctors had never heard of LADA. I challenge the author of “misdiagnosis is not harmful” to say those words to the study subjects of Tan and Lim, 2001, (“Latent Autoimmune Diabetes in Adults: A Case Series”) people with LADA who were denied insulin therapy: their average BMI was 17.2 (kg/m2), considerably under the BMI of 18.5 that is considered underweight, and their mean HBA1c was 14.3% (mean average blood glucose of 390 mg/dl), which indicates serious hyperglycemia. Two of the subject patients already had multiple diabetic complications due to poorly controlled diabetes. Would these study subjects agree with Diabetic Living that misdiagnosis is not harmful? All too frequently, Type 1 adults who are misdiagnosed as having Type 2 diabetes receive inappropriate treatment for the disease they have, as in the case of the subjects of this study who simply should have been given insulin to save their lives. ALL people who acquire Type 1 diabetes should be put on exogenous insulin as early as possible, to control glucose levels, prevent further destruction of residual beta cells, and reduce the possibility of diabetic complications.
DL: LADA is treated like type 1 and type 2 diabetes. Latent autoimmune diabetes in adults is an autoimmune disease -- the body attacks itself by destroying beta cells, which produce insulin in the pancreas. But unlike people with type 1, people with LADA often don't need insulin right away. "It's an immune process that is not as quick as it is with type 1," says Sally Pinkstaff, M.D., Ph.D., an endocrinologist at Sinai Hospital in Baltimore. "Patients [with LADA] may have some insulin resistance, but they still may have beta cells in the pancreas. They can start treatment with oral medication like a person with type 2."
FACT: An abundance of scientific studies indicate that the appropriate treatment for LADA and any Type 1 diabetes is intensive insulin therapy as early as possible. In ALL people with Type 1, both rapid onset and slow onset/LADA, the earlier that intensive insulin therapy is initiated, the better the preservation of remnant beta cells, the better the outcome. The evidence is substantial. The evidence is also substantial that many Type 2 treatments hasten the beta cell destruction in people with LADA.
What to do: Follow the Hippocratic Oath. Put all people with Type 1 diabetes on intensive insulin therapy as quickly as possible. David Klonoff MD, UC San Francisco, and Editor-in-Chief of Journal of Diabetes Science and Technology says, “It is important to correctly diagnose LADA in adult patients with new onset of diabetes to identify patients at risk of losing beta cell function, who should be started on insulin early (rather than oral agents) to help preserve beta cell function” (DiabetesMine.com, October 19, 2011).
DL: The LADA honeymoon can last for years. With latent autoimmune diabetes, the honeymoon phase -- the period when blood sugars can be controlled without insulin therapy -- can last for a year or much longer.
FACT: Frederick Allen, prior to the discovery of insulin in 1922, kept children with Type 1 diabetes alive for more than 5 years following diagnosis—the childhood-onset Type 1 diabetes honeymoon can also last for years. Now that we have insulin, why not just give people with Type 1 diabetes the life-saving insulin they need? In the 1970s, some children were put on sulfonylureas following diagnosis. In other words, childhood-onset Type 1 diabetes was treated like Type 2 diabetes, just as Diabetic Living says LADA can be treated like Type 2 diabetes. But treating Type 1 children as if they had Type 2 was not the right thing to do then, and denying insulin to a newly diagnosed LADA is not the right thing to do now.
DL: There are many unanswered questions about LADA. The medical community has yet to establish several concrete conclusions about latent autoimmune diabetes in adults. For example: Is type 1.5 diabetes an accurate descriptor for LADA? Or is it really just type 1? Some argue that 1.5 is incorrect because LADA is an autoimmune disease -- the only thing that relates it to type 2 is beginning treatment with non-insulin meds. Others say LADA may have as much in common with type 2. "There is research that shows type 1 is different from LADA," says Concepcion Nierras, Ph.D., a research director at the Juvenile Diabetes Research Foundation International (JDRF). "For example, we know that type 1 genes are different from type 2 genes. The gene that plays a role in LADA is a type 2 gene.”
FACT: Both children and adults with Type 1 diabetes also have genes for Type 2 diabetes. The genes that play a role in childhood onset and adult onset Type 1 diabetes are HLA DR3 and DR4, not Type 2 genes. JDRF’s Dr. Nierras makes this statement not based on fact, but because JDRF has long wanted to promote Type 1 diabetes as a childhood disease, and by admitting that autoimmune diabetes (LADA) is Type 1 diabetes, it means that childhood-onset Type 1 diabetes is a minority of Type 1 diabetes. However, more recently and in great contrast to Dr. Nierras’s statement, JDRF’s Bruce Bode MD says, “LADA is just a subset of Type 1 diabetes occurring later in life. IT IS TYPE 1 DM!! NOTHING MORE OR LESS. We see Type 1 presenting all the time in adulthood but most primary care physicians and even endos and CDEs miss it, thinking it is burned out Type 2 diabetes” (DiabetesMine.com, October 19, 2011).
If we have the treatment available for Type 1 diabetes/LADA, why should we do anything other than appropriately treat the disease? Why should we let a strange mindset, that denies the existence of adult-onset Type 1 diabetes and wants to declare Type 1 diabetes to be some exclusive domain of children, override the scientific facts? After all, Mary Tyler Moore, chair of JDRF International, was diagnosed at age 33. Let’s dispense with myths that do great harm (“Type 1 diabetes is a childhood disease” and “LADA can be treated like Type 2 diabetes”) and apply scientific rigor to the diagnosis and treatment of all autoimmune diabetes.