I am not a number. -- "Number 6", The Prisoner

One of the questions asked in a recent #dsma chat had to do with the people we live and work with who are familiar enough with our diabetes care to support us, make sure we have appropriate food and drink as needed, who know how and when to administer glucagon, and what to tell the folk at 911 about us. Some debate arose over the common patient-community designation of these individuals as "Type 3s".

While "my Type 3" is as understood and respected a title among many people with diabetes as "my spouse", "my significant other", "my close friend", or "my parent", it does not have the same meaning amongst medical personnel -- nor is it always understood or appreciated by the people around us who perform that First Responder (Diabetes) role in our lives. My first encounter with the term "Type 3 diabetes" was in the context of someone with type 1 (autoimmune) diabetes who develops insulin resistance (a form of type 2 diabetes) -- something that may occur after years of eating to one's insulin and eating "anything I want, as long as I give myself the appropriate amount of insulin". (Some literature refers to this condition as "double diabetes".) A different source used the term "type 3 diabetes" to refer to the insulin metabolism of the human brain (certain brain tissues produce, and use, insulin; this second version of insulin may be implicated in Alzheimer's disease). With three distinct definitions for "type 3 diabetes", there's bound to be confusion.

"Type 3" aside, current "type" designations exclude many people with diabetes or "prediabetes". These include

• **People with no beta-cell-based insulin production at diagnosis, but no indication of autoimmune cascade
• **People with gestational diabetes (GD) -- which may be considered a special case of prediabetes
• **People whose diabetes is caused specifically by lipokine interference (a side-effect of obesity) as opposed to those whose diabetes is caused by insulin resistance, or those whose impaired glucose tolerance shows up on an oral glucose tolerance test (OGTT) despite normal fasting glucose and normal HbA1c
• **People with LADA (Latent Autoimmune Diabetes in Adults) -- sometimes referred to as "Type 1.5" -- particularly during the "honeymoon period"
• **People with monogenic diabetes (MODY) -- caused by a single gene. There are at least six (6) distinct flavors of MODY
• **People who are dependent upon exogenous insulin because the pancreas has been surgically removed (e.g. in cases of pancreatitis or pancreatic cancer)

This sort of "type"-casting is often tied to stereotyping of what people have which type of diabetes -- most commonly, that only children and teens have type 1 (autoimmune) diabetes, that obese adults must have type 2 diabetes (even if they've had diabetes since they were toddlers), that nonobese adults cannot have diabetes, and that LADA does not exist. These stereotypes lead to poor quality of care at best, and -- if not actively corrected by knowledgeable patients -- complications and even death.

The flip side of this is, we do need some method of classifying the different types and subtypes of diabetes to improve the likelihood of receiving a rapid and accurate diagnosis and appropriate treatment -- and we need medical professionals to be aware of, and use, this classification system. Currently, only the MODY subtypes have this degree of classification -- and if we are to believe the mainstream media, getting an accurate MODY diagnosis is even more difficult than getting an accurate LADA diagnosis (something that has taken years, and a lot of fighting with The Healthcare Powers That Be, for many living with that form of diabetes). The hurdles I perceive are:

• **getting the medical community to embrace the concepts of multiple causes for each "type" of diabetes (especially for nonautoimmune diabetes) and tailoring therapies to the causes instead of the symptoms
• **designating and agreeing upon a more informative classification system, and
• **getting everyone from researchers to primary care physicians, CDEs, and medical journalists to accept and use this new system

and, of course,

• **making sure the mass media don't get the origins and therapies of diabetes confused, and
• **warding off further fragmentation of diabetes research dollars into areas that will benefit increasingly smaller segments of the diabetes patient base, less effectively.