Both Type 1 Diabetes and Type 2 Diabetes share one common feature: a reduced ability to produce insulin or a reduced ability to properly use insulin. In illustrations, the size of the shovel represents the amount of insulin the body can produce or use, from small to large.
Diabetes Mellitis (DM)
Sometimes called “having sugar” in everyday language, diabetes mellitus is far more complex than most people realize. According to the American Diabetes Association (ADA), there are over 30 distinct forms of diabetes, with ongoing research to understand and manage them. Currently, diagnoses are generally based on:
- Type 1 Diabetes (T1D): An autoimmune condition
- Type 2 Diabetes (T2D): Often related to insulin resistance
- Other types: Include various forms that are not Type 1
- Gestational Diabetes Mellitus (GDM): Occurs when placental hormones increase insulin resistance, usually returning to normal glucose levels after delivery
Secondary Type 2 diabetes: Occurs due to hormonal interference (e.g., steroid medications) or pancreatic disease such as cystic fibrosis
QUIRK:
Type 1 Diabetes is sometimes described as having “no shovel”, reflecting the autoimmune destruction of insulin-producing cells.
Even though Type 1 Diabetes is less common than Type 2, it is essential to understand it first because it is fundamentally different. It is an autoimmune condition, meaning the immune system attacks healthy tissue—in this case, the pancreas, where insulin is produced. A family history of autoimmune diseases (Graves Disease, Rheumatoid Arthritis, Multiple Sclerosis, Celiac Disease, etc.) increases the risk of developing additional autoimmune conditions, including T1D. Other contributing factors include vitamin D deficiency and viral infections.
Type 1 Diabetes can occur at any age—it is no longer called Juvenile Diabetes. Onset in children is often rapid and severe, with symptoms including:
- Extreme thirst
- Frequent urination, sometimes leading to incontinence or “bed wetting”
- Weight loss despite adequate eating
Older individuals may experience a slower progression with milder symptoms, which can sometimes result in misdiagnosis as Type 2 Diabetes. In adults, antibodies that attack pancreatic tissue may no longer be detectable, complicating diagnosis.
QUIP:
There is no way for blood glucose to enter body cells without insulin. Insulin sensitivity is like a door on the cell opening easily to allow glucose in.
Type 1½ Diabetes: Not an official diagnosis, but sometimes used to describe people who exhibit attributes of insulin sensitivity, normal weight, high HDL cholesterol without detectable antibodies. These are increasingly understood as forms of diabetes related to how insulin is used by cells.
QUIP:
Some individuals can produce insulin but cannot release it from the pancreas. Previously treated with injections, these patients may now benefit from sulfonylurea medications, which allow the pancreas to release insulin naturally—no injections required!
Type 2 Diabetes
Type 2 Diabetes is most often linked to insulin resistance, as described in the Metabolic Syndrome section. Over time, insulin production may decline—a concept referred to as the Pancreatic Exhaustion Theory.
Insulin resistance can be visualized as a coal stove with doors that don’t open fully. Cells have receptors that allow insulin to move glucose from the blood into trillions of cells. When insulin cannot effectively transport glucose, blood sugar rises.
- Sometimes massive doses of injectable insulin are required to manage glucose levels
- Non-insulin medications, including GLP-1 receptor agonists, can help reduce glucose levels and aid in weight management
Carbohydrate Counting
Carbohydrates have the greatest impact on blood glucose. This was demonstrated by the Diabetes Control and Complications Trial (DCCT), which followed over 1,000 participants for nearly 10 years. Carbohydrate counting, paired with mealtime insulin, helps maintain glucose stability, reducing highs and lows.
Key DCCT insights:
- Sugar and starch affect blood glucose equally
- Adjusting carbohydrate intake rather than eliminating them is crucial
The study stopped a year early due to overwhelming evidence: up to 75% reduction in blindness and 50% reduction in nerve and kidney damage
QUIP:
Since the DCCT study it is now recognized that all the chemical bonds that hold sugar molecules together in starch break apart simultaneously not from either end as was previously thought. Thus, sugar and starch have similar effects on blood glucose.
TIP:
A simplified approach to carbohydrate counting works almost as well as rigorous methods, as demonstrated at a Long-Term Nursing and Rehabilitation Center in Ithaca, NY. Basal-bolus-correction insulin protocols improved glucose stability and reduced unnecessary phone calls to physicians.
Insulin-to-Carbohydrate Ratio (ICR):
- Based on insulin sensitivity or resistance
- Ranges:
- 1:1 (severe insulin resistance)
- 1:30 (insulin sensitive)
- Children: up to 1:60
- Adjusted for growth, pregnancy, or other physiological changes
- Must be determined with a Registered Dietitian Nutritionist (RDN) certified in advanced diabetes care and approved by a licensed medical provider
TIP:
Carbohydrate counting begins with recognizing that all carbs come from plants or milk. Eggs contain 0 carbohydrates because they are neither plant-based nor milk.
QUIRK:
Sweetness, water content, and density determine carbohydrate content. For example:
- Melons and berries are high in water → 1 cup = ½ cup standard fruit carbs
- Dried fruits → smaller volume for same carb content
- Starchy vegetables (sweet corn, sweet peas, sweet potatoes) → ½ cup = 15 g carbs
QUIP:
A ½ cup of sugar (or jellybeans) ≈ 100 g carbohydrates → 400 kcalories.
Each of these images have the chain of 15 pop-beads representing a "Carb Choice" and corresponding to the size of the measuring cups.
Test Your Knowledge
A small homemade cupcake (½ cup) contains:
- 15 g carbs
- 45–60 g carbs
- 150 g carbs
Answer: 45–60 g carbs → flour, eggs, and oil contribute, not just sugar.
A cupcake can't be 15 g carbohydrates as it would be bread, not cake.
And it can't be 150 g carbohydrates as the most concentrated source of carbohydrates being sugar is 100 g carbohydrates.
Pattern Management & Technology
Continuous Glucose Monitors (CGMs):
- Revolutionizing diabetes management
- Measure interstitial glucose (fluid between cells) with slight time lag
- Lowers risk of hypoglycemia, allows better insulin dosing
Now often covered by insurance, with low-cost consumer options available
QUIP:
Using a CGM, I realized three small pancakes at breakfast could spike glucose to 200 mg/dL. Lesson learned!
Stress, Dawn Phenomenon & Somogyi Effect:
- Dawn Phenomenon: Morning rise due to cortisol and growth hormone → may require higher breakfast insulin
- Stress Hormones: Illness, injury, or emotional stress raises glucose
- Somogyi Effect: Rebound hyperglycemia following hypoglycemia → do not overtreat lows
15/15 Rule for Hypoglycemia:
- Eat 15 g of fast-acting carbs
- Wait 15 minutes
- Repeat if glucose <70 mg/dL
Follow with a balanced meal/snack
Glycemic Index & Load
- Glycemic Index (GI): How fast carbs enter the bloodstream
- Glycemic Load (GL): GI × amount of carbs consumed
- Solid carbs stay longer in the stomach → slower glucose rise
- Liquid carbs like juice spike glucose faster but small portions → lower GL
QUIP:
Think of each gram of carbs as a coal nugget. Shovel size = insulin needed to move the fuel.
TIP:
Morning carbs should favor solids over liquids due to the Dawn Phenomenon.