Category: Diabetes/Prediabetes/Hypoglycemia

OBESITY AND TYPE 1 DIABETES, HISTORY IS KING

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Obesity is a major public health disease that contributes to major complications including cardiovascular disease, liver disease, venous thromboembolisms, cancer, sleep apnea, and diabetes mellitus type 2. It is well known that obesity contributes to the pathophysiology behind the development of insulin resistance. While there is a strong association between obesity and type 2 diabetes, this was once rarely seen in type 1 diabetics. However epidemiologic studies of temporal trends show an increase in obesity in adults with type 1 diabetes. Thus, obesity is now an increasingly frequent observation yet often remains an underappreciated comorbidity. 


Methods :

Clinical
Case 1:

A 56 year old female with presumed type 2 diabetes given that she was obese on initial evaluation 7 years ago was admitted due to abdominal pain. Patient mentioned that she was started on oral diabetic agents with suboptimal results. Then she was upgrade to insulin (glarginw 14 units and aspart 5 units with meals)   with markedly improved glycemic control. Recently she underwent bariatric surgery with BMI 37 on initial evaluation with the hope that this would remove the need for insulin completely but was dismayed to find that she still required insulin despite now BMI 17.9. Laboratory studies revealed no dyslipidemia, C-peptide < 0.1 ng/dL, GAD-65 > 250 IU/ml, confirming that she is a type 1 diabetic.


Results :

Clinical
Case 2:


A 53 year old female was diagnosed with diabetes mellitus 20 years ago during routine labs and she had weighed 323 pounds at that time. She reported initial symptoms of polyuria, polydipsia, and weight loss but presumed type 2 diabetes given morbid obesity, and she later received gastric bypass that same year. She was placed on metformin 1000 mg twice daily, canagliflozin 150 mg daily, and insulin glargine 15 units daily but still had inadequate control though partly due to compliance issues. However, hba1c increased from 12.9 to 16.3% within 5 months without significant change in diet, physical activity or compliance. Lab studies reveal no dyslipidemia, C-peptide 0.9 (1.1-4.4), and GAD-65 > 250 IU/mL confirming diagnosis of type 1 diabetes.


Discussion : Emerging evidence suggests that obesity contributes to insulin resistance, dyslipidemia, and cardiovascular complications in type 1 diabetics which poses a challenge with all clinicians in correctly diagnosing the type of diabetes as presented above. 


Conclusion : A careful approach in eliciting pertinent clinical and family history should prompt studies looking to differentiate between the 2 types of diabetes which ultimately may lead to vast differences in management.

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Kelvin Tran

Endocrinology fellow 1st year
University of Arizona College of Medicine, Phoenix

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Ghada Elshimy

Endocrinology Fellow 1st year
University of Arizona College of Medicine, Phoenix
Phoenix, Arizona

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Ricardo Correa

Endocrinology, diabetes and metabolism fellowship director
University of Arizona College of Medicine-Phoenix and Phoenix VA
Phoenix, Arizona

Ricardo Correa, M.D., Es. D., F.A.C.P., C.M.Q. is an Assistant Professor of Medicine and Program Director for the Endocrinology, Diabetes and Metabolism of the University of Arizona College of Medicine-Phoenix and the Warren Alpert Medical School of Brown University in the department of Endocrinology, Diabetes and Metabolism. He is the chair of the young physician subcommittee of the American Association of Clinical Endocrinologist (YPS-AACE). Also he is editor of Dynamed and outreach unit director of Endotext.org and Thyroid manager and editorial board of multiple endocrine and internal medicine journals.
He completed his Medical School and Education Master at University of Panama. He completed a research fellowship in Epidemiology and Tropical disease at ICGES in Panama City and his internal medicine residency at Jackson Memorial hospital-University of Miami (UM) program. In 2012, he was honored with the AOA and GoldDOC Award from the UM. Then he pursued his clinical and research fellowship in endocrinology with special focus in neuroendocrinology and adrenals at National Institute of Health.
He was trained in Evidence-based Medicine at McMaster University in Canada and in Editorial process and OJS by LATINDEX. He is co-director of the Panamanian Cochrane Center and EBM advocate.
Dr. Correa has been involved in organized medicine since medical school. He has been scientific committee chair and vice speaker for the AMA-RFS, chair of the CoA for the ACP FC, Board of Trustee of the Maryland Medical Society, National Secretary of the CoA for the NHMA, Regional Vice President of the CIR, Medical Education Officer of JDN-WMA. He has been involved with local, regional and national organization in the area of medical education, leadership and physician wellbeing including the AMA joy in medicine organization, ACGME at different level including the duty hour task force, NBME as part of the board, NBPAS and other organization.
At AACE and ACE and Endocrine Society, Dr. Correa has occupied different position from been the fellow-in-training board of director member to member and advisor of multiple committees throughout the years.
Dr. Correa has been involved in multiple academic, scientific and educational activities including article Consultant, Interpretation of the Medical Literature Project, NBME, International Committee member of the Committee on publications ethics (COPE), World Association of Medical Editors, Deputy Editor of International Archives of Medicine, Editorial board and peer reviewer of multiple journals including Annals of Public Health, PAHO journal, SGIM journal, International Journal of Endocrinology, International Journal of Diabetes, International Journal of Clinical Cases and Images, International journal of case reports, etc. Also he is consultant for Latinamerican science center including Bolivia and Panama national science department.
He is board certified in Medical Quality. He is the author of the book title “Case report: basics and publication”. His research is focus on neuroendocrinology mainly on pituitary and adrenal tumor and new genetic mutations.

Sathya Jyothinagaram

Endocrinology Attending physician
University of Arizona College of Medicine, Phoenix

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