Flatbush is an area of Brooklyn, New York where the population is predominantly of Caribbean origin. In 1994, doctors at Kings County/Downstate Medical Center in Flatbush reported that they were seeing a new type of diabetes. Patients with this type of diabetes fit the profile for Type 2 diabetes but had the more severe symptoms of Type 1 diabetes. Since that first report, other doctors worldwide have reported similar cases that they called different names such as ‘atypical diabetes’ and ‘ketosis-prone type 2 diabetes,' but the most common name for this life-threatening condition is still Flatbush Diabetes. It is not actually a new type of diabetes but a serious consequence of long-standing undiagnosed, untreated type2 diabetes.
Type 1diabetes occurs when the body makes antibodies that attack and destroy the cells that make the hormone insulin. Normally insulin drives blood sugar (glucose) into muscle cells where the sugar is either used for energy or stored as fat. Without insulin, glucose cannot get into muscle cells and it backs up in the blood. Without glucose, muscle cells are forced to burn stored fat for energy. The rapid breakdown of fat produces highly acidic compounds called ketones which acidify the blood. This leads to a life-threatening condition called diabetic keto-acidosis (DKA). DKA is a medical emergency; if patients are not treated with insulin they will go into a coma and die. Fortunately, type 1 diabetes is relatively rare with less than 10% of cases. The vast majority of people with diabetes have type 2, where insulin is produced but the cells are resistant to it. Insulin resistance can be caused by several factors such as too much fat in the cells and too much circulating stress hormones. Insulin resistance leads to high blood sugar levels that can cause multiple organ damage and overwhelm the kidneys. When sugar escapes in the urine it draws water along with it and causes frequent urination and thirst, the most common symptoms of type 2 diabetes. These and other early symptoms of type 2diabetes are relatively mild and may be unnoticed or ignored for years. Type 2diabetes can be successfully treated with lifestyle changes and/or oral medications.
Patients with Flatbush Diabetes usually arrive in an emergency department with DKA and very low insulin levels, similar to people with uncontrolled type 1diabetes, but unlike type 1diabetes they have no antibodies to the insulin producing cells. When these patients are treated with insulin they respond well and within a few weeks start to produce insulin normally again. Most are able to stop taking injected insulin after 3 months and control their blood sugar with lifestyle changes alone or with oral medications.
The patients in the initial reports of Flatbush Diabetes were mostly obese, middle-aged, Black or Hispanic males of Caribbean descent. Doctors thought that this presentation of diabetes was unique to Afro-Caribbean Americans but it has now been recognized among individuals of all ethnic groups including Europeans, American Indians and Asian Americans who have long standing untreated diabetes. The lack of insulin that leads to life-threatening DKA in these patients may be due to prolonged untreated high blood sugar levels that poison insulin producing cells and shut off insulin production. Social factors that we can change such as an unhealthy lifestyle and lack of access to health care are far more important than race or ethnic group in the development of this condition.
Recent health insurance reforms will improve access to health care services. The next steps in preventing Flatbush Diabetes are lifestyle behavior changes such as eating a healthy diet, getting regular exercise, managing stress effectively and following up with your doctor for regular medical evaluations.
Dr. Rooke is the Medical Director of Atlanta Lifestyle Medicine. She is a board certified Preventive Medicine Specialist. Atlanta Lifestyle Medicine offers a comprehensive diabetes reversal coaching program that includes optimal nutrition, stress management, life skills training and exercise prescriptions.