Type 5 Diabetes: A Newly Recognized Form of Malnutrition-Related Diabetes

In a landmark decision, the International Diabetes Federation (IDF) officially recognized malnutrition-related diabetes as “Type 5 diabetes” during its World Diabetes Congress in Bangkok, Thailand, on April 8, 2025. This recognition marks a significant step toward addressing a condition that has been historically underdiagnosed and poorly understood, particularly in low- and middle-income countries (LMICs). A consensus statement, led by Meredith Hawkins, MD, professor of medicine at Albert Einstein College of Medicine, is expected to be published in early 2025, further detailing this distinct form of diabetes.

Historical Context

Malnutrition-related diabetes was first identified in Jamaica in 1955, primarily affecting young men in LMICs with a body mass index (BMI) below 19. Despite high blood glucose levels, these individuals do not develop ketonuria or ketosis, distinguishing them from those with type 1 diabetes, with whom they are often misdiagnosed. In 1985, the World Health Organization (WHO) classified malnutrition-related diabetes mellitus as a distinct category, but this recognition was rescinded in 1999 due to insufficient evidence linking malnutrition or protein deficiency directly to diabetes causation.

The reclassification of this condition as Type 5 diabetes by the IDF in 2025 reflects renewed global interest, driven by advanced research and advocacy from experts like Hawkins, who has studied the condition since 2005 through her work with Einstein’s Global Diabetes Institute, established in 2010.

Defining Characteristics

Type 5 diabetes differs significantly from other diabetes classifications, including type 1, type 2, gestational diabetes, and diabetes caused by specific genetic mutations, exocrine pancreatic diseases, or drug/chemical exposure, as outlined by the American Diabetes Association. Key features include:

• Demographic Profile: Predominantly affects young men in LMICs with low BMI (<19).
• Metabolic Profile: Unlike type 1 diabetes, individuals with Type 5 diabetes do not exhibit ketosis despite high glucose levels and insulin requirements.
• Insulin Secretion Defect: Research by Hawkins and colleagues, published in 2022, revealed that individuals with Type 5 diabetes have a profound defect in insulin secretion, challenging earlier assumptions that the condition was primarily driven by insulin resistance.

In a study of 73 Asian Indian men, including 20 with Type 5 diabetes, Hawkins’ team found:

• Lower total insulin secretion compared to lean individuals without diabetes and those with type 2 diabetes.
• Reduced endogenous glucose production and higher glucose uptake compared to the type 2 diabetes group.
• Significantly lower visceral adipose tissue and hepatocellular lipids compared to the type 2 diabetes group.

These findings have reshaped the understanding of Type 5 diabetes, highlighting the need for tailored diagnostic and treatment approaches.

Clinical Implications

The recognition of Type 5 diabetes has critical implications for diagnosis and treatment, particularly in distinguishing it from type 1 diabetes. Misdiagnosis can lead to excessive insulin administration, which can be rapidly fatal in Type 5 patients. While formal treatment guidelines are still under development, preliminary data suggest that a combination of small insulin doses and oral medications may be effective. Hawkins also emphasizes the potential role of nutrition, advocating for diets higher in protein and lower in carbohydrates, alongside addressing micronutrient deficiencies. These recommendations, however, require further research to establish evidence-based protocols.

A working group established by the IDF is tasked with developing formal diagnostic and therapeutic guidelines over the next two years, a process that will likely incorporate insights from ongoing studies in LMICs.

Global Health Significance

Type 5 diabetes is disproportionately prevalent in LMICs, where it is frequently encountered but rarely documented in medical literature, which is predominantly authored in Western countries. Hawkins, who frequently lectures in LMICs, notes that healthcare providers in these regions often express frustration at the lack of textbook references to this condition. The IDF’s recognition of Type 5 diabetes is expected to drive increased awareness, research, and inclusion in global medical education.

“This is a condition that is so prevalent among the world’s poor yet so neglected in Western literature,” Hawkins stated. “The tide is turning, and I’m excited to see global will to address it.”

Future Directions

The formal recognition of Type 5 diabetes opens the door to several critical next steps:

1. Publication of Consensus Statement: The statement, drafted in January 2025, will provide a comprehensive overview of Type 5 diabetes, including diagnostic criteria and preliminary treatment recommendations.
2. Development of Guidelines: The IDF’s working group will focus on creating standardized protocols to ensure accurate diagnosis and effective management.
3. Global Research Initiatives: Increased funding and collaboration are expected to support studies on the epidemiology, pathophysiology, and treatment of Type 5 diabetes, particularly in LMICs.
4. Educational Outreach: Efforts to update medical curricula and textbooks worldwide will help bridge the knowledge gap, ensuring that healthcare providers in both LMICs and high-income countries are equipped to recognize and treat this condition.

The designation of malnutrition-related diabetes as Type 5 diabetes is a pivotal moment in global health, spotlighting a condition that has long affected vulnerable populations in LMICs. With ongoing research, advocacy, and the development of targeted guidelines, the global medical community is poised to improve outcomes for those living with this newly recognized form of diabetes. As Hawkins aptly summarizes, “The IDF’s recognition of Type 5 diabetes is an important step toward raising awareness of a health problem that is so devastating to so many people.”

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