Type 5 diabetes has now gained significant recognition. On April 9, 2025, the International Diabetes Federation acknowledged that chronic undernutrition can lead to this distinct type of blood sugar issue, giving it a formal status within the global classification system.
“Malnutrition-related diabetes has historically been vastly under-diagnosed and poorly understood,” shared Dr. Meredith Hawkins during the announcement.
Dr. Hawkins, an endocrinologist at Albert Einstein College of Medicine and the founding director of the Global Diabetes Institute, emphasizes the importance of this new classification.
Why a Fifth Type Matters
According to the 11th edition of the IDF Diabetes Atlas, nearly one in nine adults globally is affected by some form of diabetes, with over 250 million people still unaware of their condition. Most public awareness efforts have focused predominantly on type 2 diabetes, but it’s estimated that between 20 to 25 million lean adolescents and young adults in Asia and Africa could now officially be diagnosed with type 5, presenting a public health challenge comparable to that of HIV in those regions.
What sets type 5 apart is that it manifests in areas with food scarcity, challenging the long-held belief that diabetes is solely tied to over-nutrition. This distinction is crucial for government health budgets, as the classification influences funding for screening and treatment programs that were previously designed for different metabolic issues.
“This is about equity, science, and saving lives,” highlighted Professor Peter Schwarz, president of the IDF, underlining the serious implications discussed during the congress in Bangkok.
Early Hunger Leaves a Lasting Mark
Years of research on animals indicate that low-protein diets during gestation or adolescence can hinder pancreatic development and the formation of beta cells, which produce insulin. Human studies reflect a similar trend, linking low birth weights and repeated childhood malnutrition to difficulties in glucose management down the line.
Researchers have categorized type 5 as severe insulin-deficient diabetes, indicating that the pancreas hasn’t adapted to handle sugar effectively, even while the body remains sensitive to insulin. For instance, in South India, researchers noted adults with an average body mass index (BMI) of just 18.3 kg/m², yet their blood sugar levels spiked, suggesting in-utero undernutrition.
Community nutrition programs are increasingly recognized not only as hunger alleviation efforts but also as long-term strategies for preventing diabetes. Moreover, public health economists see an additional advantage: adequately nourishing girls before and during pregnancy can help their children bypass similar metabolic pitfalls, potentially breaking a costly cycle of disease across generations.
Recent studies using advanced euglycemic clamps have shown that type 5 patients produce significantly less insulin compared to others while exhibiting normal or heightened insulin sensitivity. Additionally, type 5 individuals typically have low visceral fat and moderate liver fat, which contrasts sharply with type 2 diabetes profiles.
No autoantibodies were found, which discounts the type 1 diabetes association often linked to immune-mediated beta-cell destruction. So, while glucose levels seem alarming and C-peptide levels appear low, inflammatory signs typical of autoimmune conditions are absent. This leads many experts to speculate that oral medications, which might stimulate the remaining beta cells, could be more beneficial than high-dose insulin injections, potentially lowering costs and minimizing hypoglycemia in food-insecure environments.
Diabetes Type Causes Clinical Confusion
Dr. Hawkins expressed concerns that medical professionals are still unsure about how to treat type 5 patients, who often do not survive long after diagnosis. Many younger clinicians, accustomed to the obesity-centered approach, might prescribe high doses of insulin that can push vulnerable patients toward severe hypoglycemia.
This misclassification not only skews surveillance data but can also misdirect insulin supplies away from those who genuinely need them. For instance, when a thin teenager in rural Uganda shows signs of elevated glucose without ketosis, they may mistakenly be labeled as type 1 diabetes, which complicates the real epidemiological picture. A commentary in the Bangladesh Journal of Endocrinology in 2025 highlighted the grave risks posed by standard insulin regimens for misclassified type 5 patients, where even minor dosing errors could lead to sharp glucose drops.
Simple identification cues can help. If a patient has a BMI under 19 kg/m² and no autoantibodies, it might be time to consider type 5, especially if there’s a history of significant childhood hunger.
Steps for Care of Diabetes Type 5
Two weeks following the Bangkok vote, the IDF established a working group dedicated to developing diagnostic criteria, treatment protocols, and an international patient registry by 2027. This group, co-led by Hawkins and Dr. Nihal Thomas from Christian Medical College in Vellore, India, plans to test low-dose insulin and structured nutrition programs across various sites, with potential implications for essential medicine lists in low-income nations.
Public health agencies are already calculating the economic effects. Analysts estimate that transitioning even half of misdiagnosed cases from insulin to oral drugs could save substantial amounts annually, allowing for resources potentially redirecting toward maternal nutrition initiatives.
Advocates also call for pancreas-focused imaging to be integrated into key nutrition studies, as early detection of organ sizes could help identify at-risk children before blood sugar levels become problematic.
“We are committed to making these essential changes,” said Schwarz, emphasizing the importance of sustained momentum. The policies born from this movement will ultimately determine if type 5 remains a hidden killer or becomes a preventable consequence of poverty.
The study has been published in Diabetes Care.
