Irritable Bowel Syndrome (IBS) : Is it Autoimmune?

Read in 13 minutes

This blog post is a video that I recorded recently. The text below is the transcript of the video. I thought some of you may like to read rather than watch the video but the transcript takes 13 minutes to read! So reading the transcript versus watching the video will save you 2 minutes!

00:06               Hi,  I’m Dr Shabnam Das Kar a specialist in Functional and Metabolic Medicine from India. Welcome to the channel autoimmunity with Dr. Kar. So, uh, today’s the first episode and I’m going to discuss a very common condition that I come across in my patients called IBS, irritable bowel syndrome, and I’ll use a PowerPoint to share some of the IBS. So obviously as a functional medicine doctor, my perspective is going to be that of a functional medicine doctor. So they are going to look at IBS from, uh, from the perspective of through the Functional Medicine Lens. So what do I mean by that? Sorry. So through a functional medicine Lens, now obviously this is a little different from what traditional medicine focus because in traditional medicine, what would we do when we come across a patient with IBS? IBS is a condition where obviously if you’re somebody who’s suffering from that, you know what the symptoms are.

01:11               The commonest symptoms a week in a patient with IBS are pain, abdominal pain, the pain may be sometimes described as cramp, like sometimes it is sort of like a chronic pain. And this pain is usually something that is ongoing. So it depends, it maybe two months, three months, four months, sometimes much longer than that, and sometimes some of you described the pain as being relieved after, uh, going to the toilet. So after defecation, your pain is relieved. Now IBS is described as usually three different types. So IBS -D, which is diarrhoea predominant. So you may be having diarrhoea, you may be having constipation, you may be having a combination of both, which is IBS-M, mixed type. And IBS-C is the one where there is predominantly constipation. So you will have difficulty passing stools. Stools are hard. Now in a IBS diarrhoea where the predominant symptom is loose stools, sometimes you may have this terrible urgency where you need to use the washroom just after eating food.

02:22               So quality of life suffers quite a lot. Some of you also have bloating. You may have discomfort, so a lot of different symptoms. So what do I mean when I want to say that? Uh, when I, when I say that I’m going to look at it from a functional medicine Lens. So these are the different areas that we usually look at, and I’m going to cover them over the next few series of videos. But today the chief question I want to answer is because my areas of focus are autoimmunity and metabolic dysfunction, so is IBS and autoimmune condition? So it turns out now this was a paper that Dr. Mark Pimentel has published. This was in 2016, Dr Pimentel, he is a gastroenterologist and he’s Canadian, but he works at the Cedars Sinai Hospital in Los Angeles and many of you are familiar with Dr Pimentel and his work in Small Intestinal Bacterial Overgrowth causing IBS.

03:22               So what he found out is that yes it is a certain type of IBS could be auto immune. Now that is not a surprise because those of us who work in auto immunity, we, we say that, you know, most diseases are autoimmune until proven otherwise. So what does Dr Pimentel mean when he says about autoimmunity, in irritable bowel syndrome. Now IBS, all types of IBS and not necessarily autoimmune, but what Dr Pimentel found is in a certain subsection of people who have developed IBS following a gastrointestinal infection, that means following a gut infection, so you had acute gastroenteritis, maybe traveling at traveller’s diarrhoea or some kind of an infection like that and you probably had fever and you know, maybe vomiting after that you developed a pain and all these other symptoms of IBS. So that is called. That is an entity called post infection IBS. So normally, traditionally, what are you told?

04:33               You told that there is no one specific test for IBS, which is true because essentially the diagnosis is made based on your symptoms and by the time any of you come to me, you’ve already met the gastroenterologist, so he has already, he or she has already done the basic work. You’ve had the colonoscopy to find out if there is any problem, you might have had a biopsy and many of you have already been screened for Celiac disease. And I will talk about all of these briefly later on where the CELIAC disease and irritable bowel syndrome could coexist. So you’ve already had all that workup done and then you decide that you want to find out some more whether there is something else you can do because you are not 100 percent. Okay. So this is essentially post infectious IBS like I described before. You had traveller’s, traveller’s diarrhoea, maybe you had some kind of a gastrointestinal infection, which in countries like India is not uncommon.

05:36               And uh, so that is predominantly IBS, diarrhoea. So this autoimmunity does not necessarily apply to people with IBS, constipation, IBS-C, however, there have been some studies where they have found an auto antibodies to IBS-C as well. But I won’t go into all those details because if you are somebody who has IBS, what you are interested in knowing is what can you do. So is it important for you to find out whether you have an autoimmune IBS? That is a question I will answer. So Small Intestinal Bacterial Overgrowth is associated with IBS and that is something that Dr Pimentel has done a lot of work in and he is the person I learned a lot from, from his books, from his papers, from listening to his videos. So, uh, many of you have probably read his book called IBS Solution. So what does this, what does he mean by what do anyone.

06:37               Does anyone mean by Small Intestinal Bacterial Overgrowth? Most of you are familiar that there are these bacteria in your gut. Now most of the bacteria occupy your large bowel. That is your large intestine. So the small bowel or the small intestine is not supposed to have bacteria in normal circumstances. However, in certain conditions your small bowel may be, you know, containing bacteria, which is usually more so overgrowth, essentially more than that, there should be. So that itself can cause a whole bunch of problems and IBS is one of them. And again, what are the symptoms of SIBO? So SIBO symptoms sometimes overlap with the symptoms of IBS. So again, bloating, pain, diarrhoea, you know, things like that. You could also have belching, so Small Intestinal Bacterial Overgrowth and IBS are quite intimately related. So Dr Pimentel says if you do not treat the SIBO, your IBS will not go away.

07:45               So what did he find the from his studies, he found that there were two antibodies. Now, as many of you know, for any auto immune condition to be diagnosed, you need an antibody to be present. So what’s were these antibodies, one was the anti-Cytolethal distending toxin and the second one was anti vinculin antibodies. Now don’t bother if you don’t remember the names. So obviously most of you in particularly my audience in India, you want to know can you get this test done? Yes, you can get the tests done in the US, it’s called IBS. Um, I can’t remember the name now, but it’s done by a lab in Massachusetts, but as far as I know, the anti Cytolethal, distending toxin antibody and the anti-vinculin antibody test is not available in India yet. Yeah, it’s a blood test. So what happens if you find out whether you have autoimmune IBS or not?

08:40               Well, as a functional medicine doctor, truthfully I don’t need to necessarily tests you to know what, what type of IBS you have because my, my approach is a functional medicine doctor would always start with food first and I’m going to talk about that a little bit later, but what does it mean to have post infections IBS in India. So this is a paper by Dr Uday Ghoshal, who is from a very prestigious institution in India and he’s got a lot of papers on IBS and several other gastrointestinal conditions because gastrointestinal infections like acute gastroenteritis, these are fairly common in countries like India where we still have a relatively larger burden of waterborne diseases. So what do I mean by waterborne diseases? That means essentially the drinking water gets contaminated by faecal matter and that faecal matter can come from somebody who has an infection. So therefore the water gets contaminated and you won’t  know that seeing the water so that can cause gastrointestinal infection.

09:49               So in, uh, in the Indian population or what Dr. Ghoshal has found is there is another condition called post infectious malabsorption syndrome. So you may not be absorbing a lot of your nutrients. Now again, I don’t want to go into the details of the medical minute about what testing you should do to see whether you have fat malabsorption or you have nutrient malabsorption, but by doing a blood test for vitamin B 12, Iron, all these things you can know whether you have you nutrient deficiencies. However, sometimes the malabsorption syndrome or your nutrient deficiency may not be because of malabsorption alone, because as is well known, a lot of people in India are vegetarians and you’re culturally vegetarian, vegetarian from birth. So people who are vegetarians have a much higher incidence of B 12 deficiency. So it is not easy to differentiate whether it is your gut which is not absorbing the vitamins.

10:53               B vitamins or your diet itself doesn’t contain the B vitamins. So if you are vegetarian and you do not supplement with a B 12, then very likely you are going to be deficient. And B 12 deficiency is one of the things that I’m deficiency is very common in India even amongst men because normally our deficiencies considered to be a women’s disease. And I was an OBGY before, so we used to get a lot of iron deficiency anaemia in women, but it turns out even a lot of my men patients have iron deficiency, so obviously it’s not just one or two nutrient deficiencies, multiple deficiencies. So the malabsorption syndrome, which back in the days was also called tropical sprue, is also another common thing that happens because in countries like India, there is a background of, you know, chronic inflammation of the gut in a lot of people because of the water contamination.

11:50               So what type of infections can cause this when  we are talking about the post infectious IBS, so it could be bacterial, it could be viral, it could be parasitic to. And for those of you who are not, who don’t live in countries where there’s a problem of water contamination, you have to keep in mind traveller’s diarrhoea. Many of you travel a lot nowadays, so traveller’s diarrhoea is another thing to keep in mind. So it could be that you had a GI infection while you are on your holiday and then you came back and you had IBS. And another interesting thing is how long do do these, you know, does the effects last  .And what had happened in Walkerton, so Walkerton is  a place in Ontario Canada. So in the year 2000, there was a massive flood there and the water got contaminated. Now for people, for my listeners in India, you’re probably wondering how could that happen?

12:46               But it’s, it’s, it’s, uh, this was, uh, this was a natural calamity and massive, massive disaster. A few people lost their lives unfortunately. And a lot of the elderly. So in countries like Canada, you can drink tap water because in India you know that we don’t usually drink tap water unless we’ve boiled it or put it through a filter. And if you’re traveling you usually drink bottled water. We won’t ever drink tap water directly from the tap. Versus in countries like Canada and the US and these countries, you can actually drink tap water and not worry about getting a waterborne disease. So unfortunately there was water contamination with E. Coli and another called Campylobacter Jejuni So what they found is eight years after that event, of course a lot of people had diarrhoea and they had vomiting and you know all those things, even after eight years, some of the symptoms persisted.

13:48               And another very interesting fact was some of these people who were in Walkerton at that time and had taken the contaminated water, they also had mood disorders like depression and anxiety later on. So you know that we talk about the gut brain immune system very being very intimately related. So some of you with IBS, you’ve gone to your doctor and you’ve been told, oh, it’s all in your mind. Now mind and brain are different things. So it’s not like a personal shortcoming. There is bio biology behind all of this. So the gut brain and the immune system are intimately related and the gut brain immune system is related also to mood disorders. So it’s not just, you know, oh, it’s all in your mind kind of thing there. There are actually reasons behind that. So that is my point. If you’ve been told it’s all in your mind, well it’s probably not in your mind.

14:43               It’s, it’s all in your brain, gut and immune system that are in, that are influenced. But my point is there are solutions available and this is not something you have to live with all your life. Now, the modalities of treatment may differ in each one of you and I, you know, kind of talk about small different aspects of this whole thing over a period of a few videos. And, uh, in case you have any questions, please feel free to email me at So that’s all for today on the first edition of Autoimmunity With Dr Kar. Bye now!



Read in 3 minutes

Irritable Bowel Syndrome (IBS)

IBS is a functional gastrointestinal disorder (FGID) characterised by

  • Abdominal pain/cramping
  • Bloating
  • Gassiness
  • Diarrhoea and/or constipation.

According to the International Foundation for Functional GI Disorders (IFFGD),”the term “functional” is generally applied to disorders where the body’s normal activities in terms of the movement of the intestines, the sensitivity of the nerves of the intestines, or the way in which the brain controls some of these functions is impaired. However, there are no structural abnormalities that can be seen by endoscopy, x-ray, or blood tests. “

IBS is a Functional GI Disorder characterised by disorders of the gut-brain axis (explanation later).


  • Nausea or vomiting
  • Abdominal pain immediately after food.
  • Abdominal pain relieved by passing a motion
  • Stress-related issues.
  • Anxiety


  • IBS is distinct from IBD (Inflammatory Bowel Disease, like Ulcerative Colitis and Crohn’s Disease). IBD are autoimmune diseases causing specific conditions in the intestine.
  • Altered bowel habits in IBS may have the following characteristics:
  • Constipation may result in complaints of hard stools or infrequent motions. Often the constipation may not respond to regular laxatives.
  • Diarrhoea may mean frequent passage of small volumes of loose stools.
  • Needing to use the toilet soon after a meal may be common.
  • Constipation or diarrhoea may be a predominant feature, but sometimes the symptoms may be mixed.
  • IBS can occur after a gastrointestinal infection with a bacteria, virus or parasite–post-infection IBS.
  • Though IBS is strictly not an infectious disease, microscopic inflammation has been detected in some people.
  • Food intolerances may have symptoms similar to IBS.
  • Early life stressors (High Adverse Childhood Experiences Score) is related to IBS.
  • According to the Rome IV criteria ,the following four patterns may be seen in  IBS:
  1. IBS-D -Diarrhoea predominant
  2. IBS-C-Constipation predominant
  3. IBS-M-mixed constipation and diarrhoea
  4. IBS-U-Unclassified.
(The Rome Foundation is an independent not for profit organisation that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of functional gastrointestinal disorders).


Besides the common symptoms of IBS, which are abdominal (stomach) pain ,bloating, diarrhoea and/or constipation there may be other associated conditions like

  1. Fibromyalgia
  2. Sexual dysfunction including poor libido
  3. Urinary complaints, Interstitial Cystitis
  4. Mucus discharge from anus.
  5. Restless-leg syndrome


Though the exact cause of IBS is not known yet, the following  are considered to be important:

  • Altered pain perception. People with IBS have been found to be more sensitive to pain sensations, particularly pain related to distension of the gut.
  • Gut-brain interaction.
  • Gut dysbiosis.
  • Increased intestinal permeability (leaky gut)
  • Low-grade inflammation
  • Psychosocial disturbance

(In subsequent blog posts I will discuss how I approach the management of IBS as a Functional and Metabolic Medicine Consultant).


Read in 2 minutes
Many of my patients tell me that their brains are not functioning the way they’d like them to function. Usually the conversation goes something like this:
“Doctor, my brain is not as rapid fire as it was before” Or
“I feel my thoughts are going through Jell-O” Or
“I have brain fog”. The last is the commonest that i hear.
A large part of my medical practice in India involves taking care of people with Autoimmune Conditions.
“Brain fog” is not a medical condition but usually represents symptoms of
  • Loss of focus
  • Occasional memory lapses
  • Lack of clarity in thinking
  • Difficulty concentrating

(I will not discuss Autoimmune diseases of the brain in this post)

What is the connection between Autoimmunity and “Brain Fog”?

Studies have shown the association between many Autoimmune Conditions and cognitive decline. Some of the conditions are
  • SLE (Lupus)
  • Rheumatoid Arthritis
  • Sjogren’s Sundrome
  • Celiac Disease
  • Type 1 Diabetes
  • Hashimoto’s Thyroiditis (Hypothyroidism).And many more.

What is the common thread running through them?

​​​​​​​All these autoimmune conditions are related to a higher level of chronic inflammation and immune system dysfunction. They are also related to a gut barrier dysfunction or “leaky gut”. In fact you may often find Functional Medicine practitioners talk about “Leaky Membrane Disease”. This is not a separate disease entity but a situation where there is “leaky gut”, “Leaky Blood-Brain Barrier (BBB)” and “Leaky Endothelium (the cell lining of blood vessels)”

What can you do?

Avoid sugar and all its multiple sweetener friends too! Sugar is highly inflammatory. More importantly, sugar and many of its substitutes increase your insulin levels. High insulin is associated with a whole host of illnesses like diabetes, heart disease, cancer, dementia, hypertension and many more.

Consider eating lower amount of carbohydrate than you are eating at present. (Unless you are already eating low-carb! )

Enrich your food with good quality healthy fat. Think coconut, coconut oil, fish, avocado, nuts, extra virgin olive oil, ghee.

Consider anti-inflammatory food. Essentially this means eating real food, eating food as nature made them.

Avoid processed food.

Stop eating gluten containing food. (This doesn’t mean you start eating gluten-free processed sugar-laden food !)

Sleep well. Maintain regular sleep times. Avoid watching TV or using backlit devices (mobiles, laptops, e-readers) nearer to bedtime. Reduce your exposure to harsh ambient light. No TV or charging devices in the bedroom!

Dysregulated sleep , sleeping for less than 7-8 hours , disrupts your body’s biological clock —your circadian rhythm.

Eat food during time restricted windows. or consider intermittent fasting.

Manage stress. Try Mindfulness practice, meditation, practice gratitude. Use expressive writing.





Read in 3 minutes


Latent Autoimmune Diabetes of the Adult (LADA) is a type of autoimmune diabetes which shares common features between type 1 and type 2 diabetes.It is also called Type 1.5 diabetes or slowly progressive autoimmune diabetes.The 3 common criteria for diagnosis of LADA are:
  • Adult onset:the age at diagnosis ranges from 15 to 30 years.However, nowadays Type 2 diabetes is being diagnosed in increasingly younger people.The youngest person to be diagnosed with type 2 diabetes is a three year old girl in Texas, USA.
  • Antibody positivity: Diabetes Associated Antibodies (DAA) are usually present in people with LADA.However this may not be quite so clear-cut, given that different laboratories may have different cut-off values.These DAA include antibodies to glutamic acid decarboxylase 65 (GAD 65), insulinoma-associated antigen, islet cell & zinc transporter 8. The commonest is GAD 65 antibody.Antibody levels may fluctuate and the type of positive antibody may change over a period of time.Even a transient increase in autoantibody indicates autoimmunity.
  • Insulin treatment: Arbitrary definition of LADA include a period without insulin treatment of at least six months, but the need to use insulin is usually at the discretion of the physician.


  • Patients with LADA generally have worse HbA1c levels (measure of 3 month’s average blood sugar) than type 2 diabetes patients.
  • Often they are misdiagnosed as type 2 diabetes.Incorrect treatment will lead to higher loss of insulin producing beta cells of pancreas.
  • Studies have shown that patients with LADA need insulin treatment earlier than those with type 2 diabetes and therefore may need closer monitoring.
  • Patients with LADA have lower levels of C-Peptide. (Connecting peptide is a marker of insulin production by your body). C-Peptide levels influence treatment.
  • The sulphonylurea group of drugs like chlorpropamide,glyburide,glipizide etc which work by stimulating the pancreas to release more insulin, are not the right choice of drugs for people with LADA.
  • Despite greater use of insulin, patients with LADA have worse blood sugar control. Therefore there is something more that needs to be done.
  • When any one autoimmune condition is present, the chances of developing others are high. People with LADA have a higher incidence of thyroid autoimmunity. Hence it is important to screen for other diseases as well.


In addition to testing for DAA we would look at the following:

  • Gut Health.
  • Gut dysbiosis
  • Intestinal Permeability Dysfunction (Leaky Gut)
  • Vitamin D3 levels
  • Chronic Inflammation
  • Sleep
  • Nutrient Depletion
  • Stress Response
  • Movement/Exercise
  • Test for other autoimmune conditions, particularly thyroid autoantibodies.
  • Risk for heart disease and stroke
  • Check for heart failure.

Should everybody be screened for LADA?

That will depend on your goals.I practice patient-participatory medicine. My duty as a physician is to provide you with correct information and help  you make the best decision for yourself.


Do you have autoimmune diabetes

Predictive Autoantibodies

Vitamin D and Autoimmunity

Ebook on Autoimmunity

Gambelunghe, Giovanni, et al. "Increased risk for endocrine autoimmunity in Italian type 2 diabetic patients with GAD65 autoantibodies." Clinical endocrinology 52.5 (2000): 565-573.
Priyanka P. Brahmkshatriya, Anita A. Mehta, Banshi D. Saboo, and Ramesh K. Goyal, “Characteristics and Prevalence of Latent Autoimmune Diabetes in Adults (LADA),” ISRN Pharmacology, vol. 2012, Article ID 580202, 8 pages, 2012. doi:10.5402/2012/580202


Read in 6 minutes


Sonia Kumar (not her real name) a 38 year old mother of two young girls, spent seven frustrating months trying to get her blood sugar under control.She was recommended escalating doses of oral anti-diabetes medications. She was even accused of cheating on her diet!But none of this helped her! It took an astute physician (not me!) to test her for diabetes autoantibodies to find out that she actually had Type 1 Diabetes!

The diagnosis was missed because people often think that Type 1 Diabetes does not develop in adults.


Diabetes is a group of metabolic diseases with high blood sugar (hyperglycaemia) as the common feature. The high blood sugar results from defects in insulin secretion, defects in insulin action or both. About 20 years ago diabetes was classified into Insulin Dependent (IDDM) or Juvenile and Non-Insulin Dependent (NIDDM) or Adult Onset Diabetes. However, in the last several years it has become apparent that the use of insulin or age at onset could not adequately explain the disease conditions and specify the best treatment plan. Therefore, there is an opinion amongst diabetes researchers that the time has come for a new classification of the disease.

Diabetes develops because of an interaction between genes and the environment. Our genes have not changed in thousands of years,but our environment has.To a great extent this explains the dramatic increase in diabetes over recent years. Some of the influences have originated in the intrauterine environment before a person is born!

Exposure to environmental toxins like BPA have also contributed to the recent epidemic of diabetes.

Developments in the field of precision medicine, ethnicity-specific data and big data along with patient-participatory research will change the management of diabetes for the better.


(For a medically appropriate classification please check the American Diabetes Association website for “Etiologic classification of diabetes mellitus”).

  • Type 1 Diabetes
  • Type 2 Diabetes (Commonest)
  • Gestational Diabetes (GDM/Pregnancy Diabetes)
  • Maturity Onset Diabetes of the Young (MODY)♣
  • Latent Autoimmune Diabetes of the Adult(LADA)♣
  • Drug Induced Diabetes.♣

High blood sugar resulting from an absolute deficiency of insulin secretion. Type 1 Diabetes may be

  • Autoimmune or
  • Idiopathic.

Autoimmune Diabetes occurs when the Insulin producing cells in the pancreas are destroyed by an autoimmune process. Autoimmune markers for Type 1 Diabetes, also called Diabetes-Associated Autoantibodies (DAA) are usually present in most of these patients.

Idiopathic—In a small percentage of patients there is Insulin deficiency but no autoimmunity.

Though absolute insulin deficiency is a hallmark of Type 1 Diabetes, about 30 % of people with this condition have insulin resistance as well.


  • Glutamic Acid Decarboxylase Autoantibodies (GAD65 or Anti-GAD)
  • Insulin Autoantibodies (IAA)
  • Insulinoma-Associated-2 Autoantibodies (IA-2A)
  • Islet Cell Cytoplasmic Autoantibodies (ICA)
  • Zinc Transporter 8 (ZnT8Ab) Autoantibodies

GDM is defined as any degree of glucose intolerance that was first recognized during pregnancy. This definition would include women who had previously undiagnosed Type 2 Diabetes and also those women who developed diabetes for the first time during pregnancy.Asian Indian women are at a very high risk for pregnancy diabetes. Therefore it is very important for them to be screened at the beginning , during mid-trimester as well as in the last trimester.

GDM raises the risk of several complications in both the mother as well the baby. Increased birth defects, increased birth weight, early (preterm) delivery are some of the risks in the babies born of mothers with GDM. The mother is at increased risk of pregnancy high blood pressure and pre-eclampsia and is at a higher risk for developing diabetes later in life. In addition, she is at increased risk for heart disease even if she does not develop diabetes later on in life!


This is the commonest type of diabetes.Type 2 diabetes includes individuals who have insulin resistance and usually relative insulin deficiency. These individuals may not need insulin treatment to survive. However, use of insulin does not decide the type of the disease. Diabetes Associated Autoantibodies are absent in people with Type 2 Diabetes.


It is important to keep in mind that adults can develop autoimmune diabetes too! British Prime Minister Theresa May, who was diagnosed with Type 1 Diabetes at age 56 and Sonia Kumar mentioned above were both initially diagnosed as Type 2 Diabetics. However both of them needed insulin therapy to control their blood sugar levels,when they were found to have Diabetes Antibodies.

Sulfonylurea (SU) drugs like chlorpropamide,glyburide,glipizide which work by stimulating the pancreas to release more insulin, are not the right drugs for these people.Use of these drugs in patients with diabetes autoimmunity have shown poor metabolic control and earlier loss of insulin producing beta cells in the pancreas.

A study in apparent long-standing type 2 diabetes found that those with Diabetes Associated Autoantibodies or with low C-peptide did not respond well to glucagon-like peptide 1 (GLP-1) agonist drugs like Liraglutide,Exenatide etc.

People with one autoimmune condition are at a higher risk for other autoimmune conditions as well. Diabetes Autoimmunity has often been associated with thyroid autoimmunity.


If you have diabetes you obviously know your blood sugar and glycated haemoglobin (HbA1C) levels. In addition the following tests are important for the right treatment:

  • Diabetes Associated Autoantibodies (DAA)
  • C-Peptide ♣ :This  test can indicate how much insulin your body is producing.

(♣ Separate blog posts on these topics later.)

As Dr. Elliott P. Joslin, (who was the first doctor in the United States to specialize in diabetes and the founder of Joslin Diabetes Center) wrote “ . . . unless the physician takes care, he will fall into schematic ways and forget that it is the patient who comes for treatment and not the diabetes. Each is a case unto itself.” 



Mohan V, Usha S, Uma R. Screening for gestational diabetes in India: Where do we stand? Journal of Postgraduate Medicine. 2015;61(3):151-154. doi:10.4103/0022-3859.159302.
Goueslard, Karine, et al. "Early cardiovascular events in women with a history of gestational diabetes mellitus." Cardiovascular diabetology 15.1 (2016): 15.
Leslie, R. David, et al. "Diabetes at the crossroads: relevance of disease classification to pathophysiology and treatment." Diabetologia 59.1 (2016): 13-20.
Brophy S, Davies H, Mannan S, Brunt H, Williams R. Interventions for latent autoimmune diabetes (LADA) in adults. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD006165. DOI: 10.1002/14651858.CD006165.pub3.