Malnutrition-related diabetes mellitus: Rushing toward “type 5” amid unresolved questions and limited evidence

Abstract

Aim

To critically evaluate the historical context, diagnostic ambiguity, epidemiological relevance, and recent proposals to reclassify malnutrition-related diabetes mellitus (MRDM) amid changing nutritional landscapes and existing metabolic data.

Methods

This review synthesizes data from early clinical reports, WHO documents, epidemiological studies, and recent literature on malnutrition and diabetes. Emphasis is placed on diagnostic inconsistencies, the overuse of low BMI as a surrogate for malnutrition, and evolving nutrition trends in India and low- and middle-income countries (LMICs).

Results

MRDM was initially associated with protein-energy malnutrition, low BMI, and insulin-requiring but ketosis-resistant diabetes. However, overlap with other diabetes types, especially autoimmune forms, has raised doubts about its distinct identity. Low BMI is an unreliable proxy for malnutrition in often constitutionally lean populations in LMICs. A 2022 study suggested insulin secretory defects in MRDM, but was limited by small, male-only samples and lack of follow-up. Proposals to classify MRDM as “type 5 diabetes” are questionable, as types 3 and 4 lack formal recognition. Moreover, declining undernutrition rates in LMICs further diminish MRDM's current relevance. Emerging evidence also indicates malnutrition may be more often a consequence than a cause of diabetes.

Conclusion

Given its heterogeneity, diagnostic uncertainty, and diminishing epidemiological significance, reclassifying MRDM as a distinct type of diabetes (“type 5 diabetes”) is presently unwarranted. Future classification efforts should prioritize data-driven subtypes with clear therapeutic and prognostic implications, rather than reviving outdated constructs with limited contemporary utility.