Basal C-Peptide in the Discrimination

of Type I from Type II Diabetes

T. A. WELBORN, P. GARCIA-WEBB, AND ANNE M. BONSER
Basal serum C-peptide concentrations in diabetic patients showed two groups. Diabetic patients with
low C-peptide levels ( ^ 0.16 nmol/L) have clinical characteristics of type I diabetes, and all were on
insulin therapy. With long duration of diabetes, an increasing proportion had undetectable C-peptide.
Diabetic patients with high C-peptide levels (> 0.16 nmol/L) resemble type II diabetes. In this group
30% were on insulin therapy but duration of known disease was not associated with any decline in the
high basal C-peptide levels. The small proportion of diabetic patients with basal serum C-peptide in the
range of 0.17-0.32 nmol/L have indeterminate status, DIABETES CARE 4616-619, NOVEMBER-DECEMBER i98i.
I
n 1979, the National Diabetes Data Group
1
developed
a classification of diabetes mellitus for use as a uniform
framework in which to conduct clinical and epidemio-
logic research. The scheme was adopted by the World
Health Organization.
2
Type I or insulin-dependent diabetes
mellitus (IDDM) refers to ketosis-prone diabetes which re-
quires insulin therapy to sustain life. Type II or non-insulin-
dependent diabetes mellitus (NIDDM) is the second subclass
of diabetes, not ketosis-prone, and commonly associated
with obesity. In clinical practice, it is often difficult to allo-
cate a patient with confidence to one or other category, al-
though it is recognized in general that type I diabetic patients
have a profound insulin deficiency, and type II diabetic pa-
tients have nearly normal or elevated circulating insulin
levels.
3
-
4
This study was designed to determine the types of diabetes
by measuring insulin secretory capacity. The radioimmuno-
assay of serum C-peptide as an indicator of endogenous insu-
lin secretion is very sensitive, and is not masked by the insu-
lin antibodies occurring in insulin-treated patients. Also,
C-peptide is not influenced by such factors as liver uptake or
peripheral binding of insulin.
PATIENTS AND METHODS
Hospital clinic diabetic patients. One hundred and seven pa-
tients attending the metropolitan clinic were selected as rep-
resenting a suitably wide range of subjects in terms of age
(mean 53 yr, standard deviation 17), degree of obesity, and
treatment. Subjects with known renal failure were excluded.
Blood samples were obtained after an overnight fast for mea-
surement of plasma glucose and serum C-peptide levels.
Country survey diabetic patients. One hundred and forty di'
abetic patients in the isolated mining town of Kalgoorlie
(population 21,000), 600 km from Perth, attended a volun-
tary survey for the detection of retinopathy. Blood samples
were obtained between 9 a.m. and 5 p.m. on two consecu-
tive days. Late (more than 3 h) postprandial samples were
available from 94 subjects (mean age 55 yr, standard devia-
tion 16) with normal renal function for measurement of
plasma glucose and serum C-peptide levels.
In both groups, height without shoes and weight in sum-
mer clothing was recorded. The body mass index (BMI) was
calculated from the equation weight (kg)/height
2
(m). BMI is
linearly related to the index of percent desirable weight
(PDW). A BMI of 25 for men and 27 for women corresponds
to a PDW of 120% in both sexes. Obesity is defined as those
values equal to or greater than these criteria.
1
Plasma glucose was measured by the glucose-oxidase
method, and serum C-peptide by the double antibody im-
munoassay
5
modified from Heding
6
using antibody to syn-
thetic human C-peptide M1230, limit of sensitivity 0.02
nmol/L. This antiserum has minimum (11%) cross-reactivity
with proinsulin.
7
The fasting level for serum C-peptide by
this method in healthy adolescents is 0.52 0.30 nmol/L
(mean 2 SD),
5
and in adults, 0.55 nmol/L, range 0.20-
1.00 nmol/L (log-mean 2 SD) (unpublished data).
RESULTS
The distributions of serum C-peptide levels in the hospital
clinic diabetic patients (fasting samples) and the country sur-
vey diabetic patients (late postprandial samples) are shown
in Figure 1. The distributions are closely similar and provide
616 DIABETES CARE, VOL. 4 NO. 6, NOVEMBER-DECEMBER 1981

BASAL C-PEPTIDE IN TYPE 1 AND TYPE II DIABETES/T. A. WELBORN, P. OARC1A-WEBB, AND A. M. BONSER
HOSPITAL
CLINIC
DIABETICS
( N = 107 )
COUNTRY
SURVEY
DIABETICS
40%
20%
0%
40%
20%
0% L
1 2 3 4 5 6 7 8
SERUM C-PEPTIDE CLASS
FIG. I. Distribution of serum C-peptide levels in (1) 107 hospital clinic
diabetic patients, from whom fasting blood samples were obtained, and
(2) 94 country survey diabetic patients, from whom blood samples were
obtained 3 or more hours postprandially. Key to serum C-peptide
classes:(I) < 0.02 nmol/L; (2) > 0.02-0.04 nmo\IL; (3) > 0.04-
0.08 nmol/L; (4) > 0.08-0.16 nmol/L; (5) > 0.16-0.32 nmol/L;
(6) > 0.32-0.64 nmol/L; (7) > 0.64-1.28 nmol/L; (8) > 1.28
nmol/L.
good evidence for bimodality. The first mode represents pa-
tients with very low endogenous insulin levels and the sec-
ond mode represents those with normal or elevated levels.
The frequency of insulin therapy encountered in the vari-
ous classes of C-peptide concentrations is shown in Figure 2.
Again there is a striking agreement in the results from the
two populations. A fasting or late postprandial serum C-pep-
tide level of 0.16 nmol/L or less identifies diabetic patients
exclusively on insulin whereas of the diabetic patients with a
serum C-peptide level of more than 0.32 nmol/L, 21-29%
are on insulin. The small group of subjects with intermediate
C-peptide levels of 0.17-0.32 nmol/L have a 73% frequency
of insulin therapy.
To pursue the hypothesis that the diabetic patients with
very low endogenous insulin levels represent: type I diabetes
and those with normal or high levels represent type II diabe-
tes, the data were analyzed in terms of "low"
( < 0.16 nmol/L) and "high" ( < 0.16 nmol/L) C-peptide
classes. The level of 0.16 nmol/L or less was 100% specific
for insulin therapy, and also was well outside 2 standard de-
viations from the normal mean.
5
The results of linear regression analysis of serum C-peptide
levels with plasma glucose levels and body mass index (BMI)
in the low and high C-peptide groups are presented in Table
1. Mean levels of plasma glucose were not significantly differ-
107 CLINIC DIABETICS
( FASTING )
94 COUNTRY DIABETICS
( LATE POST - PRANDIAL
100%
50%
PERCENTAGE
ON INSULIN
THERAPY
0%
r I--I-4
2 3 4 5 6 7 8
SERUM C-PEPTIDE CLASS
FIG. 2. Percentage of diabetic patients on insulin therapy in two popula-
tions, fry serum C-peptide classes {see key in Figure I legend).
ent and no significant correlation existed between plasma
glucose and C-peptide levels in any group. No reason ex-
isted, therefore, to analyze serum C-peptide levels in terms of
plasma glucose categories.
Table 1 demonstrates differences in BMI between the low
and high serum C-peptide groups. The high C-peptide
groups have mean BMI values above the criteria for obesity,
and the low C-peptide groups have mean BMI values in the
lean range. The differences in BMI in the low versus the
high C-peptide groups are highly significant in men (hospital
clinic, t = 3.89, P < 0.001; country survey, t = 3.56,
P < 0.001) but not in women (hospital clinic, t 1.59,
not significant; country survey, t = 2.10, P < 0.05). BMI
and serum C-peptide are correlated in the high serum C-pep-
tide groups. The considerable similarity between the hospital
clinic and the country survey groups is emphasized by the lin-
ear regression equations between BMI and serum C-peptide
(CP), thus:
Hospital clinic (high C-peptide)
BMI = 23.76 + 3.95 CP
Country survey (high C-peptide)
BMI = 25.43 + 3.44 CP
(1)
(2)
In subsequent analysis, data from the two populations have
been combined because of the close concordance of results
and conclusions.
When low and high C-peptide groups are analyzed in
terms of degree of obesity, age of onset, and treatment
(Table 2), it is seen that within each group the mean BMI
does not vary significantly in comparing onset under and
over 40 yr. The low C-peptide group have a major propor-
tion with onset under 40 yr (35/46) compared with the high
C-peptide group (29/155), a difference that is highly signifi-
cant (X
2
= 51.2, P 0.001). The patients in the low C-
peptide group are all on insulin, in contrast with the high
C-peptide group, 70% of whom are on diet or oral therapy.
DIABETES CARE, VOL. 4 NO. 6, NOVEMBER-DECEMBER 1981 617

BASAL C-PEPTIDE IN TYPE I AND TYPE II DIABETES/T. A. WELBORN, P. GARCIA-WEBB, AND A. M. BONSER
TABLE 1
Mean plasma glucose levels and mean body mass index (BMI) in groups of diabetic patients with low and high serum C-peptide levels. There is no sig-
nificant correlation between plasma glucose and serum C-peptide. The groups with high serum C-peptide are obese and show significant correlations
between C-peptide levels and body mass index
Diabetic group
(males, females)
Ho !
;
p i t a l
(M12, F15)
clinic
H
f
t al
(M49, F31)
clinic
C

U n t r y
(M13, F6)
survey
Country
survey
Serum C-peptide
class
low (0. 16 nmol/L)
high (>0. 16 nmol/L)
low (<0.16 nmol/L)
high (>0.16 nmol/L)
Plasma glucose
(mmol/L)
(mean SEM)
12.6 1.3
11.1 0.4
10.1 1.3
9.1 0.6
Correlation coefficient:
serum C-peptide vs.
plasma glucose
-0.14 (NS)
+0.13 (NS)
-0.30 (NS)
+0.20 (NS)
BMI
(mean :
Males
23.3 0.9
27.5 0.5
24.2 0.8
29.3 0.8
t SEM)
Females
23.3 0.8
26.4 1.1
24.4 1.3
28.3 0.7
Correlation coefficient:
serum C-peptide
vs. BMI
+0.34 (NS)
+0.38 (P < 0.001)
+0.03 (NS)
+0.40 (P < 0.001)
NS = not significant.
Thus, using a basal serum C-peptide level of 0.16 nmol/L
as the cutoff point, our diabetic patients were divided into
two groups: one characterized by exclusive insulin require-
ment, lean body mass, and young age of onset and the other
by a high proportion on diet or oral therapy, tendency to
obesity, and age of onset beyond 40 yr.
The 11 subjects with basal C-peptide values in the range
0.17-0.32 nmol/L represent an indeterminate group. Eight
are on insulin, but five on insulin and three on diet or oral
therapy had onset of diabetes over 40 yr. The BMI values
tend to be intermediate (five men BMI 26.0 1.4; six
women BMI 24.6 2. 14, mean SEM).
The influence of duration of known diabetes on mean
serum C-peptide levels is shown in Table 3. Subjects with
longer duration of known diabetes show lower mean C-pep-
tide levels due to an increasing proportion having very low
levels ( ^ 0.02 nmol/L) at the limit of the assay's sensitivity.
With duration under 5 yr, 20% had serum C-peptide < 0.02
nmol/L compared with 63% at 5- 9 yr duration, and 78% at
10 yr duration or more (X
2
= 12.5, P < 0.01). In the dia-
betic patients with high serum C-peptide, duration of known
disease has no obvious influence on the fasting/postprandial
C-peptide levels. Although the proportion of subjects on in-
sulin therapy increases with duration, there is no evidence
for any substantial deterioration in beta-cell function as mea-
sured by the basal serum C-peptide levels.
DISCUSSION
B
imodality of serum C-peptide levels in these two
diverse diabetic populations suggested the feasibil-
ity of discriminating insulin-deficient from insulin-
resistant individuals by a single test. Using a serum
C-peptide level of 0.16 nmol/L as the cutoff point, the two
groups of diabetes segregated were the low serum C-peptide
group showing clinical characteristics of type I diabetes and
the high serum C-peptide group resembling type II diabetes.
The cutoff point selected provides high specificity for insulin
requirement, but further studies are necessary to determine
the clinical category of patients with borderline serum C-
peptide values of 0.17-0.32 nmol/L. The latter may repre-
sent predominantly lean NIDD patients taking insulin, but
TABLE 2
Mean body mass index (BMI) of diabetic patients with low (^0. 16 nmol/L) and high ( >0. l 6 nmol/L) serum C-peptide levels, by age of onset and
treatment category
<0. l 6 nmol/L
BMI, mean SEM
(no. of subjects in parentheses)
> 0.16 nmol/L
Serum C-peptide Males Females Males Females
1. Diabetes onset
S 40 yr
Insulin therapy
Diet/oral therapy
2. Diabetes onset
> 40 yr
Insulin therapy
Diet/oral therapy
23.6 0.7(20)
24.9 1.8(5)
23.2 0.7(15)
24.4 1.9(8)
27.1 2.1(7)
27.6 1.6(11)
27.9 1.1(15)
28.6 0.6(48)
28.5 3.9(5)
28.7 2.5(6)
27.4 1.4(20)
27.3 0.8(43)
618 DIABETES CARE, VOL. 4 NO. 6, NOVEMBER-DECEMBER 1981

BASAL C-PEPT1DE IN TYPE I AND TYPE II DIABETES/T. A. WELBORN, P. GARCIA-WEBB, AND A. M. BONSER
TABLE 3
Mean serum C-peptide values in diabetic patients with low and high levels, classified by duration of diabetes and by treatment categories
Serum C-peptide, mean SEM
(no. of subjects in parentheses)
Duration of diabetes <5 yr 5-9 yr >10yr
1. Diabetic patients with low (:0.16 nmol/L) serum C-peptide
Insulin therapy
2. Diabetic patients with high (>0.16 nmol/L) serum C-peptide
Insulin therapy
Diet/oral therapy
0.09 0.01(15)
0.83 0.14(18)
0.91 0.06(64)
0.05 0.02(8)
0.59 0.08(10)
1.05 0.13(23)
0.03 0.00(23)
0.79 0.08(19)
1.02 0.13(21)
could contain subjects with IDDM progressing to frank insu-
lin deficiency. We have not encountered any diabetic pa-
tients with fasting C-peptide levels in this range who fail to
show a substantial (50% or more) increment in C-peptide
levels after glucagon stimulation. Thus, the possibility of cir-
culating proinsulin, free or antibody-bound, causing spurious
elevation of apparent C-peptide levels seems, remote.
Although the results obtained from fasting compared with
late postprandial serum C-peptide levels were very similar,
sampling after an overnight fast is preferred for purposes of
standardization. The lack of correlation found between
serum C-peptide and plasma glucose levels indicates that
measurement of plasma glucose is not important in interpret-
ing C-peptide status in frank diabetes. We have confirmed
this in further studies using glucagon stimulation. It is con-
ceivable that a well-controlled patient on insulin may com-
pletely suppress C-peptide production, but we have found no
evidence for this phenomenon in a large series of glucagon
stimulation tests.
In epidemiologic studies, the measurement of fasting C-
peptide levels should provide useful data in classifying diabe-
tes, and may prove to be the method of choice. HLA typing
is not specific for type I diabetes, in that many normal indi-
viduals show the diabetic haplotypes. Islet cell antibodies are
present in some patients presenting with type I diabetes
8
but
do not persist.
In the clinical situation, there is often difficulty in allocat-
ing a diabetic patient on insulin therapy to the type I or type
II category, since ketosis proneness is not always evident,
and the absolute need for insulin can only be demonstrated
by withdrawing it under close supervision, generally in hos-
pital. Measurement of the fasting C-peptide levels allows in-
creased confidence in identifying the insulin-dependent ver-
sus the non-insulin-dependent patient.
Duration of diabetes influences C-peptide levels in IDDM,
and as our findings also suggest, in many subjects there is a
progressive disappearance of residual beta-cell function.
9
*
10
Less is known about the influence of duration of diabetes in
NIDDM. Our data show persistence of high levels of basal
serum C-peptide in NIDDM of long duration and suggest
that no substantial wasting or "fallout" of beta-cells occurs,
even in those subjects requiring insulin therapy. Thus, the
assay of basal serum C-peptide levels is especially useful in
classifying the type of diabetes in patients who have been
taking insulin for many years.
ACKNOWLEDGMENTS: The authors gratefully acknowledge the
generous support of Novo Laboratories Pty. Ltd., the Dia-
betes Research Foundation of Western Australia, and the
Lions Save Sight Foundation. We also thank Sister Annette
Morris and Sister Moira Shirley for their excellent technical
assistance.
From the Department of Endocrinoloy and Diabetes, and the
Department of Clinical Biochemistry, Sir Charles Gairdner Hos-
pital, Nedlands, Western Australia.
Address reprint requests to T. A. Welborn, Sir Charles
Gairdner Hospital, The Queen Elizabeth II Medical Centre, Ned-
lands, Western Australia 6009.
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DIABETES CARE, VOL. 4 NO. 6, NOVEMBER-DECEMBER 1981 619