When Energy Is There but Not Available: ERM and the Rise of Type 5 Diabetes

What if malnutrition wasn’t about eating too little—but about how the body allocates what it has?

That’s the provocative question posed by a new model of metabolic dysfunction called Exposure-Related Malnutrition (ERM), introduced in the preprint The Metabolic Cost of Resilience: Bioenergetic Trade-Offs in Stress Adaptation, Aging, and Chronic Disease by Tippairote et al.

ERM reframes malnutrition as a bioenergetic mismatch, not necessarily caused by dietary insufficiency, but by chronic stress-driven reallocation of energy and substrates. In this view, even people with adequate or normal intake can become metabolically “undernourished” when the demands of stress, inflammation, or immune activation consistently override the needs of repair, regeneration, and resilience.

This isn’t just theory.

A landmark 2022 study published in Diabetes Care by Lontchi-Yimagou and colleagues has now given this concept clinical teeth. Their work—recently highlighted on Medscape—characterized a distinct diabetic phenotype in low-BMI individuals from low- and middle-income countries. These patients exhibited no ketosis, preserved insulin secretion, and unusually high insulin requirements despite being lean and often malnourished in childhood. This unique profile has now been officially reclassified as Type 5 Diabetes, formerly known as malnutrition-related diabetes mellitus (MRDM).

The kicker? These patients don’t fit into Type 1 or Type 2 diabetes—they represent a distinct metabolic condition where substrate misallocation, not intake deficiency, drives dysfunction.

This aligns strikingly with the ERM framework. While ERM describes a broader range of stress-adapted undernourishment (from anabolic resistance to immune exhaustion), Type 5 Diabetes may be one glucose-centric clinical expression of this larger energy triage model. It’s a powerful real-world example of how the body’s attempt to survive chronic stress can unintentionally sabotage long-term resilience.

Why It Matters

Recognizing ERM—and the emergence of Type 5 Diabetes—forces us to think differently about malnutrition, especially in global health, chronic disease, and aging.

• It challenges the calorie-centric view of undernutrition.

• It exposes a blind spot in how we screen for metabolic vulnerability.

• And it opens the door to earlier, more targeted interventions that support recovery and resilience, not just glycemic control.

In a world where both overnutrition and undernutrition co-exist in the same communities (and even the same individuals), understanding the metabolic cost of resilience is more urgent than ever.

📖 Read the ERM framework preprint:

Tippairote T, et al. The Metabolic Cost of Resilience: Bioenergetic Trade-Offs in Stress Adaptation, Aging, and Chronic Disease.https://www.preprints.org/manuscript/202504.1142/v1

📄 Read the Type 5 Diabetes study:

Lontchi-Yimagou E, et al. An Atypical Form of Diabetes Among Individuals With Low BMI. Diabetes Care. 2022;45(6):1428–1437.https://doi.org/10.2337/dc21-1957