Podcast Summary: AACE Podcasts, Episode 59

Title: Early Detection of Type 1 Diabetes
Date: March 3, 2025
Host: Dr. Lubaina Praswala
Guests: Dr. Jeff Unger, Dr. Javier Morales

Overview

This episode of AACE Podcasts focuses on the importance of early detection and monitoring of Type 1 diabetes. The discussion explores the global burden of the disease, the stages of its development, current and emerging screening processes, and real-world clinical strategies for both healthcare providers and families. Dr. Praswala leads a candid, collaborative dialogue with Dr. Jeff Unger and Dr. Javier Morales—both seasoned clinical diabetologists—about actionable clinical pearls, screening pathways, and the emotional and social realities of living with (and managing) Type 1 diabetes.

Key Discussion Points & Insights

1. Global Burden and Demographics of Type 1 Diabetes

• Rising Prevalence:
  • There are currently about 8.4 million people worldwide with Type 1 diabetes, expected to rise to 15 million by 2040 (02:04).
• Diagnosis Not Limited to Children:
  • 40% of diagnoses occur under age 20, but 60% occur in adults (03:04).
    • “You don't really need to be young in order to have an established diagnosis of type 1 diabetes.” – Dr. Morales (03:04)
• Chronic, Life-altering Condition:
  • Dr. Unger likens managing Type 1 diabetes to "being at work 24 hours a day for the rest of your life" (02:30).

2. Early Detection & Need for Screening

• Delay and Denial:
  • Families often delay screening, missing the opportunity for early intervention (11:05).
  • Even physicians may not prioritize screening for their own families due to life stressors (12:44).
• Who Should Be Screened?:
  • Those with a family history of Type 1 diabetes or autoimmune diseases (Hashimoto’s, celiac, vitiligo, etc.) (09:40, 10:26).
    • "If you have a family history... really consider doing the monitoring at a younger age." – Dr. Unger (30:02)
  • Having one family member with Type 1 diabetes increases risk by 15 times (10:26).

3. Stages of Type 1 Diabetes

• Three Stages Explained: (06:05–07:50)
  • Stage 1: Autoimmunity begins, normal blood sugar, no symptoms.
  • Stage 2: Continued beta cell destruction, blood sugar abnormalities, still no symptoms.
  • Stage 3: Significant beta cell loss with symptomatic hyperglycemia and insulin dependence.
    • Classic symptoms: polydipsia, polyuria, unexplained weight loss, potential for ketoacidosis.
• Clinical Implication:
  • Early detection through antibodies can identify at-risk patients before clinical symptoms develop, allowing for intervention.

4. Misdiagnosis and the Importance of Accurate Identification

• “A lot of times they get it wrong. They're treating patients with type 1 diabetes as having type 2.” – Dr. Unger (08:11)
• A significant number of new onset diabetes cases in adults are misclassified as Type 2.
• Antibody screening is the key differentiator.

5. The Role of Autoantibodies in Screening

• Five Key Autoantibodies to Screen:
  (13:39, 30:58)
  • Insulin autoantibodies (IAA)
  • Glutamic acid decarboxylase (GAD) autoantibodies
  • Insulinoma-associated-2 autoantibodies (IA2A)
  • Zinc transporter 8 autoantibodies (ZnT8)
  • Islet cell autoantibodies (ICA)
• Screening Utility:
  • Two or more positive antibodies = high risk/progression, monitor closely.
  • One positive: repeat testing in 1–2 years.
• Commercial panels (e.g., TrialNet) are available for simplified comprehensive screening (13:39).

6. Continuous Glucose Monitoring (CGM) as a Tool

• Used to detect emerging glycemic instability before full onset; especially useful in children (15:10, 16:20, 23:20).
  • “If [5% of CGM readings] are above 140, you have like a 30% chance of developing type 1 diabetes in about a year.” – Dr. Unger (15:10)
• CGM provides real-time feedback for patients, useful for behavioral and lifestyle changes.

7. Immune-Modulating Therapy: Teplizumab

• Mechanism:
  • Anti-CD3 monoclonal antibody delays clinical onset of disease (16:20, 17:36).
    • “Teplizumab... has been shown to delay progression from stage two hyperglycemia to stage three by as little as two years and sometimes even longer.” – Dr. Morales (16:20)
• Administration:
  • 14-day outpatient infusion course, can sometimes be administered at home (18:29).
    • Side effects: lymphopenia, rash, leukopenia, mild infections, GI upset (28:54).
• Clinical Benefit:
  • Preserving endogenous insulin secretion reduces risk of hypoglycemia and long-term complications (19:54).

8. Monitoring Post-Screening

• Parameters:
  • Glycemic control via CGM
  • C-peptide for endogenous insulin production (22:01)
  • Glycated hemoglobin (A1c), oral glucose tolerance tests for diagnostic support
• No universal biomarker for teplizumab response, clinical follow-up required.

9. Lifestyle Interventions and Emotional Support

• Nutrition & Exercise:
  • Early education with CDEs, RDs, and exercise specialists is advised (26:42).
• Quality of Life & Diabetes Distress:
  • Both patients and families experience significant emotional burden (04:34, 27:34).
    • “About a third of the patients that have diabetes... are anxious every day.” – Dr. Unger (04:34)
  • Multidisciplinary support is critical for successful disease management.
    • “It's not just about us, it's also about the certified diabetes educator, the physical therapist... the clinical pharmacist as well.” – Dr. Morales (27:58)

Notable Quotes & Memorable Moments

On the Emotional Toll

• “It's like being at work 24 hours a day for the rest of your Life.”
  – Dr. Unger (02:30)
• “They don't want to lose my eyes, my kidney, or a leg, and I want to be able to watch my daughter walk down the aisle.”
  – Dr. Unger (03:33)
• “This is a disease state that really requires a team effort.”
  – Dr. Unger (04:34)

On Diagnosis and Management

• “If you have a family history... really consider doing the monitoring at a younger age.”
  – Dr. Unger (30:02)
• “If you have one family member [with T1DM], increases your risk by 15 times.”
  – Dr. Morales (10:26)
• “Not every type 1 diabetic is lean... lifestyle intervention really goes a long way.”
  – Dr. Morales (25:33)

On Practical Screening

• “I've got type 1 diabetes too, and I have not screened my kids. It's not a topic—I don't know, life gets in the way.”
  – Dr. Unger (12:44)
• “Please do this for your family, screen your kids. And don't just say, I'm going to do it, do it.”
  – Dr. Unger (12:03)
• “You don't have to send these people to an endocrinologist... pediatricians should do the screening as well.”
  – Dr. Unger (30:02)

Timestamps for Key Segments

• Burden and Demographics: 02:04–04:34
• Stages of T1DM: 06:05–07:50
• Who to Screen: 09:40–11:05
• Autoantibody Panels: 13:39–15:10, 30:58
• Role of CGM: 15:10–16:20, 23:20–24:05
• Teplizumab Discussion: 16:20–19:54, 28:54
• Monitoring Post-screening: 22:01–23:49
• Lifestyle and Emotional Support: 24:05–27:58
• Final Takeaways: 30:02–31:54

Key Clinical Takeaways

For Clinicians:

• Screen high-risk patients (family history, autoimmune disease) for T1DM autoantibodies—primary care can and should do this.
• If two or more antibodies are positive, use CGM to detect early dysglycemia and consider referral for immune-modulating therapy (e.g., teplizumab) if criteria met.
• Involve a multidisciplinary team (CDEs, pharmacists, dietitians) early to support patients and families.
• Understand and address the emotional toll of the diagnosis and encourage supportive behavioral health care.
• Early education and lifestyle interventions, even before hyperglycemia develops, can ease transitions and improve outcomes.

For Families and Patients:

• Early screening is critical; don’t delay even if life is busy.
• Multiple hands—doctors, educators, and family—work together to manage the condition.
• There are now therapies to delay full onset of T1DM and tools (CGM) to make management easier.

Closing Thoughts

This episode emphasizes a proactive, team-based approach to Type 1 diabetes through early identification, robust interdisciplinary collaboration, and emotional as well as medical support. The dialogue offers both practical advice and empathetic resonance, urging clinicians to make early detection part of routine practice—ultimately aiming for better patient and family outcomes.