Recent T1D Research Contradicts Common Assumptions About Patients

Dr Michael Fang | Image credit: Johns Hopkins University

Historically, research in the type 1 diabetes (T1D) space has lagged compared with type 2 diabetes. But in recent years, there has been a growing focus on population trends and the management of T1D.

In an interview with The American Journal of Managed Care® (AJMC), Michael Fang, PhD, researcher and assistant professor in the division of Cardiovascular and Clinical Epidemiology at Johns Hopkins University, discussed recent findings in the T1D space that provide insight into the epidemiology of T1D and trends in research and treatment.

This interview has been edited for length and clarity.

AJMC: Could you share insights from your research related to the epidemiology of type 1 diabetes, such as trends in prevalence or demographic patterns, and how this information can inform health care strategies?

Fang: There are 2 things that we've recently published on type 1 diabetes that I think are really cool, and hopefully relevant to health care strategies. The first paper relates to the age of diagnosis, and I think that stems back to the conception that type 1 diabetes is this childhood disease. It used to be called type in juvenile-onset diabetes, so in a lot of providers’ minds—particularly ones that were trained in the older generations—and in a lot of people's minds, it’s still seen as a disease that happens and primarily affects children. What research is increasingly showing is that half, if not more, of all type 1 diabetes cases are occurring in adulthood. That research is often based on small studies, so our study was really trying to take that assumption and take those set of findings and push it using national data.

That's what we did, and we ended up finding similar findings to some of the small studies, but in more robust data.¹ I think that has implications for our diagnoses and how we approach the diagnosis of type 1 diabetes in adults. It's really an issue that while there are a few guidelines on it when I've talked to different primary care physicians, oftentimes they're surprised. They'll say, “What? I didn't realize type 1 diabetes could occur in adults.”

There are recommended tests that you can run to check if a new case of diabetes in an adult is type 2. I think most people will assume it's type 2, but you can run the autoantibody panel and you can rule it out. I think a lot of providers may not know that that test is available and when to use it, so we're trying to sort of build awareness around: A) that it can happen in adults, B) that there are tests that you can run to check, and C) when you should run those tests.

AJMC: Can you discuss the prevalence of comorbidities such as obesity with type 1 diabetes and how their management may affect patients?

Fang: Along with the assumption that people with type 1 diabetes are young, there's also this assumption that they're lean, so we often have this categorization where older and overweight or obese patients, those are cases of type 2 diabetes. And then younger lean patients are type 1. And I think those 2 categories, at least with the type 1 sort of box, we've tried to challenge with our existing research.

We looked at obesity in adults with type 1 diabetes in another paper, and it was the first study using national data. We found that based on self-reported weight, levels of obesity are quite similar to people in the general population.² It turns out, there's quite a bit of overweight and obesity in patients with type 1 diabetes.

In terms of management, it’s challenging, because when you're overweight or obese, it means that insulin may not work as well due to insulin resistance. Then, you're administering larger amounts of insulin to yourself to bring your glucose down, and that poses potential health dangers. You may end up using more than you need, and then you might have severe consequences.

Weight management is also difficult for patients with type 1 diabetes. In patients without diabetes, the general recommendation is to modify your diet and exercise. If you're a patient with type 1 diabetes, you can't just decide to go out and start running 5 miles a day, because you're using this medication that is very dangerous. When you mix insulin with large changes to your diet or a large increase in physical activity, then the danger of hypoglycemia ends up rising quite a bit.

I think technologies can play a big role in filling that gap. The fear of hypoglycemia can be alleviated to a large extent by some of these new CGMs [continuous glucose monitors]. Studies have shown that they can reduce the occurrence of really low glucose, and it really does improve quality of life. Patients feel more empowered always knowing their glucose, and being able to address lows preemptively before they happen. And so now, if you're overweight or have obesity, you can think about adding physical activity, and you can do it in a much safer manner.

AJMC: What are the most critical areas of focus for improving the lives of patients with diabetes in general, whether in terms of research, treatment, or support services?

Fang: One of the big areas for type 2 diabetes in the US on a population level is that management has not been improving over the last 10 years. We saw these trends where things were getting better—people were improving their hemoglobin A_1c, blood pressure control was improving, cholesterol control was improving. And then somewhere around the late 2000s, something happened in the country, and things started taking a turn for the worse. Given the number of people with type 2 diabetes in this country, and given what we know about what happens when you don't manage your glucose, I think that's the big issue for type 2 diabetes. It's finding ways we can reverse those trends and get back on the right course and start improving glycemic control.

I think it’s the same for type 1 diabetes. We don't have as much data on type 1, but among the data that are available, we've seen very low levels of control in type 1 diabetes. And this is against the backdrop of all these new technologies, right? We have all these fancy gadgets that give you all this information, and we have [insulin] pumps, and now the 2 can talk to each other. But we haven't seen that translate into large improvements in the population—not yet anyway. So, I think it's similar for type 1 and type 2. Control of the disease has not shown large improvements over time.

All these new drugs are coming out and all these new devices are coming out, so we need to get them into the hands of the people who need them. But for the device piece, we also have to help people understand and it's not just putting it on—you have to do that second step of translating it and using that information effectively for management. And I don't think we're quite there yet.

References

1. Fang M, Wang D, Echouffo-Tcheugui JB, Selvin E. Age at diagnosis in U.S. adults with type 1 diabetes. Ann Intern Med. 2023;10.7326/M23-1707. doi:10.7326/M23-1707

2. Fang M, Jeon Y, Echouffo-Tcheugui JB, Selvin E. Prevalence and management of obesity in U.S. adults with type 1 diabetes. Ann Intern Med. 2023;176(3):427-429. doi:10.7326/M22-3078