Bringing Birmingham to You: type 1 diabetes

We were delighted that nearly 600 alumni and friends registered to join our ‘Bringing Birmingham to You – what’s next for type 1 diabetes?’ on 15 February 2023.

To support your engagement with this topic please find a summary of the key points from the discussion, in addition to some further questions that we didn’t get around to answering during the webinar.

Key take-aways

Diagnosis and genetics:

Type 1 diabetes can present at any age. As we get older it tends to automatically get stamped as type 2, but it can be type 1, and it is important to get the diagnosis right because treatment changes accordingly. Over 95% diabetes in children is type 1, so it is much easier to differentiate the two forms of diabetes in children.

As with many other autoimmune conditions there is a genetic component, meaning there is a hereditary possibility of those sets of genes being passed on, but there are many genes predisposing to this disease, and it requires a certain combination of those to give that pre-disposition.

We know there are many different genes involved in the development of type 1 diabetes. People have combinations of different variants that might pre-dispose them, but even then, there is probably only 12-15% of people with T1D where there is family history of type 1. There are a lot of families who don’t have a family history. Genes are important but we need to also consider that there are things in the environment too, so it’s a combination of environmental factors and genes.

Prevalence of type 1 diabetes is 0.3% in the general population, and it goes up to 3% if there is a first-degree relative with type 1 diabetes, but that still means the chance of not getting is 97%.

Screening and prevention:

In the ELSA study the screening age is currently 3 – 13. It takes a few years for antibodies to generate, so if we began screening at birth the antibodies aren’t there, and you can end up with a false negative.

In terms of the future: at present, there isn’t a screening for adults yet, but there is an argument for us offering the screening to adults. The reason for not screening adults is because we don’t yet understand the natural history with adults, whereas with children we can give a fairly accurate diagnosis. For adults, it is more challenging. Internationally, countries haven’t progressed into screening adults yet either, but we are thinking of taking the ELSA age up, and it’s worth noting that screening is open in Wales and England, with it beginning in Scotland and Northern Ireland later this year.

Therapies:

The ELSA study will hopefully pick up people before the immune system has caused so much damage that they become insulin dependent. This provides an opportunity to stop that progressive march to insulin dependence in patients. The Teplizumab study has delayed disease progression and prevented people from going into the insulin dependent phase by years. However, this is a monoclonal antibody study and treatment will be expensive as the drugs are expensive to produce.  David and Parth are working on an approach where they administer fragments of the antigens recognised within the disease and effectively switch off the cells causing the disease. We’ve tried this in Graves’ disease and in multiple sclerosis, and the treatment has proved safe with increasing evidence of efficacy. Ultimately this approach will be much more straightforward and probably less expensive than the monoclonal antibody approaches, so hopefully we could identify children or adults at the very early stage of their disease and use this approach to prevent further progression of the disease.

There is going to be a lot of different drugs coming through the pipeline that will benefit different people in different ways. This field has exploded in the last few years, through work at Birmingham and elsewhere. We have had insulin for 100 years and the next 100 years looks very promising due to this research.

Drugs like teplizumab look really promising but don’t really target the underlying cause of the disease - just dampen it down. What we’re really looking for with the antigen specific approach that Parth and David are working on is a way of stopping the disease in its tracks and hopefully we can intervene early enough to do this and retain the insulin producing cells.

Health inequalities

Tim’s study is addressing children and young people diagnosed with type 1 diabetes and dependent on insulin for treatment. We know getting better sugar control can reduce risk of damage, such as eye and kidney damage, if not well looked after.

Unfortunately, we know that in the UK, children from diverse communities have worse glucose control. Although everyone’s sugar control has got better, the gap between affluent and less affluent populations has widened. These widening inequalities have got worse during the pandemic. We don’t know why these populations have a high risk and more difficulties controlling their glucose.

Tim’s study wants to listen to these communities and work with them to create an action plan that families will feel comfortable with, and that will support them to improve their self-management and effectively “level up” the gap. He will ask children and young people with diabetes and their families from poorer and/or ethnic minority backgrounds how language issues, feelings, income, living conditions and food availability affect how they manage diabetes, so that together, they can find ways to make diabetes management easier and more successful.

The study will use social media to explain their results so thatpeople living with diabetes can see what the study is doing. There will also be public meetings to discuss results alongside reports written for doctors, nurses, dietitians and leading ‘influencers’ in diabetes and NHS care.

Exercise

Type 1 diabetes (T1D) is a disease where the body’s own white blood cells attack the pancreas and stop insulin production, resulting in high blood sugar. Regular participation in exercise is key to supporting health and wellbeing in people with T1D. Around 70% of people with T1D do not meet current recommended exercise guidelines.

We know that you need to be careful when you exercise for fear of low blood sugar or hyperglycaemia. It’s all about managing the amount of insulin in the body, the type and amount of carbohydrates you’re putting in your body, and the type of exercise you need to do as well. It’s all a competition for the glucose in the body, so if you are putting insulin into the body, it will attempt to lower the glucose, and with the muscle also demanding glucose, it can lead to a reduction of the glucose.

We know that more continuous aerobic exercise can lower blood glucose levels, whereas high-intensity exercise like strength training can lead to an increase. This is largely due to the stress response you get when you exercise, and the high levels of adrenaline.

The EXTOD-Immune project will use a popular and effective home-based exercise programme that links to the research team via a mobile phone application. We will test whether this programme slows the progression of T1D, by altering white bloods cells so they do not attach and enter the pancreas.

Additional Responses from Q&A

1. "My wife has had Coeliac Disease for over 20 years and has developed (late onset autoimmune diabetes in adults) LADA in the last two years. Does this offer a way of understanding the process of developing diabetes? She started taking insulin, long and short acting at the age of 69."
   
   Both Coeliac Disease (CD) and type 1 diabetes (T1D) arise in individuals because of a breakdown in immunological tolerance mechanisms. In CD this is a loss of tolerance to a food component, whereas in T1D it is loss of tolerance to self-antigen/s. The coincidence of the two conditions in one person does suggest that there are common tolerance pathways affected.
2. "Any comments on the DIY community as well as more people starting to use Night scout, Android APS, Loop etc?"
   
   As the NHS moves to automated insulin delivery (in effect Looping), DIY is not really needed. However, we still have some patients who use DIY looping. As healthcare professionals we cannot advocate DIY systems as they have not been through CE (or UK equivalent) marking.
3. "Is there a higher risk of getting diabetes - or other autoimmune diseases - if there is both type 1 diabetes and pernicious anaemia in the family (from my parents)"
   
   If there is a family history of auto-immune diseases, then there is an increased risk of developing auto-immune conditions. However, most people who develop T1D do not have a family history.