'I'm a Survivor': Incoming ADA President Has Type 1 Diabetes

Miriam Tucker

July 31, 2019

"I feel fortunate to be alive. Despite aging and related stiffness, I feel wonderful."

These are the words of Robert H. Eckel, MD, 71, who — when he takes over as co-president of the American Diabetes Association (ADA) in January — will bring unique credentials to the position: he has lived nearly his entire life with type 1 diabetes, while spending a 46-year career focused on heart disease in type 2 diabetes.

Told repeatedly in his younger days that his life span would be limited by his type 1 diabetes, Eckel nevertheless managed to grow up — despite very basic tools in terms of diabetes control — having just two hospitalizations for diabetes complications. Although his childhood was restricted by his disease — preventing him from doing a lot of fun things other kids did — he has, in most other ways, not allowed type 1 diabetes to limit him at all.

He chose his medical specialty to fit in with his diagnosis. And more than 65 years after that diagnosis, despite experiencing some complications from his diabetes, he has carved out a distinguished career as an endocrinologist, had two successful marriages, and has five children.

 

Charting the sometimes challenging aspects of combining family, career and diabetes management, Eckel spoke exclusively to Medscape ahead of his forthcoming new positon with the ADA.

Eckel is an endocrinologist but he didn't want to study his own disease; thus, he is perhaps better known in the cardiology community, where he has conducted extensive research into the links between lipids/lipoprotein metabolism and obesity, diabetes, and cardiovascular disease.

He's currently professor of medicine in the Divisions of Endocrinology, Metabolism and Diabetes, and Cardiology; professor of physiology and biophysics; and the Charles A. Boettcher II Chair in Atherosclerosis at the University of Colorado Anschutz medical campus. He also directs the Lipid Clinic at University of Colorado Hospital in Denver.

Former AHA President: "I Cross-Dress as a Cardiologist"

In 2005–2006, Eckel served as president of the American Heart Association (AHA).

"I cross-dress as a cardiologist," quipped Eckel in an exclusive interview with Medscape Medical News

Indeed, one of his agenda items in recent years — and that he plans to highlight during his ADA co-presidency — has been to try to develop a new "cardiometabolic" subspecialty of internal medicine, a field that he believes would tackle a large unmet need.

"As the population ages, they're more obese, there's more type 2 diabetes, and more cardiovascular disease. We need specialization," he said.

"We need diabetologists to get more trained in cardiology, and cardiologists to get more trained in diabetes-related medicine."

Eckel's good friend, cardiologist Darren K. McGuire, MD, told Medscape Medical News, "Bob was a super AHA president…adding to the usual duties of the role a specific and consistent focus on bridging our disciplines together, given the very tight and important connection between diabetes and cardiovascular risk and disease."

McGuire is professor in the Department of Internal Medicine at the University of Texas Southwestern Medical Center in Dallas and director of the Parkland Hospital and Health System Outpatient Cardiology clinics.

McGuire also says of Eckel: "He is a very effective unifier, leaving behind any pretense, ego, or personal agenda to the greater mission of cooperation and collaboration of our disciplines to the betterment of the lives of the patients with diabetes we all care for."

"I anticipate he will bring more of the same as ADA president, moving forward with a focus on the existing and growing collaborations ADA has with various cardiology societies."

Affordable Insulin and Access to Technologies Key for Those With T1D

Eckel will also focus on cardiovascular disease in type 1 diabetes as well as type 2.

"Now that we have cardiovascular outcomes trials showing the benefits of newer glucose-lowering medications in type 2 diabetes almost exclusively, we need more work in type 1 as well to show that we can reduce cardiovascular disease in those patients too, beyond modifications in glycemic control," he explained.

Of course, he's very attuned to the needs of the type 1 diabetes population, having been diagnosed with the condition in 1953 at age 5. Back then, there was no glucose testing and no adjustment of insulin doses.

Today, he has some complications, including limited night vision, an elevated coronary calcium score, chronic but stable kidney disease, and flexion contractures in his elbows and wrists.

Nonetheless, he now wears an insulin pump and a continuous glucose monitor (CGM) and has a respectable hemoglobin A1c of 6.2%.

Eckel hopes to see more people with type 1 diabetes gain access to technologies, including faster-acting and lower-priced insulins.

"For type 1, the challenges are really related to technology and its implementation in a cheaper insulin price range," he said.

"I didn't feel well often"

When Eckel was first diagnosed, he was put on a daily injection of globin insulin, a long-defunct formulation with a duration of about 18 hours, leaving about 6 hours a day without coverage.

He remembers performing frequent urine tests in a small tube, which would turn from blue ("negative", no glucose in urine) to orange (high levels of glucose in urine), essentially reflecting blood sugar levels several hours prior.

"I never took Regular insulin to correct because I never knew when I was high," he recalls.

"I didn't feel well often. My mother thought I didn't want to go to school."

 

She would boil his glass insulin syringes daily. Sometimes they would fall on the floor and break. He wasn't able to go to camps or stay at a friend's overnight until he was a teen, when plastic syringes became available.

Despite all that, he was only hospitalized twice, both times for diabetic ketoacidosis — at diagnosis and again at age 7.

He did have several severe hypoglycemic episodes, but his mother, older brother, teachers, coaches, and others around him knew to give him juice. (His father had died of cancer when Eckel was less than a year old.)

"I didn't miss too many school days for T1D-related illness. I played baseball and was able to compete somewhat but I was slow to develop. Type 1 diabetes affects growth and development. My puberty was late and I wasn't very big or strong. I couldn't compete with kids my own age," says Eckel, who is 5'9" now.

"I Was Curious About Why People Got Sick"

Eckel couldn't afford to go away to college, so he lived at home while attending the local University of Cincinnati. He also went to medical school there and married his high school girlfriend while a med student. At that point, he was still taking one shot a day and testing his urine.

The decision to go to medical school had more to do with his parents than with his diabetes, he says.

"I went to medical school because my father was a family physician during World War II," he explained. "My mother wanted one of us boys to be a doctor. My brother had no interest so it fell to me. I liked science and chemistry at a young age."

After medical school he moved to Madison, Wisconsin, for his house staff training in internal medicine. About midway through, he decided he wanted to be more than just a general internist.

"I was curious about why people got sick and why they didn't respond to therapies and I thought I wanted to do some research."

Since he had majored in bacteriology as an undergrad, his first thought was to subspecialize in infectious disease, in which the University of Wisconsin excelled. But, in those days infectious disease was primarily a hospital-based speciality, and he feared having to work nights while navigating his type 1 diabetes.

Indeed, during medical school, internship, and residency when he'd been on-call at night, he would eat a large snack in order to prevent hypoglycemia.

"I probably ate at 250[mg/dL] and went to 400[mg/dL]…I remember feeling poorly many nights and was probably high but had no way to measure that," he said.

Back in medical school, he had become interested in lipids after hearing a lecture by Charles Glueck, who had worked at the National Heart, Lung, and Blood Institute with Donald Fredrickson, the scientist credited as being among the first to link cholesterol to heart disease. 

"At that time it wasn't known that cholesterol [was] related to heart disease. It was still a black box," Eckel said. "Charlie's lecture impressed me…I liked endocrinology in general — thyroid disease, metabolic bone, reproductive endocrinology, all those things I found kind of interesting. But I wanted to do research into how metabolic disease relates to cardiovascular disease."

"Didn't Want to Study My Own Disease"

Eckel continues: "I remained curious about type 1 diabetes, but didn't want to study my own disease. I was also thinking about a [clinical] backup plan, in case research didn't work out."

So for his fellowship, he looked specifically for an institution that was researching the overlap between metabolic and atherosclerotic disease — what he now hopes to turn into a new medical subspecialty — and ended up at the University of Washington under the famed atherosclerosis expert Edwin L. Bierman, MD.  

"It was an incredibly amazing experience at the University of Washington. I thank Ed Bierman for giving me a chance. It was a highly competitive program and I really didn't feel I had the credentials so I was very fortunate [to get accepted]."

It wasn't until around that time — in the late 1970's — that fingerstick blood glucose testing became available. "I used to cut the strips in quarters because they were expensive, and compare them to the chart. For the first time I had an ability to understand a little more what was going on with my glucose," Eckel says.

At some point — he can't remember exactly when — he began using a glucose meter and transitioned to a more physiologic multiple daily insulin injection regimen.

In the mid-1990s, he went on an insulin pump. HbA1c testing had become the standard of care around the mid-1980s.

He'd spent several decades living with type 1 diabetes without the benefit of any of those tools: "I'm a survivor," Eckel said. 

From Denver to Diabetes Leadership

Eckel was next recruited to the University of Colorado in 1979 by another giant in the diabetes research universe, Jerrold M. Olefsky, MD, who today is associate dean for scientific affairs and professor of medicine at the University of California San Diego. 

 

Eckel has had a prolific 40-year career in Denver, with more than 300 published articles bearing his name.

He was among the first researchers to use the "euglycemic clamp" technique to study lipid metabolism and was a co-investigator on the first randomized controlled trial of liposuction surgery, demonstrating its limitations.

And in 2012, his work helped illuminate the effect of carbohydrate consumption on weight.

Today, about 20%-25% of Eckel's time in Denver is clinical, seeing patients with diabetes (types 1 and 2), a variety of lipid abnormalities, obesity/ metabolic syndrome, and other complex patients with overlap between metabolic and cardiovascular disease. He devotes much of the remaining time to research and running the lipid clinic. 

His type 1 diabetes is under control today.

"I'm 70-180 mg/dL [blood glucose] between 80% to 85% of the time."

"It's only the technology [insulin pump and CGM] that's allowed me to do that. I probably don't need to [have an HbA1c of] 6.2%. I'd be happy at 6.7%-6.8%."

"My goal is now to stay in range. Sometimes I overshoot or undershoot, but for me time-in-range is the relevant number in terms of the current science."

Per ADA leadership structure, Eckel will share his upcoming ADA presidency — he'll be the medicine/science president along with healthcare/education president Mary de Groot, PhD.

In addition to promoting access to diabetes-related technology and affordable insulin for type 1, and promoting the idea of a "cardiometabolic" subspecialty, he'll have another agenda item: boosting research funding.

"Diabetes research spending by the NIH is far less than it needs to be based on the population explosion of obesity and type 2 diabetes. We need more money per capita to be spent on a disease that's more common and increasingly deadly as people age. We can't dismiss that message," Eckel stressed.  

According to McGuire, Eckel's friend and UT Southwestern cardiologist, "The ADA has been a super partner with our cardiology community and societies and I am proud to be a part of that organization. Bob will continue to advance that tradition as ADA president, and I look forward to supporting him in that mission every step of the way." 

Eckel's Sons Have Type 1 Diabetes: Still Little Idea of What Triggers It

Eckel's two sons also have type 1 diabetes, although his three daughters don't.

He was a single parent to his five children for a year and a half after his first wife, Sharon, died of breast cancer; he's now married to his second wife, Margaret.

He recalls having mumps prior to his own diagnosis in the early 1950s and says: "Isn't it amazing that here we are 65 years later and [we] still have very little idea what takes the genetically susceptible individual and brings on this life of type 1 diabetes?"

Eckel has received consultant/advisory board fees from Kowa, Novo Nordisk, Regeneron Pharmaceuticals, Inc, and Sanofi. McGuire has received fees for consulting, advisory board activity, and/or serving on clinical trial executive/ monitoring committees from Applied Therapeutics, Boehringer Ingelheim, Sanofi US, Novo Nordisk, AstraZeneca, Lilly USA, Metavant Sciences, Ltd, Merck Sharp & Dohme, Janssen Research and Development, GlaxoSmithKline, Eisai, Esperion, and Lexicon Pharmaceuticals, Inc.

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