'Push the Bar Higher': New Statement on Type 1 Diabetes in Adults

Miriam E. Tucker

October 04, 2021

A newly published consensus statement on the management of type 1 diabetes in adults addresses the unique clinical needs of the population compared with those of children with type 1 diabetes or adults with type 2 diabetes.

"The focus on adults is kind of new and it is important...I do think it's a bit of a forgotten population. Whenever we talk about diabetes in adults it's assumed to be about type 2," document coauthor M. Sue Kirkman, MD, told Medscape Medical News.

The document covers diagnosis of type 1 diabetes, goals and targets, schedule of care, self-management education and lifestyle, glucose monitoring, insulin therapy, hypoglycemia, psychosocial care, diabetic ketoacidosis (DKA), pancreas transplant/islet cell transplantation, adjunctive therapies, special populations (pregnant, older, hospitalized), and emergent and future perspectives.

Initially presented in draft form in June at the American Diabetes Association (ADA) 81st Scientific Sessions, the final version of the joint ADA/EASD statement was presented October 1 at the virtual European Association for the Study of Diabetes (EASD) 2021 Annual Meeting and simultaneously published in Diabetologia and Diabetes Care.

"We are aware of the many and rapid advances in the diagnosis and treatment of type 1 diabetes...However, despite these advances, there is also a growing recognition of the psychosocial burden of living with type 1 diabetes," writing group co-chair Richard I.G. Holt, MB BChir, PhD, professor of diabetes and endocrinology at the University of Southampton, UK, said when introducing the 90-minute EASD session.

"Although there is guidance for the management of type 1 diabetes, the aim of this report is to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes," he added.

Noting that the joint EASD/ADA consensus report on type 2 diabetes has been "highly influential," Holt said, "EASD and ADA recognized the need to develop a comparable consensus report specifically addressing type 1 diabetes."

The overriding goals, Holt said, are to "support people with type 1 diabetes to live a long and healthy life" with four specific strategies: delivery of insulin to keep glucose levels as close to target as possible to prevent complications while minimizing hypoglycemia and preventing DKA; managing cardiovascular risk factors; minimizing psychosocial burden; and promoting psychological well-being.

Diagnostic Algorithm

Another coauthor, J. Hans DeVries, MD, PhD, professor of internal medicine at the University of Amsterdam, the Netherlands, explained the recommended approach to distinguishing type 1 diabetes from type 2 diabetes or monogenic diabetes in adults, which is often a clinical challenge.

This was also the topic prompting the most questions during the EASD session.

"Especially in adults, misdiagnosis of type of diabetes is common, occurring in up to 40% of patients diagnosed after the age of 30 years," DeVries said.

Among the many reasons for the confusion are that C-peptide levels, a reflection of endogenous insulin secretion, can still be relatively high at the time of clinical onset of type 1 diabetes, but islet antibodies don't have 100% positive predictive value.

Obesity and type 2 diabetes are increasingly seen at younger ages, and DKA can occur in type 2 diabetes ("ketosis-prone"). In addition, monogenic forms of diabetes can also be disguised as type 1 diabetes.

"So, we thought there was a need for a diagnostic algorithm," DeVries said, adding that the algorithm — displayed as a graphic in the statement — is only for adults in whom type 1 diabetes is suspected, not other types. Also, it's based on data from White European populations.

The first step is to test islet autoantibodies. If positive, the diagnosis of type 1 diabetes can be made. If negative and the person is younger than 35 years and without signs of type 2 diabetes, testing C-peptide is advised. If that's below 200 pmol/L, type 1 diabetes is the diagnosis. If above 200 pmol/L, genetic testing for monogenic diabetes is advised. If there are signs of type 2 diabetes and/or the person is over age 35, type 2 diabetes is the most likely diagnosis.

And if uncertainty remains, the recommendation is to try noninsulin therapy and retest C-peptide again in 3 years, as by that time it will be below 200 pmol/L in a person with type 1 diabetes.

Kirkman commented regarding the algorithm: "It's very much from a European population perspective. In some ways that's a limitation, especially in the US where the population is diverse, but I do think it's still useful to help guide people through how to think about somebody who presents as an adult where it's not obviously type 2 or type 1...There is a lot of in-between stuff."

Psychosocial Support: Essential but Often Overlooked

Frank J. Snoek, PhD, professor of psychology at Amsterdam University Medical Centers, Vrije Universiteit, presented the section on behavioral and psychosocial care. He pointed out that diabetes-related emotional distress is reported by 20%-40% of adults with type 1 diabetes, and that the risk of such distress is especially high at the time of diagnosis and when complications develop.

About 15% of people with type 1 diabetes have depression, which is linked to elevated A1c levels, increased complication risk, and mortality. Anxiety is also very common and linked with diabetes-specific fears including hypoglycemia. Eating disorders are also more prevalent among people with type 1 diabetes than in the general population and can further complicate diabetes management.

Recommendations include periodic evaluation of psychological health and social barriers to self-management and having clear referral pathways and access to psychological or psychiatric care for individuals in need. In addition, "All members of the diabetes care team have a responsibility when it comes to offering psychosocial support as part of ongoing diabetes care and education."

Kirkman had identified this section as noteworthy: "I think the focus on psychosocial care and making that an ongoing part of diabetes care and assessment is important."

More Data Needed on Diets, Many Other Areas

During the discussion, several attendees asked about low-carbohydrate diets, embraced by many individuals with type 1 diabetes.

The document states: "While low-carbohydrate and very low-carbohydrate eating patterns have become increasingly popular and reduce A1c levels in the short term, it is important to incorporate these in conjunction with healthy eating guidelines. Additional components of the meal, including high fat and/or high protein, may contribute to delayed hyperglycemia and the need for insulin dose adjustments. Since this is highly variable between individuals, postprandial glucose measurements for up to 3 hours or more may be needed to determine initial dose adjustments."

Beyond that, Professor Tomasz Klupa, MD, PhD, of the department of metabolic diseases, Jagiellonian University, Krakow, Poland, responded: "We don't have much data on low carb diets in type 1 diabetes...Compliance to those diets is pretty poor. We don't have long-term follow-up and the studies are simply not conclusive. Initial results do show reductions in body weight and A1c, but with time the compliance goes down dramatically."

"Certainly, when we think of low carb diets, we have to meet our patients where they are," commented Amy Hess-Fischl, a nutritionist and certified diabetes care and education specialist at the University of Chicago, Illinois. "We don't have enough data to really say there's positive long-term evidence. But we can find a happy medium to find some benefits in glycemic and weight control...It's really that collaboration with that person to identify what's going to work for them in a healthy way."

The EASD session concluded with writing group co-chair Anne L. Peters, MD, director of clinical diabetes programs at the University of Southern California, Los Angeles, summing up the many other knowledge gaps, including personalizing use of diabetes technology, the problems of health disparities and lack of access to care, and the feasibility of prevention and/or cure.  

She observed: "There is no one-size-fits-all approach to diabetes care, and the more we can individualize our approaches, the more successful we are likely to be... Hopefully this consensus statement has pushed the bar a bit higher, telling the powers that be that people with type 1 diabetes need and deserve the best."

"We have a very long way to go before all of our patients reach their goals and health equity is achieved...We need to provide each and every person the access to the care we describe in this consensus statement, so that all can prosper and thrive and look forward to a long and healthy life lived with type 1 diabetes."  

Holt serves on the speakers' bureaus for and receives research support from Novo Nordisk. He serves on speakers' bureaus for Abbott, Eli Lilly, Otsuka, and Roche. He also served as Editor-in-Chief of Diabetic Medicine until December 2020. DeVries received research funding from Afon, Eli Lilly, and Novo Nordisk. He served on advisory boards for Adocia, Novo Nordisk, and Zealand Pharma and was on a speakers' bureau for Novo Nordisk. Hess-Fischl is an auditor for the ADA's Education Recognition Program. She is a participant in a speakers' bureau for Abbott Diabetes Care and Xeris. She is also a member of Xeris' advisory board. Klupa has served on advisory boards for Abbott, Ascensia, Bioton, Boehringer Ingelheim, Dexcom, Eli Lilly, Medtronic, Roche, Sanofi, and Ypsomed. He has received research funding from Medtronic and is a participant in speakers' bureaus for Abbott, Ascensia, Bioton, Boehringer Ingelheim, Eli Lilly, Medtronic, Novo Nordisk, Roche, Sanofi, and Servier. Snoek is consultant for Abbott, Eli Lilly, Sanofi, and Novo Nordisk, and serves on the speakers' bureaus for Abbott, Eli Lilly, Sanofi, and Novo Nordisk. He has received research funding from Sanofi and Novo Nordisk. Peters serves on advisory boards for Abbott Diabetes Care, Eli Lilly, Novo Nordisk, Medscape, and Zealand Pharmaceuticals. She has received research support from Dexcom and Insulet and has received donated devices from Abbott Diabetes Care. She holds stock options in Omada Health and Livongo and is a special government employee of the FDA.

EASD Annual Meeting 2021. Presented October 1, 2021.

Diabetologia. Published online October 1, 2021. Abstract

Diabetes Care. Published online October 1, 2021. Abstract  

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.

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