167 | Type 1 Diabetes Update: Screening, Staging and Tech

I question whether the carb counting is the tool that we're teaching versus the diabetes tech literacy. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian. And in case you haven't noticed, diabetes care has changed a lot. And if you're not working in endocrinology every day, it can be really hard to keep up. So today, we're giving you a type 1 diabetes refresher. My guest is Sarah Hormachea, a registered dietitian, certified diabetes care, and education specialist who has spent more than a decade working in diabetes care. She also recently updated the chapter on nutrition for type 1 diabetes in the newly published edition of the American Diabetes Association's Medical Nutrition Therapy Guidance. So in this episode, we talk about screening for type 1 diabetes before a child shows up in DKA, different stages of type 1 diabetes, why diabetes technology is changing everything about nutrition education and carb counting. And Sarah talks about ways to interpret CGM data without having the patient become terrified of every glucose spike. And she answers the question we all might be thinking: can patients with type 1 diabetes go on a GLP1 if they need weight management therapy? So if you haven't reviewed diabetes since you were in school, this is an episode for you. Grab your coffee or drive safe and enjoy my conversation with Sarah. Sarah, thank you so much for joining me on the podcast. I'm really excited to dig into this topic with you. Welcome to the show. Thanks for having me. Okay, let's start at the beginning and talk to me about screening for type 1 diabetes because there have been some things that have changed. So I'm curious who should we screen and how do we do that?

So as far as early screening or screening for early diagnosis, we're largely looking at risk factors. So who might have a risk for type 1 diabetes? We know if you have a family history of type 1, you're about 15 times more likely yourself to present with type 1. So anyone with a family history, a sibling, a parent, a grandparent, would be a good candidate to screen. However, up to 90% of folks with new onset type 1 don't have anyone in their family. And so that begs the argument that there are other folks who should be screened. So other things we look at are coexisting autoimmune disorders, things like celiacs or lupus, um, Hashimotoitis, right, would be good red flags for potential screening. Fortunately, it is super easy to get screened. It's a very simple four-lab panel. Um, of course, you then need to read and interpret the results, but there are a lot of resources online to help with that.

Okay, because my listeners, a lot of them are pediatric care providers like myself. I'm a pediatric PA. I actually do a lot of these screenings. So do you know what labs they are actually ordering? Is it autoantibodies for this?

Yes, there are four. There's four labs in a panel you can order. And a lot of times they're bundled. So they look at autoantibodies. There's one related to insulin, there's one related to beta cells, there's one related to zinc transporter. At least one positive is a sign that an individual should have continued screening. And then two positive autoantibodies usually is grounds for staging of early diagnosis.

Is there a certain age that this should be done? For example, at age 10, or just the moment we hear or see a risk factor, we should screen.

Arguably they are screening in the ICU, right? They're see, they're screening in the PICU and the NICU. They're screening kiddos really young. They're looking even at cord blood screening. But most of this sort of community health, public health screening is happening after age two. Um, we're seeing it more two to six or two to ten, kind of in that early pediatric range. Um, every individual is different, every practice is different. Um, largely what can shape our screening too is whether someone is eligible for treatment. Um we now have options if someone does receive an early diagnosis that we can help, we can do something, right? Before it was just a nice to know, and now we can actually do something.

Now, you recently mentioned staging. So can you walk us through the different stages? Because if you're not in endocrinology, maybe even pediatrics, you might not know that there are actually different stages of type one diabetes. And just help us understand what's happening metabolically at each stage.

It used to be that you either had diabetes or you did not for type one. And things got a little more nuanced in the last few years, and now we're trying to understand how type one um starts and progresses and how we might identify and help folks navigate through that diagnostic process. And so when someone is presenting with overt type one diabetes, we are they are already at stage three, and we're recognizing that there may be one to two to even more, right? We we this may evolve as time goes by, stages that precede someone showing up at the hospital with full-blown type 1 diabetes. And so, if we were to look a little bit earlier down that spectrum, right, of what it means to have a type 1 diagnosis, stage one would be an individual with two or more autoantibodies. So we've run a screening panel on them, two or more have come back positive. Their glucose may be fairly normal and they may have no signs or symptoms whatsoever. But because they are presenting with two or more autoantibodies, we know that at some point, the odds are very, very likely, right, that they will develop type 1 diabetes. We can then look at stage two. So stage two is two or more positive autoantibodies plus some dysphysemia, so abnormal glucose. Again, kiddo may not be symptomatic, right, in the sense that they may not be losing weight or have excessive thirst, et cetera, right? All of these quintessential um hallmark symptoms of type one, but clearly their glucose is abnormal. And then finally, stage three or a full-on diagnosis of type one would be two or more positive antibodies, dysglycemia, and symptomatic. So they're thirsty, they're tired, they're um presenting with DKA, you know, hopefully not. But that helps us understand how diabetes can exist on a spectrum and how we can screen and help identify, diagnose, get insurance coverage, right? Offer treatment much earlier down the pipeline than waiting for someone to present at the hospital with a very traumatic DKA case.

Yeah, unfortunately, that is the picture of most of my patients who I've diagnosed with type 1 diabetes. They're already stage three, they're in DKA, unfortunately. So I'm really passionate about screening and getting them tested and you know treated early on. But I'm curious for those kiddos who are in like stage one, especially, but maybe stage two, what can clinicians and families do with that information?

There's quite a few options, some of them pharmacotherapy, others community support, training, education. Um, for the longest time we asked, why screen? What can you do? What's the point? I don't want to know. I don't want to live in that anticipation. Um, but the reality is that knowledge is power, right? And we now know how traumatic physiologically, psychologically, a hospitalization for DKA can be, especially for a child. And so I don't know, I'm not buying that excuse anymore. I think we need to know, we need to be ready as families, as clinicians, um, so that we don't have to put child through that. Um, so from a pharmacotherapy standpoint, there is a treatment option. The treatment, the branded name is called TSILD. So T-Sield is uh an infusion therapy that we can um start folks on to help delay the onset into stage three. And recently it was just approved for early, early, early onset stage three. So for younger folks ages eight to 17, if they do present with DKA, if we can get them started within usually the first eight weeks or so, evidence is showing really promising for allowing them to stay kind of in that honeymoon period a little bit longer. So a big part of this is the dynamic within the family. If we know somebody is staged at stage one or stage two, we can say, hey, this is what it might mean to have DKA. This is what you're looking for, this is why we want to keep an eye on your blood sugars. This is why we just want to keep you looped in with primary care, right? Don't let years and years go by because you feel fine. So we want to make sure that these kiddos are really linked in. There are some clinicians, especially as we get into the type of the functional integrated medicine, who will say that there are nutritional strategies you can use to prevent the progression. And they're looking at this more from an autoimmune standpoint. Like, what is the connection between nutrition or lifestyle and autoimmune disorders? I would argue that the science is still largely unsettled. I don't know that there's an evidence-based approach to eating to prevent the onset, you know, or the progression of type one diabetes. Um, certainly we know that, you know, promoting and educating on a healthy lifestyle, healthy weight, physical activity is good for everyone. And so we may say, you know, you this is especially important for you because down the road, you are, odds are you'll probably have a chronic health disease. So let's set you up for good health and wellness now.

I can imagine families are probably a little bit scared if they get like that stage one, stage two. So are they needing to check their glucose during that time, or is it just something that's done in an annual well check?

There's a variety of strategies we can use. We might give a kiddo or give a family um a glucometer and ask them to check periodically and say, hey, are you noticing a trend? Are you noting noticing increases? Um, we might be strategic and ask them in and around foods, or we might put a continuous glucose monitor on them, maybe once every six months or once a year. Um, for other folks, that's it's that's a lot to ask. And so we'll say just come come back into clinic, we'll continue to watch your autoantibodies, but at least helping them understand that this is likely coming down the pipeline and that you can go on to have a healthy, thriving life, even living with a type one diabetes.

We'll get back to the episode in just a minute, but I'm curious, have your patients ever asked you if you could just give them a meal plan? But what's interesting is patients are actually asking for structure and guidance around nutrition without feeling so overwhelmed. That's why I love the Peas and Hoppy Meal Guides app. It was built by my friend and registered dietitian Ann Kent. Every week she provides simple, flexible meal plans your patients will actually follow, giving them more variety and nutrition without adding to their mental load. Check out peasandhoppiness.com slash exam. And if you use code exam room, you'll get 20% off. All right, now let's get back to the episode. All right, let's get into the nutrition because you know that is the focus of my podcast. And so for years, we've heavily focused on carbohydrate counting. Is that still the foundation of type 1 diabetes management or has it changed over the years?

So certainly we know that in the setting of type one, right, the the issue at large is an insulin problem, right? So an individual no longer makes the insulin that they need to function. And a good portion of that insulin is being used to help glucose, largely from food, enter into the cell. Now, we also make glucose, other areas of our body, right? Our liver is a part of gluconeogenesis and making making glucose, but a good chunk of the insulin, the glucose that gets into our body is being managed by insulin. And so our our approach, largely in folks living with type one, has been you can eat what you need to eat or what you want to eat so long as you cover it with insulin, right? Especially because we have insulin now, wasn't always a tool that we could use so easily and accessibly. So we want to establish healthful eating patterns, right? Normalcy with eating in food from a young age. And we try to keep an open mind when it comes to like what you can eat, when, how, where. Of course, children and young adults do best if they can eat general healthful eating, right? So nutritious food, whole grains, lean proteins, fruits, and vegetables, at which point we need to give them guidance on how to administer insulin. And so the skill of carp counting becomes just that. It's a tool to help folks dose their insulin. And I would argue it's even a tool that we're not really putting a lot of emphasis on teaching to the degree of accuracy that maybe we once were. If I have 30 minutes of a session with someone, is it better spent teaching someone how to carp count? Or maybe it's developing their diabetes tech literacy so that they understand what tools are available to them to help them understand the amount of carbs that are in foods and how they can dose their insulin. And so more often than not, we're talking about smart apps, we're talking about AI integration, we're maybe talking about how to cross-reference. Um, there was a huge um wave of presentations this year at the American Diabetes Association scientific sessions in New Orleans, tons and tons of discussion on AI integration, right? Where are we at? What's happening? What's safe? What can we trust? Where are we going? You know, right now we are not seeing a lot of um pumps on the market with AI integration, but we are definitely seeing this huge influx of apps, especially apps that use photos to identify um what is on a plate, what is the nutrient profile, what are the carbohydrate estimates. And surprisingly, they are really accurate. So if they are dosing on a regimen that is quite complex, for example, if they're using an insulin to carb ratio, so one unit of insulin covers 15 grams of carb. And then they also have a correction factor. So we might say if your blood sugar is higher than your target, maybe what you want you add a target of 120, you're gonna add additional insulin to help course correct. It's a lot of math, right? There are apps for all of this. And so, how can we match someone with an app to help relieve the burden of all of the math and keep them safe? Um, so carbohydrates, still important, still valid, but I question whether the carb counting is the tool that we're teaching versus the diabetes tech literacy.

I love the advancements in diabetes medicine. I think it's absolutely fascinating. I mean, I remember when like insulin pumps were like all the rage, like it was life-changing for so many people and CGMs with their influx on the market now. Do they all end up getting an insulin pump or should they have one? And or like a CGM? Is that something that's like a staple in care?

American Diabetes Association comes out with their standards of care every year. And every year they update what is recommended for every stage of diabetes. And it is evidence-based recommended now to at least consider and offer diabetes technology. So consider the situation, consider the family, consider the support, consider the unique individual, and have this conversation on where it might fit in. Though not everybody is going to be a good candidate from day one. And what we've seen over the life cycle of someone or lifespan of someone's diabetes is they may cycle in and out. They may go through periods where it feels very relevant, a growth, development, pregnancy, where your insulin needs are just changing so rapidly, versus times where life feels very stable, maybe even stagnant, maybe there's gaps in insurance coverage. While tech, diabetes tech is amazing, it is a constant reminder, it's a visual reminder that you live with diabetes.

Um, and some folks need to need a break from that. And that's okay. I want to pause and talk a little bit more about CGMs because they're like such a hot topic on social media for those who don't even have diabetes, but that's a whole nother topic. Um, I'm curious how you discuss the results or the readings with your patients so that they don't freak out because social media tells us any glucose spike is bad and we need a flat line, right? So I would love to hear some of that counseling and those reassuring things and how you explain glucose metabolism and what information they're seeing on their CGM. So CGM is a phenomenal tool.

It has become a very valid tool to assess simply another vital, right? We talked about our blood pressure, our heart rate, our sleep quality, our pain. Glucose is now seen as simply another metric of our health and wellness. So I think first part of your question is yes, it is valid. It is a metric, it is a marker of health. We're looking at it more. It has value as clinicians. We need to understand how to read and interpret it. No, no excuses, right? Because our patients and clients are coming in with this data just like they're coming in with their aura ring data. And they want us to help them make informed decisions about their health and wellness. As far as how we can coach and counsel our clients, we're looking at big picture trends, that we're looking at change over time, that most people have a level of glucose variability that they live with day to day that they just don't know about. And making room for this nuanced conversation can help put our clients' minds at ease. When it comes to glycemic targets, we have great targets for type one. We have great targets for type two, right? They're very defined. We say ideally, glucose no lower. It used to be 70, now it's 80. Ideally, glucose no higher than 180. And we can even use time and tight target, which is no higher than 140. We don't really have a consensus on glucose outside the setting of diabetes. And that is because all of these anomalies can occur. And more important is how quickly do we recover? How quickly do we get back to baseline? So it's nuanced and it can feel complex, but I think we can slim it down and have a concise message for our clients and say, hey, I love that you're bringing this into session. This is amazing data. So let's use it. Um, but let's use it as part of all the other data we're capturing today, including your blood pressure, your cholesterols, so on and so forth.

Okay, I want to talk about a hot topic recently that's been in the headlines, and that is all about sugar substitutes, specifically aspartame, because the Who recently classified it as a group 2B carcinogenic act agent, and the internet is going crazy over it. And I know with patients with diabetes, we do talk about lowering their added sugar intake. And often these sugar substitutes are wonderful options. So, how do we balance this tension when patients are coming and asking us, like, hey, do I need to avoid these sugar substitutes now? How do you answer that?

Always make it clear that I see low and non-nutritive sweeteners as a tool in the toolbox. So if you walk into your closet, your shed, your tool shed, and you look at all your different tools, you're gonna think about what is the job that you need to get done, and you're gonna pick the right tool for the job. Some of those tools are um a little riskier to use, right? And some of those tools um could be used really easily, right? So I'm gonna pick the right tool for the right job. When I work with clients living with type 1 diabetes, their goal is to lower their blood sugar and achieve better glycemic control or management. And so we talk about low and non-nutritive sweeteners as a tool. If they are consuming quite a bit of added sugar, then low and non-nutritive sweeteners can be a phenomenal replacement to help them achieve their bigger outcome, right? And so really thinking about the individual client themselves and the risks and what risk are they willing to take in order to optimize their glucose control or glucose management. Going back to the standards of care, right? American Diabetes Association in section five on medical nutrition therapy, they endorse the use of low and non-nutritive sweeteners. So there was enough of a consensus amongst all the endocrine experts at the American Diabetes Association for it to be a line item in those standards of care and say, hey, it is a tool that we need to talk about. Um, and there's no reason folks can't use this in lieu of sugar. Would I love everybody to just cut their added sugar? Yes, of course, but that is a big ass. That's a big ass. If you're standing there in the sugar baking aisle and you're looking at all the options and you're going, okay, I'm on board with low and non-nutritive sweeteners, but which one? You could probably get a different answer from, you know, every time you went on the internet or look for an article. But in general, some of the first gen, like aspartame, are falling out of fashion, right? We're seeing a lot fewer products with things like aspartame. And then the four most popular are gonna be your sucralose, which is what devia, monk fruit, and then a new player that entered the game is allulose. And allulose. Is fascinating because we're seeing some research now that not only is it glucose neutral, but it may actually have glucose benefit in that allulose itself may post or blunt these perennial excursions that happen after a meal. And allulose originally derived from like raisins, dates, apricots. So food derived, though it is manufactured now commercially. So lots of different options. Sugar alcohols are certainly out for debate now, too. We're seeing some research around like absorbitol and erythritol and cardiovascular health outcomes. But again, I would encourage folks to look at the products that they're consuming. You know, they may not even be consuming that much of those non-nutritive sweeteners to begin with. And what are their risks? Another example I can like at this to is our recommendation as dietitians around grilling, right? Grilling is a phenomenal cooking method. It is keeps the heat outside, right? It adds flavor, it cuts down on the fat. We can see all the fat drip down. But grilling over an open flame can be carcinogenic. So there are risks that come with grilling, even though it is a phenomenal cooking tool and strategy. So again, risks, pros and cons to every strategy, but really think about the individual, what we're trying to achieve, and what risk are we willing to expose them to in order to achieve those health.

Yeah, it's a really nuanced question. So I loved that answer. So thank you for giving us that approach. And really that's how we should all be thinking is balancing risk versus benefit. And like clinicians are so used to doing that in a lot of the decisions that we make with our patients. So I think that's really helpful. And it's also helpful to remind patients they sometimes think that, you know, diabetic diet, quote, is like a no-sugar diet. And that's such an old school way of thinking. And so I love how you bring in like the balance and really just choosing the right tool for the right season or the right occasion, right? Sometimes you do need to have that slice of cake if it's your birthday, you know, versus maybe other times we can make a better, lower sugar choice. I want to transition to an into weight management for kind of the last segment of our chat, because this can be complicated for patients with type 1 diabetes. So I'm curious to hear like what makes it so different and maybe difficult with someone who depends on insulin versus someone who doesn't.

Yes, weight management in the setting of type one is unique. And for someone living with type one who is seeking a clinician to assist them with weight management, really would ensure and that they are working with someone who understands the nuances. It's a disservice for someone living with type one to follow a plan or program that was really designed for someone with minimal disruption to their insulin production, or even someone that is oral medication managed, type two. And a lot of that has to do with the risks that are associated with insulin itself. And so I'll start there. With type one, we get so hyper focused on insulin, but we forget that there are four other hormones that are disrupted, including things like glucagon that's made in the alpha cells, right? And that is uh tasked with raising glucose. And when do we raise glucose? Well, when we're fasting in between meals, we know that raising glucose is a big part of weight management. And we're seeing this in the new trials on um retitrutide or retaglotride, right? Is a new uh triple TLP GIP therapy coming down the road. And the third agonist in there, the third hormone in there is um glucagon. And so we know that there is a strong correlation between the presence of glucagon and weight management. And for individuals living with type one whose alpha cells are impacted, they do not make glucagon in the same way. And so they are missing at some point both a gas and a break to manage their glucose, but also the way their body stores glucose, whether it's stored in body fat or muscle, et cetera. Other hormones like GLP and GIP are disrupted. And so when you have a clinician, right, or you are a clinician and you're working with someone with type one on weight management, it's really important to think about all the hormones that are impacted with this disease state. And so really ensuring that you are looking at what is the largest driver of their low glucose and making sure that there is a plan in place for that. It is quite different from weight management in the setting of type two versus weight management in just the general population.

Now, the last question I have, we won't get too deep into it, but I do think it's interesting that maybe a lot of people might not have realized patients who are living with type 1 diabetes can go on a GLP one. So it can be offered to them. But I'm curious, like, what are your hesitations there? What do we need to think about, talk about if they are looking for this type of management? Because it's just so popular, so widespread.

Just last week, so this is July 2026. Just last week, there was a new consensus statement and pre-publication, just came out entitled Adjunctive Treatment of GLP1 Therapy for People Living with Type 1. And the consensus was that we should offer it, we should prescribe it, we should monitor it, right? That it is absolutely a tool. Um, and the practice is there. We're just waiting for the for the powers that be to be signed off on the evidence. We talk about the biggest limiting factor to this GLP1 therapy getting approved in the setting of type one. It's studies, it's studies. The complaint is that there just are not enough randomized control trials of individuals with type one using encryption therapy. But it's a chicken or the egg issue. How do you get studies if you can't legal, you know, if you can't ethically prescribe it? And then how do you how do you get the evidence that it works if you can't get the studies? And so the fear is always these risks of lows. Oh my gosh, who will manage the insulin if they start on GLP1 therapy? Well, folks with non-insulin should have routine management, anyways, right? The other concern certainly is hyperglycemia, um, especially DKA. So, in the setting of low insulin, high glucose, you know, could these folks be at higher risk for DKA? It's also another condition called euglycemic DK, right? Where glucose seems relatively normal, but still insulin is low. And there may be some worry that, you know, people may feel that, oh, my glucose seems relatively low. I can lower my insulin or even stop my insulin. But we know in the setting of type one, odds are you'll never be able to stop insulin, right? And so I think there's some fear there. But we are seeing individuals with type one on encogen therapy. It is being prescribed both off label or for alternative reasons, like sleep acne, obesity treatment, et cetera. Um, and we are going to see it continue to be prescribed and used more widely as more of these consensus statements come out and clinicians feel more comfortable with it.

And people ask for it. Sarah, this has been such a great conversation. Thank you so much for sharing all of your wisdom. If people want to learn more about you or connect with you online, where would we send them? Yes, my website, it's Sarahhermachea.com. Sarah, thank you so much for the gift of your time today. I appreciate you being here. Thanks for having me. And thank you guys for carving out time for nutrition today. I will see you next week.