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Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine.

I'm Melanie Cole. And today, we're talking about pediatric diabetes prevention. Joining me is Elizabeth Gunkle. She's a nurse practitioner and diabetes educator in the Division of Pediatric Endocrinology at Weill Cornell Medicine. Elizabeth, thank you so much for joining us. Why don't you start by telling us a little bit about diabetes and type 1 diabetes, how common it is, really tell us a little bit about what it is.

Elizabeth Gunkle: Yeah. So, thank you so much for having me. As a general term, diabetes is focused on the pancreas not making enough insulin. And when we don't have enough insulin, this leads to high blood sugars. We typically think about diabetes as two main forms of diabetes, so type 1 diabetes and type 2.

We used to think of type 1 as being a childhood diabetes and type 2 being adult diabetes. But we've now really realized that we can see either of these conditions across the lifespan. Type 1 diabetes is much rarer than type 2. It's really only about 5% or 10% of diabetes here in the U.S. But type 1 diabetes is really what we'll be focusing on today, because we've realized we can identify type 1 diabetes earlier on. Type 1 diabetes is an autoimmune condition. So, what this means is the immune system sort of inaccurately identifies these cells in the body as an invader. And so, it gradually breaks down these insulin-producing cells in the pancreas, which lead to these high blood sugars. And so, we identify type 1 diabetes with these auto-antibodies. So, this is what we'll be testing for when we talk about diabetes screening and prevention.

Melanie Cole, MS: Well, thank you for that. I'd like you to tell us about the new Diabetes Prevention Program at Weill Cornell Medicine, which entails type 1 diabetes screening for the general population. Tell us about that.

Elizabeth Gunkle: Yeah, absolutely. So, we used to think about type 1 diabetes as somewhat of a binary diagnosis. Someone went from having no diabetes to having type 1 diabetes and needing insulin. And now, we've realized that we can identify these antibodies earlier on to catch things before someone needs insulin and is very sick.

So here at Weill Cornell, what we typically offer is a video visit with me or one of my diabetes colleagues where we can really go through all the ins and outs of what is type 1 diabetes, what are the risk factors for developing type 1, how do we screen, et cetera. And so, our typical process after doing the video visit is we can offer one of two things. We either can order these five commercially available antibodies through Quest or LabCorp or our hospital, or we sometimes will have families go through our partnership with Barbara Davis Center in Colorado. They have a program called ASK, A-S-K, so autoimmunity screening for kids. This is a great research-based opportunity to do screening that is outside of insurance, so it's guaranteed to be free. We generally don't have many issues with insurance coverage through a commercial lab, but it is potentially variable. So, we give all of our families both options.

Melanie Cole, MS: That's great. So, you just briefly mentioned another association that are involved in this initiative and program. Expand on that just a little bit. How did that come about?

Elizabeth Gunkle: We were really trying to make sure that our patient's had access to this valuable information for screening. And so, we wanted to see what sort of partnerships we could develop for research opportunities. And Barbara Davis, their ASK program is really amazing because they actually offer type 1 diabetes screening for the general population, which is not overly common.

Many of the other programs are focused only on people who have a family history of type 1 diabetes, whereas Barbara Davis says, "You know, we know family history is a risk factor. But in reality, almost 90% of patient's who developed type 1 had no family history." And so, they're trying to develop more and more support to say like, "This is really something that we should be offering to the general population."

Melanie Cole, MS: That's excellent. And tell us, Elizabeth, about exciting advancements in diabetes prevention about a medication called TZIELD, which can actually delay the onset of type 1 diabetes. Really?

Elizabeth Gunkle: Honestly, it's a really, really amazing advancement. And, you know, I tell my families there's never a good time to develop type 1 diabetes. But in terms of the rate of research and new trials and new technology, this is a pretty exciting time to be within the field of diabetes. I do think before, really explaining how teplizumab or TZIELD works, I do want to briefly explain what we now know about the different stages of type 1 diabetes, because that is really where TZIELD targets its intervention.

So, we used to think life before diabetes and then life with diabetes. But now, we realize that there's this process of how type 1 diabetes develops. So, we know that someone starts off with some sort of risk factor. There's then some sort of environmental trigger. This might be a virus or other things within the environment, but it kickstarts that immune activation. And so, immune activation is what ultimately leads to those antibodies developing.

And then, over time, those antibodies that gradually are breaking down more and more cells in the pancreas that produce insulin. And once we get to a critical level, which is usually like 80% of our cells that are gone, we typically then have those symptoms. And that's when we were previously being diagnosed with type 1 diabetes. So once someone has two antibodies, they technically have type 1 diabetes, and then depending on where the blood sugars are and how someone is feeling, that determines what stage of type 1 diabetes they're in.

So, there are three stages, all of which to qualify for. You initially have to have, again, those two positive antibodies or more. Stage one means someone is feeling great and blood sugars are totally normal. Stage two, which is what we're going to focus on with  teplizumab, is once the blood sugars are starting to become a little bit abnormal, right? We have some of those warning signs, but the person's still feeling well. So, it's not something that would otherwise necessarily have been picked up without screening. And then, stage three is really what we used to think about, historically, like what classical type 1 diabetes is when someone is very sick. They often are in the hospital and they need insulin.

So, the way that  teplizumab or TZIELD works is it focuses on that middle stage, so stage two, the body's starting to have a hard time keeping up with those blood sugars. And this medication is a monoclonal antibody. What that means is that it's working with the cells in the immune system, trying to protect those cells in the pancreas and trying to reduce inflammation. The medication is not a cure, but it is a delay. And so, the goal, and sort of what the research shows, is that it can delay the onset of needing insulin by about two to three years on average.

Melanie Cole, MS: Wow. Like you said, it's a very exciting time in your field. That's really cool. So, who can benefit from this program? You know, and patient selection is certainly going to be an issue. Tell us about who can join, who can benefit, and what you're doing.

Elizabeth Gunkle: Really anyone who's interested is more than welcome to schedule a visit with us. And we can meet with them, explain what services we offer. We have been generally targeting most of our interventions for screening with people with type 1 diabetes, family history, or any autoimmune history. The reason being is because we know that people who do have autoimmune conditions or type 1 diabetes in the family, they're about 15 times more likely to develop type 1 than the general population. However, if anyone is interested, we're happy to see them. We're happy to do the screening. If the screening shows no antibodies, then we give recommendations on when we might want to repeat it. But if those antibodies are positive, then you're in a great place. We have a wonderful team that can explain to you what the next steps are and whether we qualify for any of these medications or trials.

Melanie Cole, MS: Well, you just got right to my next question. Tell us about your team, Elizabeth. What type of multidisciplinary group is really involved in the program? Because, while you're telling us that, I'd like you to speak about the support that's available for individuals at risk because that really goes together with the team approach and that multidisciplinary approach for those with pre-diabetes, gestational type 1 or type 2. Kind of put that all together for us with this multidisciplinary team, how many people, who's involved.

Elizabeth Gunkle: We have a fantastic team. We all work so, so closely together. We are a relatively smaller group compared to a lot of the other teams within New York. But I say we're the mom and pop shop, one of the few mom and pop shops in Manhattan. We know all of our patient's really, really well. All of our team is very close. So, we have three main diabetes attendings. We have two nurse practitioners, including myself, which we're both diabetes educators as well. We have three fellows. We have a registered dietician who's also a diabetes educator. We have a social worker, a psychologist. We have two amazing nurses. So, we really have excellent multidisciplinary support for our patient.

Melanie Cole, MS: Wow. You sure do. Tell us a little bit about some of that support when you're working with these patient's. And I have to say, Elizabeth, that when you're working with patients, especially our younger kiddos that are growing up to learn how to manage their diabetes, which is definitely not easy. And then, they're transitioning even to adult care and maybe they've got a glucose monitor and maybe they've got, you know, all of this technology going on. How do you work with the families, because it really has to be a family initiative, doesn't it?

Elizabeth Gunkle: Oh, absolutely. Here at Cornell, we are so individualized with our approach to each of our patients. So, we really do try to understand, where someone's at, what other support do they need with any social services, any psychological services, but also for their management. We are of the mindset of like, "Why not try something?" Right? It's not one-size-fits-all. If our standard bread and butter approach isn't working, what else can we try? And so, we really pride ourselves in being very individualized in our approach for management of this condition, because it's 24/7, right, 365 days a week. These kids and these families don't have a break from diabetes. And so, whatever we can do to support them, we give them our hundred percent.

Melanie Cole, MS: I am sure you do. I can hear that in your voice. Wrap it up for us with your best advice for families and patient's living with diabetes type 1 and the amazing program at Weill Cornell Medicine.

Elizabeth Gunkle: Just know that you have a huge T1D community. There are so many different community resources as well. But if you're interested in setting up care with us, we are more than happy to screen for any family members for type 1 diabetes. And we do also try to do some community events with our patient's with our type 1 diabetes, elementary school camp that we do every summer. We try to do some teens events as well. But just really make sure that you lean on your community and also your healthcare team.

Melanie Cole, MS: Great information, Elizabeth. Thank you so much for joining us today and sharing your program and your expertise. That was great information. And Weill Cornell Medicine continues to see our patient's in-person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcast, Spotify, iHeart, and Pandora. For more health tips, go to weillcornell.org and search podcasts. And don't forget to check out Back to Health. We have so many great podcasts there as well. I'm Melanie Cole. Thanks so much for joining us today.

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