Simon Floss (Host): Hello and welcome to Innovations, a cutting edge podcast series brought to you by the experts at Sanford Health. You’re listening to our 15th episode, “A Pledge to End Type 1 Diabetes.” I’m your host Simon Floss with Sanford Health News. Today, we’re learning what Sanford Health is doing to prevent type one diabetes from Dr. Kurt Griffin, a pediatrics endocrinology specialist and Dr. Mike Wilde, vice president medical officer for Sanford Health in Sioux Falls. Thanks for joining us today, gentlemen.
Dr. Kurt Griffin: Thank you for having us.
Dr. Mike Wilde: Thanks, Simon.
Host: Let’s start things off with both of your backgrounds in this field. How long have both of you been studying and working with type one diabetes? Dr. Griffin, we’ll start with you.
Dr. Griffin: All right. So, I have been board certified in pediatric endocrinology for coming up on 20 years here. So that’s the specialty that winds up providing a lot of the specialty care for the kids with type one.
Host: And, Dr. Wilde?
Dr. Wilde: So, I’ve practiced as a general internist, so mainly dealing with patients from the adult side. But as we’ll find out, I’m sure later in the podcast here also a personal suffer of the illness and have family members as well. So, certainly have some quite a bit of interest in the disease and finding better treatment and a cure.
Host: Well, as you mentioned, we get a lot of topics to get to here today. We’ll start with children type one diabetes in children. What percentage of the population is diagnosed with this disease?
Dr. Griffin: So, a good ballpark number for the kids is about half a percent or one in 200. One of the things that we’re finding out now is there actually a lot of people who wind up getting type one diabetes later in life as adults. I think a lot of times they’re overlooked because we all know type one diabetes is a pediatric disease. And if we don’t think about that, that can be missed. But, as we’re starting to look at it more carefully, we’re finding them actually people who are diagnosed well into adulthood.
Host: And Dr. Griffin, what challenges do families with type one diabetes face?
Dr. Griffin: You know, I have to admit I’m fortunate enough not to be living with myself. But, I definitely work very closely with a lot of the families who are living with it. One of the biggest challenges is when we’re treating with insulin, we try to do the best we can to mimic what the body should be making on its own, but it can’t anymore. And this means that you need constant vigilance. Every time somebody is going to eat multiple times per day, we need to know what the blood sugar is, what the carbohydrate intake is going to be, and then figure out how do we try to balance that with the right amount of insulin and the unfortunately, number one, we’re never going to be as good as somebody own pancreas should have been. And number two, it means, you can never take a break. And if you think about somebody who may be taking blood pressure medicine, if you decide to skip that for a week or something gets away, you can’t take it for a week, that’s probably not a good idea, but it’s also probably not going to be really that severe that day. Whereas being off a little bit on the insulin actually is a big problem.
Host: Dr. Wilde, many families are impacted by type one diabetes. You mentioned that yours is included in that in that list. Can you just talk about a little bit of your journey?
Dr. Wilde: Sure, and I like Dr. Griffin and what he was talking about in terms of the impact on the day-to-day life. I was diagnosed 38 years ago. Growing up in a small town in Northeast, South Dakota which by South Dakota standards, I guess is relatively sizable, but certainly the access to care, and we had connections in Minneapolis. So I received a lot of my initial care in Minneapolis and then transitioned as Watertown had some more physicians come in, transitioned my care there. My father was also type one, so certainly learned the history with his journey as well. Just have seen a lot of technological advances through the years. Unfortunately I have a daughter who’s diagnosed with type one at about the same age as I was, and had wonderful care in the Children’s Castle and with a pediatric center chronology team and just seeing her journey and, you know, my journey and how we kinda are different, but the same and the same pathology is, has been kind of interesting to follow, and I wish I didn’t have to go through it.
Host: You know, in Sanford’s footprint. We do have a lot of rural towns, rural cities, how does type one diabetes look in those smaller towns, which may be different than other parts of the country.
Dr. Wilde: Having lived in a small town and practicing as an internist and working with folks from smaller towns, it’s really that, like Dr. Griffin pointed out, you don’t get time off from diabetes. There’s at least at minimum every six month appointments, if not three month appointments. You have to be vigilant, kind of have to be a planner with the prescriptions that you take, like test strips and insulin and devices now with insulin pumps and sensors and things like that. And it’s really working with the logistics of a small town pharmacy to get those things. It’s the travel to and from healthcare providers. What if there’s a blizzard and they can’t get insulin into the pharmacy? Things like that you have to think about, that I would imagine in your more urban areas where things are more readily available, you really have to kind of be a planner in regard to things that could happen.
Dr. Griffin: I would add that as we’re moving on in time, one of the big advances, or many of the big advances are really with the technology. We now have the ability to be able to collect information from a continuous glucose monitor from an insulin pump. We actually showed during the early days of the COVID pandemic here, we could do some of this actually remotely by video. One of the challenges is even as you get away from the larger small towns and we get out into the really rural areas, there’s not enough internet service to cover that. So, that actually is a significant barrier. We have other families that don’t have a computer. They wind up getting a pump and a sensor, and they’re able to use the devices that come with it, but they don’t have a computer that actually download that.
Host: That presents a lot of challenges.
Dr. Griffin: It’s full of challenges. As we’ve been talking about, it’s ever present. My goal is for my patients to have as normal life as possible, given that they have to take care of all these things. So, I don’t want it to be the only thing they think about, but they don’t get a break. That’s part of what really drives me to try to find something different.
Dr. Griffin: So, insulin is lifesaving. We can manage things sometimes better than others, but it doesn’t take care of the underlying disease process, which is at its heart is an auto-immune attack on the cells making insulin. The insulin just replaces what we’re not able to make. So, that’s been the focus of my research career for the last decade and a half is how do we find a way to rebalance the immune system or somebody eventually, how do we find a way to prevent somebody from getting type one in the first place?
Host: In the terms of finding something different, let’s move to the PLEDGE study itself now. What exactly is that?
Dr. Griffin: So, the pledge study is Sanford’s effort to increase screening for people who may be on the road to type one diabetes. And this is something that diabetes TrialNet, which is an international consortium, a lot of NIH funding has gone into that, they’ve been looking at family members of people who already have the disease because they’re at higher risk. But, the mathematics of this workout so that more than 90% of the people who are going to get type one diabetes don’t already have in the family. We’re not even looking at all those people. Diabetes TrialNet has also been able to take some of those people that are on that road to diabetes, and we now have the first study that is shown, at least in a smaller group, they can slow that down. One treatment upfront was slowed down by an average of two years, how long it took somebody to actually get full on diabetes. So, that’s the first time we’re showing we can get some traction here, if we can get in earlier.
Dr. Griffin: As I said, the problem with that is ignoring 90 plus percent of the people who might need that. So how do we find them? And the short answer is we start screening for antibodies. We look at a little bit of blood it can be done off of a finger stick. Right now we’re looking kind at ages about two and about five. So, when kids are coming in for WellCare anyway, and see who may have antibodies against pancreatic proteins, that says, ‘Hey, they’re at risk for progressing to diabetes.’ One thing that’s really innovative about this is how we’re approaching. We’re trying to bake this into routine clinical care for the children. And there’ve been a couple of other places where they’ve tried doing some general population screening, but clinical research, usually you wind up, you have a clinical research coordinator who winds up sitting in the waiting room, and as people are in the emergency department or coming into a clinic, they get approached and ‘do you want to participate?’
And, it’s fairly labor intensive. What really helped us to get this going was being able to present some of the unique resources and commitment of Sanford to the Helmsley charitable trust, because they’ve been funding some of these other small things, and they’ve been frustrated that, ‘boy, you just can’t enroll that many people, you can’t test that many people.’ By baking it into our routine care and make it as easy as possible for people to sign up, make it as easy as possible for the providers, for the staff on down the line, through the lab. Our goal is to screen as many people as we can. That’s what leveraging Sanford’s infrastructure has let us to. And, that’s what lead to just for the first two years, well over a million dollars in support from the Helmsley charitable trust.
Host: And Dr. Wilde, what type of information is being collected? I understand that the study also collects information for type one diabetes, as well as celiac disease. What’s that connection?
Dr. Wilde: Both of those diseases have auto-immunity, which means your essentially your immune system attacks something that shouldn’t, and in the setting of type one diabetes, as Dr. Griffin alluded to it’s it’s pancreatic proteins. It’s the cells that produce insulin. In celiac disease, it’s the cells that have helped break down certain things that we eat. A lot of times, auto-immunity does not occur in an isolated organ. It can occur in other organs. Type one diabetes can go celiac disease, which is essentially a gluten intolerance. There are cases. It’s more common to have celiac disease in the setting of type one diabetes.
Host: What is so innovative about this study?
Dr. Wilde: I think Dr. Griffin alluded to that there’s been a lot of progress made because as you look at prevention of type one diabetes, it’s another step. It’s another arrow in the quiver of finally defeating this disease. At the same time, research is challenging. People have to take it upon themselves to participate, to talk to a coordinator, to check in every so often, things like that. There’s been good progress made. I look at the diabetes walks and things like that, or the screenings has become much easier and there’s good learning from that. This process, again, trying to make it more patient centered so that the information can be gathered. It’s part of the wellness visit that nearly every child goes through, should go through and hopefully make it as easy, as patient centered as possible, so that research isn’t burdensome. People should be excited about research. They can help progress us, especially within Sanford. We have so many employees, and I know there’s type one diabetics out there, there’s people without other auto-immune conditions, and certainly would ask them to consider participation as appropriate, because it’s Sanford working for Sanford to try to do a great thing,
Host: Dr. Griffin, can you explain how the study is potentially able to impact so many children?
Dr. Griffin: For me, that’s one of the really humbling aspects of this project. It’s not just so that we can screen 3000 kids in the first year, or another 30,000, the two years after that is our plan. There’s a lot on the back end of this that’s not readily visible for most of the people participating. That’s the frankly economic analysis. How do we look at what are the costs of doing this, which we can measure, because we’re doing it in the setting of our health system, but also what are the cost savings? What does this prevent in hospitalizations rated ketoacidosis at diagnosis and the worst control of blood sugar that you have if you’re present in DK? We have actually engaged with our health plan and the hospital system, so that we can measure a lot of these things and really try to make a real assessment as to, ‘how can we make this actually cost effective?’
We have some people on our population, health area of the research group that are there, and they have very sophisticated models for this that we can actually adjust and say, ‘okay, if we move this slider, how far does it have to go before this now pays for itself?’ And, so beyond my near to medium term goal of, I want to offer this to every kid in our system, in our, in the Sanford footprint, more importantly, this has the potential of if we can show it’s cost effective, this becomes standard of care, and part of the routine screening that kids go through. Especially because we’re just now getting the point where we’re starting to get some traction for what can we do to actually intervene, not just to have somebody know that they’re on the path. At a minimum, the monitoring that we’ll be doing for anybody that’s on that path, we can, we should at least be able to prevent people coming in quite so sick and start appropriate treatment much earlier than the usual presentation, which is nobody knows they have diabetes until they come in and wind up in an intensive care unit.
Host: Dr. Wilde, why is Sanford making an investment in type one diabetes and pledge? And, why are you so passionate about getting the word out?
Dr. Wilde: We’ve committed to curing type one diabetes. It’s a great task, it’s a great cause. It it obviously takes time. It takes great minds. As I alluded to earlier, this is part of the progress toward that cure. I think one of the more attractive things that we’ve learned through research in what’s called immunology and things like that, is really how auto-immunity leads to type one diabetes and what can be done to prevent that. It initially starts with a delay in a diagnosis, or like Dr. Griffin was alluding to. So, you kind of have a heads up, because otherwise you diagnose type one diabetes and you’re kind of fine, and then you’re really not. Your life really changes in not a lot of time. All of a sudden, and I kind of likened to when my daughter was diagnosed, to literally bringing home a child from the, from the hospital after birth. You went in one way and you came out another way, and that’s the way it was with type one diabetes.
All of a sudden, ‘Hey, what’s her blood sugar? What are we going to do about insulin? When’s the last time she tested, she’s going to go out and play. She got tests,’ things like that. So, when you look at a study like this and delaying the time to diagnosis, or, or eventually leading to prevention of diagnosis, that’s a tremendous opportunity. I think Dr. Griffin’s research, and like I alluded to earlier with the ease of this process, makes it a very attractive study that I think we have a lot of people that can willingly participate in this. And, frankly give us a lot of answers and make progress toward that ultimate goal.
Host: Dr. Griffin, what do you envision the future of type one diabetes looking like? I wish my crystal ball worked that well,
Dr. Griffin: I wish my crystal ball worked that well. I would start with how much it has changed just in the time that I’ve been in practice with the types of insulin we have, the technology we have. The technology is advancing by leaps and bounds to where it’s beginning to not be automated, but start to have some automation light. So if you think about, you can’t really fall asleep while you’re driving your Tesla on autopilot, but you can almost do something.
Host: I saw a video of that by the way, and that is absolutely terrifying.
Dr. Griffin: Not recommended, no.
Dr. Wilde: (Laughs)
Dr. Griffin: That’s a way that we’re going to make progress faster and faster and particular for all the people who already have type one diabetes, that’s going to have the biggest impact for them. In the longer term, yes, how do we find ways to rebalance the immune system for people that maybe are diagnosed fairly recently or on their way there? It’s one of those things where the earlier you go in the younger you go, the more gentle you have to be in terms of safety and ethical balances. We know that the way we look at how type one starts, it probably starts with just reacting to one particular protein. And, we have some studies that are in the pipeline where for that one particular protein, or two particular proteins that are most common to trigger, how do we take out all the cells that make antibodies against just those two proteins and leave all the other ones alone?
And there’s actually a wave where we think we can do that, and we’ll be, we’ll be trying that. That’s the sort of thing that you can, you know, if it’s a safe, as we all hope and expect that kind of approach to be that antigen specific specific therapy, that’s just one thing you could see giving to just a little tiny infant, who’s just starting to react, and nip it in the bud. As opposed to waiting until they’re much further on the immune system is really revved up, you’re reacting to many, many different proteins. That’s a much harder situation to try to fix at that point.
Host: Now, both of you can answer this last question. How can Sanford employees and community members participate in PLEDGE?
Dr. Griffin: I’m glad you asked. So especially starting with the community members, talk to your Sanford primary care provider. Our goal is to try to get this spread as widely and as far across our footprint as we can. There is also a website that’s under Sanford research, but if you use Google, you should be able to find that. Then, for the providers, as we’re rolling out to each clinic, we’re trying to provide enough information and trying again, to make this as easy as possible. For families, what we’re doing right now is children who are eligible, who are coming into a clinic that has this up and going, we’re actually setting up if we know they have an appointment coming, we send them a message through My Chart. That’s another thing that’s really innovative about this. As I said, we don’t have a coordinator sitting in the office recruiting. We can send us a message through My Chart and they can actually go through the consent process through My Chart. And then when they come in, they’re already essentially enrolled, the order’s already in place, and at the end of their visit, they stop by the lab, which they may well need to stop there anyway, and we can just grab a little bit extra blood while they’re actually being drawn, or they’re just, you know, get their blood drawn, and off they go.
Host: Dr. Wilde, anything else you’d like to add?
Dr. Wilde: There’s a lot of camaraderie at Sanford, a lot of folks working together and good friends out there. There’s a lot of people that are parents of younger children, I think Dr. Griffin lays out a great process that with just a little bit of effort you can participate in a very important project. Tell your friends, talk about it at work. Talk about the fact that it’s easy to do. It’s a great thing to do. It’s participating in very exciting research and that’s some of the best marketing we can do is just within our own employees and then talking amongst their friends and things like that. We’re all connected with various media outlets and social media, especially, and just really get that message out that it’s okay to do this. It doesn’t take necessarily an extra blood draw like Dr. Griffin alluded to, there’s probably going to be a blood draw at the appointment anyway, and a little extra sample is taken and it’s for, it could be frankly, for the betterment of that child, or it’s going to be for the betterment of children going forward.
Host: Dr. Wilde and Dr. Griffin, thank you both so much for your time today and sharing this innovative and incredible study that we’re doing.
Dr. Wilde: Thanks, Simon.
Dr. Griffin: Thank you.
Host: Before we wrap up a reminder that Sanford Health Innovations Podcast is now available on your favorite podcast apps, like Apple and Spotify, as well as our website, Sanford Health News. If you enjoyed this conversation, follow us, give us a thumbs up and share your comments. We love hearing from you and hope you find these conversations insightful.
Thanks for listening. I’m Simon Floss with Sanford Health News.