New UK Prime Minister Brings Spotlight to Type 1 Diabetes

Miriam E Tucker

July 13, 2016

Today Theresa May becomes the second woman to serve as prime minister of the United Kingdom, but she'll be the first major world leader living with type 1 diabetes.

Mrs May, 59, replaces David Cameron and will face what is likely to be an intense, drawn-out process negotiating the United Kingdom's exit from the European Union (aka "Brexit") as the country voted to do on June 23 (or work out some alternative, although she has vowed to proceed, stressing that "Brexit means Brexit"). And all the while she'll also have to manage her type 1 diabetes, which she was diagnosed with just 4 years ago while she was the United Kingdom's home secretary.

In July 2013, a few months after her diagnosis, she spoke publicly about the challenge and how she was meeting it. She told the UK Daily Mail : "It was a real shock and, yes, it took me a while to come to terms with it," but "the diabetes doesn't affect how I do the job or what I do. It's just part of it's a case of head down and getting on with it."

She was 56 years old at the time and had been losing weight, feeling tired, and drinking a lot of fluids but attributed those to job stress and a fitness program she had recently begun. She was initially misdiagnosed with type 2 diabetes — a common occurrence in those who develop autoimmune diabetes in adulthood — and finally diagnosed with type 1 in November 2012.

Following her diagnosis, Mrs May attended several events sponsored by the JDRF (formerly the Juvenile Diabetes Research Foundation) in the United Kingdom, including a ball in 2015 that raised £620,000 to support the organization, according to the group's website.

Theresa May [Source: Matt Dunham/AP]

Whether she'll continue that advocacy as prime minister and how she'll manage her own condition going forward remain to be seen. Most news reports have said that she takes four insulin injections a day, and there has been no mention of her using an insulin pump or a continuous glucose monitor (CGM).

Two endocrinologists who specialize in type 1 diabetes, Simon Heller, MD, professor of clinical diabetes at the University of Sheffield, United Kingdom, and Irl B Hirsch, MD, professor of medicine at the University of Washington, Seattle, offered Medscape Medical News their thoughts about how Mrs May's type 1 diabetes might affect her role as prime minister, what advice they would give her, and the significance of having someone with type 1 diabetes in such a prominent position.

Both also noted that Mrs May's story provides an important message to clinicians to consider the diagnosis of autoimmune diabetes — type 1 or the slower-onset latent autoimmune diabetes of adulthood (LADA) — in adults whose clinical pictures don't quite fit those of classic type 2.

Yes, She Can

Dr Heller, who was interviewed by British news media at the time Mrs May revealed her diagnosis, told Medscape Medical News: "I tried to convey the fact that I felt she'd be totally capable and that it wouldn't present any barrier to her. I continue to feel that."

But, he added, "it is intriguing to speculate how closely she'll keep her blood glucose levels close to normal.…The challenge of keeping tight blood glucose control without becoming hypoglycemic is true for everyone [with type 1 diabetes] doing a job, but for her hypoglycemia would be a disaster.…Hopefully she has good practitioners."

Dr Hirsch noted that many famous people in the past have done well with type 1 diabetes, including the US actress Mary Tyler Moore and the major league baseball player Ron Santo. Today, there are many more examples, including US Supreme Court justice Sonia Sotomayor, Olympic gold-medal swimmer Gary Hall Jr, and pop singer Nick Jonas.

"You can look at all the famous people with type 1 diabetes who did fine. I don't think this will impair her job at all," he said.

Indeed, in the Daily Mail interview Mrs May herself named five-time British Olympic gold-medal rower Steve Redgrave as her inspiration. "He said, 'Diabetes must learn to live with me rather than me live with diabetes.' That's the attitude," she noted at the time.

"If I Were Her Doctor…"

Dr Hirsch said that if Mrs May were his patient, he would strongly urge her first to get a CGM, in order to minimize the risk of hypoglycemia. And he would also encourage her to use the "share" function to allow a family member or someone else to have access to her glucose readings. Third, he would encourage her to wear an insulin pump so that she'll be ready when the hybrid closed-loop systems (aka artificial pancreases) become available in the next year or two.

"Controlling this large empire is a very important role, but taking care of your own health should also have a very high priority," Dr Hirsch observed.

Adoption of diabetes technology has been slower in the United Kingdom than in the United States and other European countries, although it is starting to catch up.

The UK's National Health Service (NHS) will allow insulin pumps for patients with type 1 diabetes who meet certain criteria — with either frequent disabling hypoglycemia or persistent hyperglycemia despite best efforts to achieve good control — and just recently the Medtronic Veo pump/CGM system was sanctioned for use in those with hypoglycemic unawareness.

The problem with CGM, Dr Heller pointed out, is "we still haven't worked out how to help patients use the data."

Regarding Mrs May, he said, "I think technology might be useful, but she would have to have the time.…You could see how the easiest thing would be to run a bit high so you don't have to worry as much. I hope that hasn't happened, but I don't know."

While many high-level government officials use private healthcare rather than the NHS, Dr Heller noted that type 1 diabetes patients actually often do better in the NHS because that's where expert multidisciplinary teams are more often available.

"Whoever looks after her must have a real dilemma in deciding whether she has got the time to self-manage. I can't imagine her going on a skills training course with a bunch of other people."

Should She Advocate?

Dr Hirsch expressed hope that Mrs May would elevate diabetes to a global health priority: "We can only hope that she'll make this a greater priority than any of us have seen in the past with any government."

But Dr Heller thinks she might do well to refrain from discussing her condition publicly as much as possible, for political reasons. "I think it would be unwise for her to give any ammunition to people. Politics is a tough business and people are always looking for your weakness. If she were to make a big deal of it, I think it could be used against her."

Rather, he said, she could be a role model simply by making her diabetes a nonissue. "I don't think we should put extra pressure on her to be a superadvocate for diabetes. Just showing she can do the job would be fantastic.…Automatically, people will be encouraged that if you can be the prime minister of the UK, then there are very few jobs you can't do with type 1 diabetes."

Type 1 Diabetes Not Just for "Juveniles"

At the time Mrs May was diagnosed, much was said about how unusual her age was at diagnosis of type 1 diabetes. But actually, half of all people with autoimmune diabetes are diagnosed after age 18 years, and initial appearance in people in their 40s, 50s, and even older is not as rare as many medical textbooks claim.

Dr Hirsch says his oldest new-onset type 1 diabetes patient was 92, and Dr Heller recently saw a new-onset type 1 patient in her late 50s with ketoacidosis.

Unfortunately, like Mrs May, many adults with new-onset autoimmune diabetes are initially misdiagnosed with type 2 diabetes by primary-care clinicians, who simply write a metformin prescription when they see high blood sugar without appreciating other clues such as excessive weight loss without trying, extreme thirst, frequent urination, and a family history of not only type 1 diabetes but other autoimmune conditions including celiac and thyroid disease — both Graves' and Hashimoto's — and vitiligo.

For such patients — or those who aren't heavy to begin with, although obesity doesn't rule out type 1 — ordering an anti–glutamic acid decarboxylase (GAD) or multiantibody panel will help in making the correct diagnosis, both experts said.

But C-peptide levels are not a good indicator to distinguish between the diabetes types, Dr Hirsch said, noting that data from his team suggest that people with older-onset type 1 may have more residual C-peptide function, which may confound their diagnosis but also make them less vulnerable to hypoglycemia.

"When diagnosed with type 1 later in life, patients may continue to make a little endogenous insulin and that makes diabetes easier to control — they don't have giant swings or a big risk of low blood glucose levels."

"There's a very good chance that the current prime minister of the UK is still making a little bit of her own insulin," he observed.

And she's part of a positive trend, Dr Hirsch noted. "This new prime minister will be like many people with type 1 diabetes in the next 20 or 30 years.…Our new challenge will be taking care of type 1 diabetes in a more geriatric population. It's not a topic we know much about because this population didn't exist previously. That's not her situation now, but if she takes care of herself, she'll be there."

Before then, Dr Heller said, "She has a huge job on her hands.…I wish her well."

Dr Heller is a speaker for Sanofi, Eli Lilly, and Novo Nordisk and is on advisory boards for Lilly and Novo Nordisk. Dr Hirsch has done research with Novo Nordisk and consulted for Abbott, Intarcia, and Roche.

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