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Endocrinology

Could GLP-1 Break the Insulin-Obesity Cycle in Type 1 Diabetes?

Children’s endocrinologists are taking a closer look at how GLP-1 can help T1D patients. (Stock photo)

By Charles Buchanan

Over the course of a century, insulin has become the foundation of diabetes treatment, saving countless lives and transforming the fatal disease into a manageable chronic condition. Yet a majority of people with type 1 diabetes (T1D)—80%, according to Giovanna Beauchamp, M.D., a pediatric endocrinologist at Children’s of Alabama and the University of Alabama at Birmingham—still struggles to achieve optimal glycemic control with insulin alone.

GLP-1 receptor agonists, a therapy originally developed for type 2 diabetes (T2D) that has become a popular weight-loss aid, could provide a solution. In the past few years, a growing number of pediatricians and endocrinologists have prescribed GLP-1 along with insulin for T1D and reported promising outcomes. Beauchamp and Ortal Resnick, M.D., a pediatric endocrinology fellow at Children’s, recently published a review of clinical research that details GLP-1’s impact and offers hope that more patients may be able to take charge of their disease.

Weight Control for Diabetes Control

Maintaining a healthy weight and achieving good diabetes control are difficult even with technology such as insulin pumps, continuous glucose monitors, and automated insulin delivery systems—because the challenge is insulin itself, Beauchamp said. The anabolic hormone causes people with T1D to gain weight, setting off an escalating cycle of complications.

In fact, about 60% of people with T1D are considered overweight or obese, Resnick said. “On average, a patient that starts on insulin treatment gains five kilograms in the first five years of treatment. So we know the treatment by itself causes weight gain.”

Resnick
Beauchamp

Overweight and obesity also are increasingly common in people with T1D at the time of diagnosis, which shows that the traditional stereotype of T1D as a disease affecting only lean individuals is not entirely accurate, Resnick explained. Obesity, associated with increased inflammation in the body, may contribute to triggering or accelerating autoimmune processes in people who are genetically predisposed to developing T1D.

That additional weight also increases insulin resistance, which means that patients need more insulin, which leads to more weight gain—and then the loop begins again. Round after round, the stakes get higher, eventually spiraling into obesity that sparks inflammation and further destruction of beta cells. Severe diabetes, threatening damage to the heart, kidneys, eyes, and other organs and tissues throughout the body, can set in early.

GLP-1 therapy provides an off-ramp from the worsening cycle. Formally known as glucagon-like peptide-1 receptor agonists, the medications are based on the body’s natural GLP-1 hormone, which affects insulin secretion and helps us to feel full after we eat. Prescribing them as a therapy efficiently ramps up both processes, as seen in patients with T2D who have benefited from GLP-1’s improved glycemic control and weight loss over the past two decades. In T1D, just as in T2D, GLP-1 curbs the appetite and makes insulin more effective. Eating less leads to weight loss and reduced doses of insulin.

Research Review

For their research review, Beauchamp and Resnick analyzed results from about a dozen clinical trials of GLP-1 in patients with T1D. They compiled evidence about the medication’s effects on weight and HbA1c, an individual’s three-month average amount of blood sugar, among other measures.

Their findings revealed that adding GLP-1 led to consistent weight loss across all the trials, and most participants were able to lower their insulin doses. HbA1c improved around 0.3%, a small number that nevertheless has significant meaning for patients because it indicates better glycemic control, Resnick said. “The fact that they’re losing weight and their total daily insulin is decreased . . . is a big outcome that we think will affect their long-term complications.”

Beauchamp agreed. “The best way that we are going to see improvement in those potential complications is by improving glycemic control and with weight management. By helping with weight loss and consequently decreasing the amount of insulin that our patients will need, the rate of diabetes-related complications should decrease.”

Maintaining Glucose Balance

Naturally, physicians may be wary of reducing insulin because of the chance it could disrupt patients’ glucose balance and push them into hyperglycemia—high blood sugar. Beauchamp and Resnick investigated that potential outcome and found that, in the studies they reviewed, adding GLP-1 and decreasing insulin resulted in fewer instances overall of hyperglycemia and diabetic ketoacidosis, a severe insulin deficiency requiring intensive care. As for hypoglycemia—low blood sugar—the risk exists, but endocrinologists can carefully monitor and manage the balance between the two medications in response to each patient’s weight loss and decreased insulin need, Resnick said. Patients should continue to eat enough for healthy nutrition, and following a balanced diet is essential. Otherwise, “very easily, you can become malnourished if you decrease your appetite and eat only nonnutritional food,” she said.

The most common side effects of GLP-1 that Beauchamp and Resnick identified in their review were nausea and vomiting, the result of the medication slowing the process of gastric emptying. People who experience this are often used to eating big meal portions, Resnick said. Consuming smaller portions and decreasing the meals’ fat content helps reduce nausea and vomiting, as does increasing the dose of GLP-1 at a slower, more gradual pace, she added.

A Treatment for Life?

Another key question on the minds of many physicians: What are the health implications of taking GLP-1 long term? Beauchamp noted that GLP-1 likely would be a lifelong treatment, alongside insulin, because of its benefits in helping patients with T1D control obesity and reduce their risk for related complications. However, she emphasized that researchers currently don’t have enough data to say for sure.

“We need more time, and we need more research,” Beauchamp said. That actually was one of the crucial takeaways from their review of previous work—that more studies are needed. So far, only a few trials have focused on GLP-1 specifically for T1D, and most used an older version that was administered daily, now superseded by a stronger weekly formulation. And no existing study has followed patients early enough in the course of their disease to observe whether the medication can preserve some beta-cell function.

Still, “we have been using GLP-1 for T2D for about 20 years now [and] from what we know . . . it’s pretty safe,” Resnick said. Patients also don’t receive the same amount of GLP-1 forever, she added. Once the initial dose helps them lose weight, patients are prescribed smaller doses to help them maintain their target weight.

Beauchamp hopes that more pediatricians and endocrinologists will become comfortable using GLP-1 for T1D. Personalizing the therapy for each patient is the key to navigating potential challenges, she said. “Those of us who have used it for patients with T1D and obesity, we see wonderful benefits. I think they are all very pleased with those results, which then lead to better diabetes control, [an] overall better outlook in life, and being able to live a healthy and happy life.”

To learn more about the research Beauchamp and Resnick are doing on GLP-1, check out this episode of the Children’s of Alabama PedsCast.

July 30, 2026 by
Endocrinology

Helping Teens with Diabetes Move to Adult Care

Christy Foster, M.D., leads a new clinic that helps prepare adolescents for the transition to adult care.

By Rachel Arterberry

For adolescents with diabetes, moving from pediatric to adult healthcare can be one of the most vulnerable periods in disease management. Studies have shown that gaps in care often occur during this transition, increasing the risk for complications such as worsening glycemic control and diabetic ketoacidosis.

To address this challenge, Children’s of Alabama recently launched the Bridge Clinic, a dedicated program designed to help adolescents and young adults with type 1 and type 2 diabetes gain the skills and confidence needed to successfully navigate healthcare independently.

The clinic, which officially began seeing patients this spring, provides a structured, multidisciplinary approach to transition planning for patients beginning at age 16 and continuing through their move to adult endocrinology providers.

“We really want to help patients build confidence over a couple of years before they leave pediatric care,” Christy Foster, M.D., assistant professor in the Division of Pediatric Endocrinology and physician in the Bridge Clinic, said. “Our goal is to partner with them so that transitioning into adult healthcare doesn’t feel abrupt or overwhelming.”

The idea for the clinic grew out of a healthcare transition workgroup that has spent several years refining educational tools and identifying ways to improve continuity of care for adolescents with diabetes. Although transition topics are already incorporated into routine endocrinology visits, Foster says the Bridge Clinic offers an opportunity to explore those issues more intentionally and in greater depth.

Patients in the Bridge Clinic continue seeing their primary endocrinologist every three months, while alternating visits with the clinic approximately every six months. During those visits, they work with a multidisciplinary team that includes physicians, diabetes educators, dietitians, and social workers.

One of the clinic’s distinguishing features is its encouragement of adolescents to take a more active role in their own healthcare. Patients are asked to spend at least part of their visits independently with providers, allowing them to practice discussing concerns, asking questions, and making decisions about their diabetes management in a familiar and supportive environment.

“We’re trying to create a safe place where patients can gain skills for navigating the healthcare system while still having the security of their family being involved if needed,” Foster said.

For many patients diagnosed in early childhood, this may be the first time they are expected to discuss concerns directly with their provider, describe their medications, or discuss adjustments to insulin doses without relying on a parent.

The clinic also focuses heavily on practical life skills that become increasingly important as teenagers gain independence. Topics include learning how health insurance works, understanding prescription costs, requesting medication refills, navigating college life, driving safely with diabetes, and managing alcohol use.

Rather than simply providing information, the Bridge Clinic emphasizes hands-on learning.

Patients may be asked to complete “scavenger hunts” between visits to determine the out-of-pocket costs of medications, practice refilling prescriptions, or explore insurance options available through college, employment, or other coverage plans. The team then reviews those experiences during follow-up visits and helps troubleshoot any challenges.

Social workers collaborate closely with families to discuss changes that often accompany young adulthood, including moving into dormitories, entering the workforce, or transitioning to a different insurance plan. Dietitians address healthy habits and nutrition concerns that become more relevant as adolescents begin making more independent choices.

Another key objective of the clinic is to reduce the number of patients who lose care during the transition from pediatric to adult endocrinology.

“We know from the literature that this is a high-risk period for gaps in care,” Foster said. “Anything we can do to help prevent that gap and maintain continuity has the potential to make a meaningful difference.”

As patients approach adulthood, the Bridge Clinic team helps identify an adult endocrinologist, prepares a transition summary letter, and guides patients through establishing care with a new provider.

The clinic currently has the capacity to see approximately 30 patients per session and serves a population of more than 800 patients aged 16 and older with type 1 or type 2 diabetes.

Although the program is still in its early stages, Foster hopes it will become an important resource for families seeking additional support during a period that can feel daunting for both patients and parents.

“This is really about giving young people the opportunity to practice being successful adults with diabetes,” Foster said. “If we can help them gain knowledge, confidence, and independence before they leave pediatric care, we’ve given them a stronger foundation for lifelong health.”

July 28, 2026 by
Endocrinology

Ashraf co-edits textbook on pediatric diabetes

Ambika Ashraf, M.D. is the director of the Division of Pediatric Endocrinology and Diabetes at Children’s of Alabama and UAB.

By Amy Richardson

A new textbook, co-edited by Children’s of Alabama pediatric endocrinologist Ambika Ashraf, M.D., offers a comprehensive look at pediatric diabetes, highlighting the latest research findings and clinical guidance for managing diabetes in children and adolescents.

Written by international experts from leading diabetes care centers, “Pediatric Diabetes” covers major forms of the disease, including Type 1 diabetes (T1D), Type 2 diabetes (T2D), Wolfram syndrome and cystic fibrosis-related diabetes. It also provides up-to-date management strategies for evolving diabetes phenotypes and current clinical approaches to care.

Ashraf, who also serves as director of the UAB Division of Pediatric Endocrinology and Diabetes, says the book addresses a critical gap in clinical resources focused specifically on pediatric diabetes. “Most available information on pediatric and adolescent diabetes has historically been limited to chapters within larger pediatric endocrinology books, without the space to cover specific topics in depth,” she said. “That’s what makes this book valuable. It fills a genuine gap in the literature.”

Ashraf co-edited the 15-chapter volume with Benjamin Udoka Nwosu, M.D., professor of Pediatrics and Endocrinology at the Zucker School of Medicine at Hofstra/Northwell in New York. She also co-authored two of the book’s chapters: “Precision Medicine in Diabetes Phenotypes” and “Neonatal Diabetes.” Mary Margaret Barr, M.D., a fellow in the Joseph S. Bruno Pediatric Endocrinology Training Program at UAB, co-authored Neonatal Diabetes with Ashraf. Barr will be joining the Division of Pediatric Endocrinology and Diabetes as a faculty member in July 2026.

Pediatric diabetes one of the most common chronic diseases among individuals under age 20 in the United States. In 2022, an estimated 21,732 youth under 18 were newly diagnosed with T1D, and 14,490 were diagnosed with T2D. Between 2001 and 2017, the prevalence of T1D in U.S. youth increased by 45%, with the largest increases among non-Hispanic white and non-Hispanic Black youth. Over the same period, T2D prevalence increased by 95%, with the largest increases among non-Hispanic Black and Hispanic youth. Based on increasing rates, by 2060, the number of youth with T1D is projected to reach 335,000, and the number of youth with T2D is expected to reach 220,000—increases of 65% and 673%, respectively.

“Pediatrics Diabetes” is published by Springer as part of the Contemporary Endocrinology series and is available in print (ISBN: 978-3-032-17035-4) and eBook (ISBN: 978-3-032-17036-1) formats at Springer.com and Amazon.

Ashraf also holds the Ralph Frohsin Endowed Chair in Pediatric Endocrinology at UAB and serves as associate director of the UAB Comprehensive Diabetes Center. Ashraf is also co-editor of “Pediatric Dyslipidemia,” published by Springer in 2023.

July 21, 2026 by
Endocrinology

The Future of Type 1 Diabetes Management

The future of type 1 diabetes management may involve more than just insulin. (Stock photo)

Think type 1 diabetes (T1D), and you think of insulin. You think incurable. You think forever. But the introduction of the first disease-modifying drug, the immunomodulator teplizumab, along with investigational approaches such as beta-cell preservation, gene editing and stem cell therapy, show that what we thought was the final word was really just the opening argument.

“For so long, we treated type 1 diabetes symptomatically with insulin alone, which is absolutely essential and life-saving,” Children’s of Alabama pediatric endocrinologist Ambika P. Ashraf, M.D., said. “But if we recognize it as an autoimmune disease, then we need to treat the immune process driving it, not just the high blood sugars. You don’t treat rheumatoid arthritis by just controlling inflammation alone,” she said.

To highlight where the field is at this important point in time, Ashraf co-edited a journal supplement, a special collection of research articles on T1D, in Frontiers in Endocrinology.

The supplement, published as a collection of 14 peer-reviewed articles, brings together researchers from around the world to address immune modulation, beta-cell preservation, remission, screening, gene editing, stem cell therapies and metabolic memory. The goal was not to champion one therapy, Ashraf said, but to show how the future of type 1 diabetes care will be built from complementary approaches to slow, stop or even prevent disease progression.

Two articles are authored by researchers at Children’s and the University of Alabama at Birmingham (UAB).

“When you look at all this work together as a collection, you start thinking about different ways to approach the management of type 1 diabetes,” she said.

The idea emerged while Ashraf and her colleagues were outlining a chapter on disease-modifying therapy for a pediatric diabetes textbook. “There was simply too much important work happening,” she said. “It became clear that disease-modifying approaches in type 1 diabetes deserved a deeper, more focused conversation.”

When Frontiers invited proposals for a themed issue, the timing was perfect.

“We knew this was it—bringing together the growing body of research that is shifting type 1 diabetes from a condition we only manage to one we may be able to change, delay or even prevent,” she said.

The supplement focuses on three questions: Can we slow or stop the immune destruction of beta cells? Can we preserve insulin production?  Can we delay or prevent the onset of symptomatic type 1 diabetes?”

“Remission is so important because if you stop autoimmunity, then you can get back to having normal function,” she said. At the same time, beta cell preservation is also key. “They go hand in hand.”

Another theme in the supplement is screening for antibodies that predict type 1 diabetes risk before symptoms appear, which opens the door to interventions when they are most beneficial. But universal screening is only practical if therapies are effective and accessible, Ashraf said. “If we had a medication that we could confidently say, ‘Take this, and it would reliably reduce your risk of developing T1D,’ then universal screening would be transformative,” she added.

Several articles in the collection explore therapies that support beta‑cell health without suppressing the immune system but by strengthening the cells themselves. These include medications like verapamil, experimental TXNIP‑targeting drugs and high‑dose GABA, all of which aim to help insulin‑producing cells survive longer.

Perhaps the most important message of the supplement is that there likely will not be a one-size-fits-all approach for people with T1D, but a mix of options based on the individual patient. As Ashraf and her co-editors wrote in an editorial in the issue: “The innovative concepts highlighted here will undoubtedly shape the future of diabetology and inspire further research into state-of-the-art, disease-modifying therapies for T1D.”

February 12, 2026 by
Endocrinology

Increasing Foot Exams in Kids With Type 2 Diabetes

A QI project at Children’s helped improve the rate of foot exams for patients with type 2 diabetes. (Stock illustration)

When you think about type 2 diabetes in kids, you likely think about blood sugar, insulin and diet. But what about feet?

For kids—and adults—with diabetes, feet can be the canary in the coal mine when it comes to microvascular damage from high glucose levels. In the feet, neuropathy increases the risk of foot ulcers and even amputation. In the eyes, it can lead to vision loss, and in the kidneys to chronic kidney disease.

“Young people with type 2 diabetes are very different from adults,” said Mary Margaret Barr, M.D., a pediatric endocrinology fellow at Children’s of Alabama. “Their disease is usually much more aggressive. It causes issues earlier, and it can be harder to control.”

Current American Diabetes Association guidelines call for comprehensive foot exams upon diagnosis of type 2 diabetes and annually thereafter.

Yet when Barr set out to see how well clinicians documented complete foot exams in medical charts at Children’s, a large gap emerged.

Her review came after the hospital transitioned to a new electronic health record (EHR) system. She found that after the transition, documented foot exams in pediatric patients with type 2 diabetes fell from about one in four visits to almost none. “Basically, one or two kids out of 30 or 40 had a documented foot exam,” she said.

It wasn’t that clinicians didn’t know the guidelines; it was just different in the new system.

Recognizing that reality, the team launched a formal quality improvement project—later named UndeFEETed—to understand what was getting in the way and how to fix it.

A Small Exam That Takes Time—and Intention

A proper diabetic foot exam is not a glance at a pair of sockless feet. It requires time, tools and attention.

It starts with a neurological exam to test nerve sensation in the foot. A monofilament (soft strand of nylon) is tapped gently on the foot and toes to assess if the patient can feel where it is tapping without looking, followed by tuning fork vibration tests, a pinprick test, or a tendon hammer test to assess ankle reflexes. The vascular assessment includes checking blood flow in the foot and ankle.

For children—especially those who are younger or developmentally delayed—this exam can be challenging. And in a busy clinic, where providers juggle multiple screening requirements, preventive exams that aren’t automated can quietly fall away.

“There’s a really big list of screenings that come along with diabetes visits,” Barr noted. “It does get overwhelming.” But most of these other screenings are incorporated into the daily clinic flow, with documentation rates averaging more than 80%.

Plus, there’s no reimbursement for foot exams despite the time required to properly do one. “That’s frustrating,” Barr said.

She’s not surprised that when she presents the UndeFEETed data at conferences with other endocrinologists around the country. “Everyone’s like: Yeah—no one does foot exams.”

But a documented foot exam is more than just paperwork: it’s a safeguard that problems won’t be missed.

“If a foot problem was found, it could be addressed early rather than later,” Barr said.

That matters because children diagnosed with type 2 diabetes today will live with the disease for decades. Large studies show that by their mid-20s many already show signs of permanent nerve damage, Barr said.

Her team identified four main barriers to documented foot exams: lack of standardized documentation, limited access to exam tools, time pressures, and uncertainty about how to record the exam in the new EHR.

Physicians, nurse practitioners and clinic nurses worked together to redesign workflows. A new diabetes note template embedded foot exam documentation directly into routine visits. Supplies were in all exam rooms. Nurses helped flag when exams were due.

The team resisted adding pop-up alerts in the new EHR, which also helped. Instead, they built seamless, non-intrusive reminders into the charting process.

The results were striking. Within months, documented foot exams rose from less than 5% to more than 20%. Once more providers adopted the new template, documentation climbed to 50%—double the original goal.

However, after the initial changes were implemented and the system was running for a while, that figure dropped to about 30%. So Barr and her team are continuing to investigate other options in the EHR to help. They are also working with the nurses to identify the best way to communicate with the clinicians they work with most often, whether it’s a sticker or a certain word to help them remember to conduct a foot exam.

Barr hopes the work eventually leads to tracking long-term outcomes, including whether earlier and more consistent screening reduces complications. For now, the focus remains on getting the fundamentals right. “Our biggest goal is to make sure that kids who are about to graduate from pediatric care and go into the adult world have foot exams on record,” she said.

February 12, 2026 by
Endocrinology

QI Project decreasing no-shows in endocrinology clinic

Thanks to a QI project, fewer patients are missing appointments in an endocrinology clinic at Children’s of Alabama.

Missed appointments are nothing unusual in the world of clinical care. In Children’s of Alabama’s subspecialty clinics, a no-show rate of around 30% is not out of the ordinary. In some cases, these absences can derail a patient’s progress or allow their condition to worsen.

That’s why a team of clinicians at Children’s of Alabama started a quality improvement (QI) project to increase retention in the hospital’s Prediabetes and Metabolic Syndrome Clinic. Led by Grant Adams, CRNP; Christy Foster M.D.; and Jessica Schmitt M.D., MSHQS, the project has reduced no-show rates for return patients in the clinic from 37% to 18% in less than a year with support from the KPRI Quality and Safety Award.

The clinic, which opened in late 2022, was established to provide a centralized and dedicated clinic within the Division of Endocrinology and Diabetes for youth with metabolic syndrome and/or prediabetes. “Obesity and prediabetes are all too common in our youth,” Schmitt said. “When patients are referred to us, we want to be able to provide solutions beyond what pediatricians can provide. Further, some health care providers feel less experienced or comfortable managing obesity-related complications in children and counseling on lifestyle interventions. We felt it would be beneficial to assign these patients to a specialized team equipped to provide comprehensive, compassionate care focused on addressing these specific health concerns. As this patient population is a special area of interest for Grant, he was an ideal provider to lead this clinic.”

But when patients don’t return for follow-up appointments, it’s difficult for providers to achieve those solutions. That’s why the QI project was necessary. And it’s been effective; the team achieved the no-show decrease in the clinic by encouraging more patient-oriented options when educating and refining healthy habits. They operated under the motto: EMPOWER Healthy Habits. Providers adopted a modified version of the American College of Lifestyle Medicine (ACLM) pillars of health: sleep, social connections, stress management, activity, nutrition and mental health. They encouraged each patient to set SMART goals addressing one or two of these health domains.

Once a patient chose their goals, the team offered tools to help them succeed—for  example, a sound machine for sleep; activity dice for activity; portion containers for nutrition; craft kits for stress management; card games for social connections; journals for mental health.

All subjects were offered a body composition analysis and had access to a digital exercise platform, if interested. Same-day consultations with social work and nutrition were offered and encouraged. “Providing a human-to-human connection with a focus beyond the scale engaged patients and their families, particularly those who previously felt that healthy habits were out of reach,” Adams said.

Providers also worked with the families to determine the best methods for contacting them. When medically appropriate, they allowed shared decision making to guide follow-up frequency and modality (phone, MyChart, telemedicine, or in-person visits). “We’re working with families to make changes that meet their goals where they currently are, not a provider’s ideal change behaviors. This promoted the patients’ and families’ autonomy and agency,” Foster said. “This changed the dialogue from provider-dictated change to patient-centered.”

Provider training also played a crucial role. They received training in motivational interviewing (MI). “MI is frequently quoted as the ideal way to promote patient-led behavior change, but most providers have not received any training,” Schmitt said. “After working with Dr. Matthew McKenzie, the MI trainer working with the team, when I lean into MI techniques, I find visits more collaborative, rewarding and effective than when I try to tell a patient or family what to do.” The training is ongoing.

The team’s initial goal when they began the project in the December 2023 was to reduce no-show rates for return visits by 19% for a reduction from a baseline of 37% to 30% by July 2025. They nearly met that goal in the first stage alone, reducing missed appointments to 31% between December 2023 and July 2024. By the end of stage two in November 2024, the rate had fallen to 18%.

The work is evolving and continues as the EMPOWER Healthy Habits team continues to find better ways to serve their patients and families. “We are reassured by this success and look forward to working on sustaining these results,” Adams said. “In future endeavors, we look forward to evaluating if increased retention has health benefits for our patients, which is the ultimate goal.”

January 9, 2025 by
Endocrinology

Connection between weight and type 2 diabetes

Children’s of Alabama is one of 15 institutions across the U.S. involved in the DISCOVERY study. (Stock photo)

It’s a troubling trend: Type 2 diabetes diagnoses have rapidly increased in children and teens, especially during the COVID pandemic. Now, University of Alabama at Birmingham (UAB) and Children’s of Alabama investigators are joining others from 15 prominent institutions across the United States to reveal the factors leading to this phenomenon, which poses massive public health implications worldwide.

The DISCOVERY study aims to determine why some children who are overweight or obese develop type 2 diabetes while others do not. Children with diabetes tend to have a more rapid progression than adults to other serious health conditions and complications such as high blood pressure, kidney disease and retinopathy, experts say. So it’s crucial to fully understand the contributing factors in order to more precisely predict which children are at the highest risk—and potentially prevent them from developing the condition.

“Very few longitudinal studies have been done to determine which of these kids converts to type 2 diabetes,” said DISCOVERY co-investigator Barbara Gower, Ph.D., who’s also a professor and chair of the Department of Nutrition Sciences at UAB. “This study is designed to recruit at-risk children and see who actually converts to type 2 diabetes, looking at a broad suite of factors—everything from social risk factors to biological factors.”

Ambika Ashraf, M.D., study co-investigator and director of the Division of Pediatric Endocrinology at Children’s, agrees. “Even though we understand that high BMI predisposes someone to type 2 diabetes, what is really unclear is what prompts a child who has all these risk factors to convert,” she said.

The issue is particularly relevant to Alabama, which is one of 15 states considered to be in the “Diabetes Belt” because the incidence of type 2 diabetes is about one-third higher than the national average. Children’s cares for more than 80% of the state’s pediatric type 2 diabetes patients, with nearly 650 such children referred for evaluation for new-onset cases between March 2017 and March 2021. Additionally, hospital admissions for new-onset pediatric type 2 diabetes cases in Alabama more than doubled over a two-year span that led up to the early stages of the pandemic.

Over the next two years, DISCOVERY will enroll approximately 3,600 children and teens ages 9-14, all with a BMI at or above the 85th percentile and HbA1c levels of 5.5% or higher. Children will be tracked for between two-and-a-half and four years, completing comprehensive annual visits, including a three-hour oral glucose tolerance test and detailed physiological assessments. They will also undergo a brief visit every six months, along with telephone checks every three months to monitor for type 2 diabetes.

The study’s size is a huge strength, says Gower, also a senior scientist at UAB’s Diabetes Research Center. “Because the actual conversion rate to type 2 diabetes is still quite low, we need a lot of sites and participants in order to have enough children to analyze,” she explained.  

Ideally, Ashraf and Gower say, the DISCOVERY trial will produce new insights that help clinicians pinpoint exactly which children with high BMIs are most vulnerable to developing diabetes and stop the process.

“If we can determine the risk factors that predispose certain individuals to develop type 2 diabetes, that could have a huge impact,” said Ashraf, also a professor of pediatric endocrinology and associate director of the Comprehensive Diabetes Center at UAB. “It may have a global impact, too, because type 2 diabetes is going to cause a huge economic impact throughout the world.”

January 7, 2025 by
Endocrinology

Ashraf’s study shows characteristics of hybrid diabetes

A study led by Ambika Ashraf, M.D., shows the unique challenges that patients with hybrid diabetes face.

A study led by Children’s of Alabama endocrinologist Ambika Ashraf, M.D., highlights the unique characteristics of hybrid diabetes (HD) or double diabetes, distinguishing it from both type 1 and type 2 diabetes. It is pivotal in understanding the different trajectories of diabetes in children and may pave the way for more targeted treatment strategies.

The study, titled “Children and Adolescents With Hybrid Diabetes: A Management Conundrum” is a retrospective analysis from 2016 to 2020, examining 102 subjects with type 1 diabetes (T1DM), hybrid diabetes (HD), and type 2 diabetes (T2DM). It was published in the journal Endocrine Practice.

Key findings of the study indicate that children with HD show a blend of autoimmune diabetes autoantibody positivity (a hallmark in T1DM) and insulin resistance (a hallmark of T2DM), creating a complex treatment and management scenario.

Researchers found that patients with HD were still insulin dependent at a two-year follow-up, like patients with T1DM. Patients with HD also had a strong positive family history of T2DM and preserved endogenous c-peptide production, like patients with T2DM.

“Our study findings underscore the need for healthcare providers to be vigilant in diagnosing and managing this distinct form of diabetes, which poses unique challenges due to its hybrid nature,” said Ashraf, who’s the director of the Division of Pediatric Endocrinology and  Diabetes at the University of Alabama at Birmingham (UAB). “The study calls for further research to develop precision treatment strategies for pediatric patients with hybrid diabetes. Our team of researchers wants to encourage more research specifically on using insulin sensitizers and incretin based therapies.”

Other study authors included first author Charles A. Gagnon BS, UAB Heersink School of Medicine medical student, and Jessica Schmitt M.D., assistant professor in the Division of Pediatric Endocrinology and Diabetes.

August 12, 2024 by
Endocrinology

On the Front Lines of the Pediatric Obesity Crisis

In the Children’s of Alabama SHINE clinic, a multidisciplinary team take a holistic approach to helping patients with obesity.

About one in five children and adolescents in the U.S., representing nearly 15 million individuals, have obesity.[i] That puts the multidisciplinary Strategies for Health, Interventions, Nutrition, and Exercise (SHINE), clinic at Children’s of Alabama on the front lines of this complex issue. “It’s not just about weight loss,” pediatric endocrinologist Christy Foster, M.D., said. “We address the root causes of obesity and the various comorbidities associated with it. This holistic approach is vital for the long-term success of our patients.”

The clinic is run by adolescent medicine specialist Stephenie B. Wallace, M.D. In addition to Foster, the team includes a registered dietician, a physical therapist, an exercise physiologist and a social worker. Together, they create individualized plans for each patient focused on achievable goals.

Soon after starting in the clinic, Foster cared for a teenaged girl with obesity. The patient’s mother had type 2 diabetes, and the teenager had pre-diabetes. “Mom was just very worried and concerned for her,” Foster said. “But the girl was just very defeated. She felt it was her fault.” That’s not unusual, she said. “That’s one of the things that is tough around this condition. There’s a lot of shame and guilt.”

Christy Foster, M.D.

Foster assured the girl that her weight did not define who she was. She asked her to pick a goal to work toward. “She wanted to be a nurse,” she said. “So that became her motivation. I told her that if you want to take care of your patients, you have to take care of yourself first.”

When the teen returned for her next appointment, “she had such a light,” Foster said, and she’d started going to the gym. “There wasn’t a huge change all at once,” she said. “But she found the motivation. And that was one of the things she needed.”

The clinic’s philosophy is that obesity is a chronic disease, not a personal failing. “There are genetic, environmental, and psychological factors at play,” Foster said. “What I appreciate most about this clinic is our collective willingness to find creative solutions. We meet families where they are and tailor our recommendations to their unique circumstances. This adaptability is crucial for making a real difference in our patients’ lives.”

The clinic also emphasizes early intervention, encouraging primary care clinicians to refer patients before they develop the metabolic diseases of obesity, such as type 2 diabetes. “We now see that type 2 diabetes constitutes most of our new onset diabetes cases in children. This is a stark increase from a few decades ago,” Foster said.

New guidelines on childhood obesity from the American Academy of Pediatrics call for an aggressive approach to treatment, including pharmacotherapy and, in some situations, bariatric surgery. “We’re navigating these new recommendations carefully,” Foster said, “always weighing the benefits and potential risks. Cost is also a consideration, as insurance coverage varies.” In addition, the two newest weight-loss drugs, semaglutide and terzepatide, are only approved for use in adults, although they may be used off-label for children.

[i] Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/php/data-research/childhood-obesity-facts.html.

August 5, 2024 by
Endocrinology

Going ‘beyond the scale’ in prediabetes treatment

A Children’s of Alabama clinic offers a family-centered approach to prevent prediabetes from progressing to diabetes. (Stock photo)

A lag in care for children with obesity and its complications can spell the difference between prediabetes and a full-blown case of diabetes. Recognizing this, Children’s of Alabama pediatric nurse practitioner Grant Adams, CRNP—who has always had a “big heart for children struggling with obesity”—spearheaded a new clinic at Children’s to fill the gap.

The result is the Prediabetes and Metabolic Syndrome Clinic, which was established in late 2022 and runs half-days every Tuesday at the Children’s Diabetes and Endocrine Clinic. The clinic is meant to prevent delays in care for children referred by their pediatricians for prediabetes, weight management and related issues.

These young people face the high risk that their prediabetes will progress into diabetes, a disease which affects more than 350,000 children and adolescents under age 20 in the United States, according to the Centers for Disease Control and Prevention (CDC). Nearly 20% of children and adolescents nationwide cope with obesity, predisposing them to diabetes as well as other health conditions.

Children’s pediatric endocrinologist Christy Foster, M.D.,  assisted Adams in establishing the clinic, which also includes physicians, a registered dietitian and a social worker. The team aims to move “beyond the scale” with a family-centered approach that emphasizes healthy eating habits and movement as well as medication management.

“My vision was to instill habits that would be lifelong,” Adams said. “We want to reinforce that just because there’s a family history of diabetes, it’s certainly not inevitable.”

To that end, clinic visits—which take place every three to six months—deeply involve parents and other caregivers. While staff members closely monitor patients’ well-being and lab work, the resulting positive changes often have ripple effects on the entire family.

“Rather than doing more prescriptive-style medicine where everyone is assigned the same interventions, we work with families to see what can be reasonably done for and with them,” said endocrinologist Jessica Schmitt, M.D.,  an assistant professor in the Division of Pediatric Endocrinology and Diabetes at Children’s and the University of Alabama at Birmingham (UAB).

“At every visit, we talk about how food is fuel,” Adams added. “Regardless of a child’s age, it’s not their responsibility to buy and cook the food, especially if they’re not teenagers. They rely on a family approach—and families buy in.”

Even so, results are mixed. Some children and teens who visit the clinic improve their diets and lifestyles dramatically, with associated improvements in their weight, blood sugar levels, and problems such as high cholesterol.

“This is a lifelong commitment, not a diet,” Adams said. “It isn’t a sprint, it’s a marathon.

“If we can affect this generation, my vision is that their kids will be affected positively,” he added. “Obesity is a pandemic, and we’ve got to stop it somewhere. I’ve decided it needs to start with kids. This is a generational problem, and we can make a positive impact.”

January 29, 2024 by