#41–Jake Kushner, M.D.: How to thrive with T1D and the valuable insights that can benefit anyone

KEYPOINTS

• 01

  Type 1 diabetes is common and often missed.

  Kushner says about 1 in 300 people have type 1 diabetes, typically diagnosed around age nine. He calls it the most common life-threatening, medication-requiring illness of childhood, meaning one to three new diagnoses a year in a typical school. Its incidence has roughly doubled since 1960. At Boston Children's he was the first clinical fellow in 10 years to specialize in it, instead of the rare metabolic diseases academic medicine tends to prize.

• 02

  It is a slow autoimmune loss of the pancreas's insulin-making beta cells.

  Beta cells make up only about 5% of the pancreas, in islets surrounded by digestive tissue. As they release their unique antigens, autoimmunity can spiral and destroy them over time. No single virus has been proven to cause it. Kushner says higher body weight raises risk at the population level but predicts poorly for individuals. It could either strain beta cells or expose autoimmunity that would otherwise have stayed hidden.

• 03

  Genetics raises risk but leaves most children unaffected.

  HLA genes are a major factor. A tenfold family risk turns 1 in 300 into about 1 in 30, which still gives about a 97% chance a child won't develop it. Identical twins share it only about 50–60% of the time early on, rising toward 80% by adulthood, according to George Eisenbarth's cohort. Kushner once treated identical twins where only one had it, and knew a family in which all three sons had it.

• 04

  The DCCT showed that tighter glucose control prevents complications.

  Beginning in the mid-1980s, roughly 1,400 patients at a cost of about $100 million, which Kushner says should be checked, went from an A1c of about 9% to 7%. Centers crowdsourced methods on conference calls. The trial was stopped at about seven years because the eye and kidney benefits were too large to withhold. The downside was more hypoglycemia and weight gain, as patients ate carbohydrates to treat lows.

• 05

  Seven years of tighter control still paid off decades later.

  After the trial both groups drifted to an A1c of about 8%, yet over the next 23-plus years the former tight-control group had less major kidney disease, less cardiovascular disease and fewer deaths. Kushner recalls about a third fewer primary cardiovascular events. He notes that people with type 1 who gained the most weight since the DCCT era have had somewhat worse cardiovascular outcomes, a weak association.

• 06

  Volatility is the core problem, and blaming patients makes it worse.

  Kushner says the same meal can need very different insulin depending on stress, sleep, exercise and the fat and protein in it, so fixed insulin-to-carb formulas fall short. He calls the label 'noncompliant' grotesque. Attia compares chasing glucose readings to a beginner pilot fixated on the instruments, which causes overcorrection back and forth, instead of watching the horizon.

• 07

  Diabetes distress is huge and often unspoken.

  On a 1–10 distress scale, Kushner says teenagers with type 1 diabetes for five years or more on high-carb diets typically score 7–8. Some with an A1c near 14 break down in tears because no one had asked. Because the distress feels normal to them, they assume life just 'sucks'. He has seen patients go from an A1c over 14 to under 7 and be astonished at how differently they could think and feel.

• 08

  Bernstein's 'law of small numbers' reshaped Kushner's practice.

  Richard Bernstein, who has type 1 diabetes, is still practicing in his 80s and was one of the first to test glucose at home. He argues that fewer carbohydrates mean less insulin and therefore smaller mistakes. His Diabetes Solution recommends low-carb, higher-protein eating, not a ketogenic diet, with longer-acting insulin to cover protein and fat. Kushner estimates about 10 grams of protein act like roughly 6 grams of carbohydrate, with a delay of hours.

• 09

  Strict keto and SGLT2 inhibitors carry particular risks in type 1 diabetes.

  Without beta cells, nothing limits ketone production. Attia fasting for a week peaks around 6–7 mM BHB, while acidosis begins around 10–14 mM, so Kushner calls prolonged fasting probably a bad idea in type 1. Off-label SGLT2 inhibitors can cause diabetic ketoacidosis with normal glucose (euglycemic DKA), including deaths. Kushner discloses he has consulted on one of these drug programs.