Beyond Autoantibodies: A New Approach to Predicting Type 1 Diabetes in Children

In this episode of MD Newsline, Dr. Brittany Bruggeman, a pediatric endocrinologist and physician-scientist at the University of Florida, discusses groundbreaking research presented at the American Diabetes Association (ADA) Scientific Sessions on the role of the exocrine pancreas in predicting Type 1 diabetes. Traditionally, researchers have focused on the insulin-producing islets, but Dr. Bruggemann explains why the much larger exocrine pancreas may hold valuable clues for identifying children at the highest risk of developing Type 1 diabetes years before symptoms appear. She explores findings from the TEDDY birth cohort, showing that changes in fecal elastase, a marker of exocrine pancreatic function, can be detected as early as four months of age in children who later develop Stage 3 Type 1 diabetes. Dr. Bruggemann also discusses how combining exocrine biomarkers with islet autoantibodies improves prediction accuracy, the clinical implications of exocrine pancreatic insufficiency, and how future advances in proteomics, imaging, AI, and multiomics may transform early diagnosis and disease prevention. Episode Highlights Why the Exocrine Pancreas Matters For decades, Type 1 diabetes research has centered on the insulin-producing islets. Dr. Bruggemann explains why researchers are now shifting attention to the exocrine pancreas, which makes up approximately 97% of the pancreas and may show measurable changes long before clinical diabetes develops. The TEDDY Study and Early Biomarkers Using more than 4,500 stool samples collected from over 250 children enrolled in the TEDDY study, researchers measured fecal elastase, a marker of exocrine pancreatic function, to determine whether early pancreatic changes could predict progression to Type 1 diabetes. Detecting Changes Before Autoimmunity One of the study's most surprising findings was that children who progressed rapidly to Stage 3 Type 1 diabetes already demonstrated differences in fecal elastase at an average age of four months—well before islet autoimmunity is thought to begin. This suggests that exocrine abnormalities may precede the autoimmune process itself. Improving Prediction by Combining Biomarkers Fecal elastase alone provided limited predictive power, but when combined with islet autoantibody status, researchers significantly improved their ability to predict progression to Stage 3 Type 1 diabetes within a one- to two-year timeframe—an important goal for clinical trials and disease-modifying therapies. Clinical Implications for Patients Dr. Bruggemann explains when clinicians should consider testing for exocrine pancreatic insufficiency, particularly in patients with established Type 1 diabetes who experience gastrointestinal symptoms such as bloating, cramping, or stool changes. She emphasizes that fecal elastase testing is inexpensive, reliable, and can identify a treatable condition that is often overlooked. Challenges and Limitations Although promising, fecal elastase testing requires stool collection, and sample quality can influence results. Dr. Bruggemann discusses current limitations and ongoing efforts to develop symptom-based screening tools that could help identify which patients should undergo testing. The Future of Type 1 Diabetes Prediction Looking ahead, Dr. Bruggemann envisions combining fecal elastase, serum biomarkers, genetic data, MRI imaging, proteomics, and artificial intelligence to build more accurate risk prediction models capable of identifying children most likely to develop Type 1 diabetes within the next few years. Key Takeaway Dr. Bruggemann's research suggests that the exocrine pancreas may provide previously overlooked biomarkers that improve the early prediction of Type 1 diabetes. While fecal elastase is not sufficient as a standalone predictor, combining it with autoantibodies, serum biomarkers, genetics, and advanced imaging could lead to earlier intervention, better clinical trial enrollment, and a deeper understanding of how Type 1 diabetes begins long before symptoms appear. Resources Website: https://mdnewsline.com/ Newsletter: https://mdnewsline.com/subscribe/ Contact with Dr. Brittany Bruggeman: Here